Clinical Handbook of Mindfulness (28 page)

Other Examples of the Problem Formulation Approach

Further examples of how mindfulness components have been incorporated

into existing treatments following a problem formulation approach include

the following: the mindfulness component in DBT for borderline personality

disorder
(Linehan, 1993),
Acceptance-based behavior therapy for generalized anxiety disorder
(Roemer & Orsillo, 2007),
mindfulness-based CBT for co-occurring addictive and mood disorders
(Hoppes, 2006),
and Mindfulness-

and Acceptance-based Group Therapy (MAGT) for social anxiety disorder

(Kocovski, Fleming, & Rector, 2007).

Looking more closely at generalized social anxiety disorder, Koszycki,

Benger, Shlik, and Bradwejn
(2007)
conducted a randomized controlled

trial comparing MBSR and Cognitive Behavioral Group Therapy (CBGT;

Heimberg & Becker, 2002).
They found that CBGT, the current gold standard group intervention for social anxiety disorder, was superior to MBSR

on a number of outcome variables. However, they did find MBSR to be help-

ful, resulting in medium to large effects. They provided a rationale for using

MBSR with this patient population. However, the MBSR program was not

adapted for patients with social anxiety disorder, and it was administered

by an instructor who typically delivers mindfulness training to the public.

Although positive effects were obtained with MBSR, the usual standard of

care was found to be superior and therefore should remain the first-line psy-

chological group intervention. Alternatively, an attempt at integrating MBSR

and CBGT might prove fruitful.
Kocovski et al. (2007)
have incorporated

mindfulness techniques along with acceptance- and exposure-based strate-

gies using a problem formulation approach. Pilot groups have demonstrated

that this approach is feasible and acceptable to patients, and there is prelimi-

nary evidence in support of its effectiveness. A trial comparing this treatment

(i.e., MAGT) to CBGT is underway. Additionally,
B¨

ogels, Sijbers, and Voncken

(2006)
report positive results from a small pilot study where they integrated MBCT and another intervention, task concentration training, for the treatment of social anxiety disorder.

Overall, although there are many positive findings regarding mindfulness

techniques
(Baer, 2003),
it is important to study exactly how mindfulness works for each disorder. This can be helpful in terms of the development

of a problem formulation for a particular disorder or support for an existing

problem formulation. Hence, the next section outlines the specific mecha-

nisms of change that have been theorized and/or empirically supported.

Mechanisms of Change: Biological Factors

Research examining the physical benefits of meditation has been extensive

(e.g.,
Aftanas & Golosheykin, 2005;
Hankey
,
2006;
Orme-Johnson, Schneider, Son, Nidich, & Cho,
2006; Travis & Arenander, 2006).
However, this research
Chapter 5 Mindfulness and Psychopathology

89

has often focused on experienced meditators who have had many years of

training. For example,
Travis and Arenander (2006)
examined a sample of

individuals who had been practicing TM for an average of 22 years. These

highly experienced groups have then been compared to individuals who

have had no experience with meditation. A number of positive findings have

emerged from studies of this nature. Travis and Arenander found experienced

meditators to have higher frontal alpha asymmetry and greater electroen-

cephalogram (EEG) coherence than non-meditators. Frontal alpha asymme-

try has been associated with affective responding
(Davidson & Irwin, 1999)

with particular patterns of asymmetry found in individuals with depression

(Gotlib, Ranganath, & Rosenfeld, 1998).
EEG coherence is indicative of brain coordination and has been linked to intelligence
(Cranson et al., 1991),
creativity
(Orme-Johnson & Haynes, 1981),
and mental health (Travis & Arenander). There is also support from EEG findings that long-term meditation

leads to a better capability of moderating the intensity of emotional arousal

(Aftanas & Golosheykin, 2005).
Furthermore, in a second study, Travis and Arenander found that EEG coherence increased over one year as individuals

practiced TM, indicating that even minimal meditative experience can lead

to improved brain functioning.

Other physical outcomes that have been observed in experienced

meditators include the following: decreased hypertension (Orme-Johnson &

Walton,
1998),
increased sensory acuity
(Carter et al., 2005),
decreased systolic blood pressure
(Wallace, Dillbeck, Jacobe, & Harrington, 1982),
and decreased brain responses to pain
(Orme-Johnson et al., 2006).
A complete review of research in this area is beyond the scope of this chapter (see

Cahn & Polich, 2006,
for a review of EEG, ERP, and neuroimaging studies across various forms of meditation; see
Newberg & Iversen, 2003,
for a model integrating data on neurotransmitter and neurochemical substrates that may

underlie meditation). In sum, there is evidence that intensive meditation

practice is physically beneficial across a variety of domains. It is important

to question, however, whether these benefits are unique to very experi-

enced meditators or whether these benefits are also evident in individuals

who undergo more short-term forms of meditation (i.e., mindfulness train-

ing programs such as MBSR or MBCT).

Studies that have specifically examined how mindfulness techniques affect

the brain are limited.
Davidson et al. (2003)
investigated brain and immune changes in participants who were randomly assigned to receive MBSR (Kabat-Zinn,
1990)
or a wait-list control group. Compared to the wait-list con-

trol condition, participants who received MBSR showed greater left-anterior

activation immediately after the mindfulness training intervention was com-

pleted and at a four-month follow-up assessment. In addition, the group that

received MBSR also showed greater left-anterior activation after they wrote

about positive and negative life experiences. Greater left-anterior activation is

associated with positive emotions
(Davidson, 1992),
both dispositionally and during positive mood inductions. It is also associated with adaptive responding to negative or stressful events
(Davidson, 2000),
which may explain why individuals in the mindfulness group had increased left-anterior activation

even after writing about negative life events. This study also investigated

how mindfulness training affected immune functioning. All participants were

given an influenza vaccine after the completion of mindfulness training

90

Nancy L. Kocovski, Zindel V. Segal, and Susan R. Battista

(or lack of training in the control condition), and antibody levels were mea-

sured at two time points. Results revealed a significantly greater increase in

antibodies from time one to time two for the mindfulness group as compared

with the control group. This study provides initial support for the idea that

even short-term mindfulness training can have widespread physical benefits

for individuals. However, it should be noted that the sample used by David-

son and colleagues was not comprised of individuals seeking treatment for

any clinical disorder, but rather, they likely represented a healthy population.

Given that mindfulness techniques are currently being used within clinical

samples to treat a variety of disorders, it is important to examine the biologi-

cal mechanisms of change that are specific to the problem undergoing treat-

ment.
Barnhofer et al. (2007)
recruited a sample of individuals who had a history of suicidal depression, and randomly assigned them to receive MBCT

(Segal et al., 2002)
or treatment as usual. EEG readings were taken before and after the treatment period, which lasted eight weeks. Changes in prefrontal

asymmetry were not found in the group that received MBCT. However, the

group that received treatment as usual showed decreased levels of prefrontal

asymmetry at the eight-week reading. The researchers concluded that the

MBCT group had developed a more balanced pattern of prefrontal activa-

tion, whereas the treatment-as-usual group experienced more right-sided

activation, a pattern associated with avoidance. The researchers suggested

that developing a more balanced pattern of prefrontal activation, and hence

a more balanced affective response style, may help to prevent depression

relapse by decreasing the likelihood that one will fall back into a negative

cognitive style. This study provides preliminary insight into potential biolog-

ical changes that are the result of a specific mindfulness intervention and

how such biological factors can be connected with the specific disorder that

one is suffering from. Hopefully, future research will follow this path, namely,

that of investigating a particular mindfulness intervention and the biologi-

cal changes that occur compared to a control group, and perhaps going one

step further by having a competing empirically supported intervention as the

comparison group. Finally, with respect to biological mechanisms of change,

there is recent research examining the brain regions involved in the tendency

of minds to wander, which may help with this type of research
(Mason et al.,

2007).

Mechanisms of Change: Psychological Factors

There is growing evidence indicating that mindfulness has a number of

positive effects on well-being. Although it is difficult to pinpoint exactly

how mindfulness leads to these positive outcomes, a number of psycho-

logical mechanisms are likely responsible. At this point in time, many of

the proposed mechanisms have not been empirically studied, but rather,

remain theoretical. It is of utmost importance that future research focus

on experimentally examining each psychological mechanism and link sup-

ported mechanisms to specific disorders. Additionally, for a variable to be

considered a mediator of treatment outcome in a randomized controlled

trial, it is important to show that the variable is affected by treatment before

Chapter 5 Mindfulness and Psychopathology

91

changes occur in the outcome variable (Kraemer, Stice, Kazdin, Offord, &

Kupfer,
2001).
At present, even the variables that have been investigated empirically do not meet this temporal requirement. This section will briefly

outline psychological mechanisms that have received empirical attention,

and meet some of the criteria supporting mediation, as well as those that

are currently theoretical and warrant further investigation.

Increased

Metacognitive Awareness
,
Decentering, Reperceiving, and

Defusion

Metacognitive awareness
(Teasdale et al., 2002),
decentering, reperceiving

(Shapiro, Carlson, Astin, & Freedman, 2006),
and defusion
(Hayes et al.,

1999)
are terms that describe a similar concept in mindfulness training.

Essentially, these refer to the extent to which individuals can view their

thoughts as being passing mental events as opposed to being true reflections

of reality
(Teasdale et al., 2002). Shapiro et al. (2006)
theorized that mindfulness practice would provide training in how to shift one’s perspective

so that thoughts and experiences could be viewed more objectively. There

is some evidence that increases in metacognitive awareness, decentering,

reperceiving, and/or defusion are associated with positive outcomes in mind-

fulness training. For example, Teasdale and colleagues examined the effects

of MBCT on a sample of individuals who had a history of recurrent major

depression. It was found that those who underwent MBCT experienced an

increase in metacognitive awareness and were less likely to relapse compared

to those who received treatment as usual. It is unknown, however, whether

increases in metacognitive awareness were directly responsible for reduced

relapse rates.

Decreased
Rumination

Rumination is the extent to which one dwells on the emotional conse-

quences of an event and has been implicated as a contributing factor in both

depression and anxiety
(Nolen-Hoeksema, 1991; Kocovski & Rector, 2007).

Jain et al. (2007)
compared distressed students who had undergone a mindfulness meditation program with those who had undergone a relaxation train-

ing program on a number of variables. Results revealed that both programs

reduced distress and increased positive mood compared to a control condi-

tion. However, only the meditation group demonstrated significantly reduced

rumination compared to the control condition. Additionally, it was found that

decreases in rumination mediated the relationship between condition (mind-

fulness meditation or control) and reduced distress, such that the mindful-

ness meditation group reported less distress at the end of treatment, partially