Clinical Handbook of Mindfulness (61 page)

Therapy. 31
, 149–154.

Rachman, S., & Shafran, R. (1998). Cognitive and behavioural features of obsessive-

compulsive disorder. In R. P. Swinson, M. M. Antony, S. Rachman & M. A. Richter

(Eds),
Obsessive-compulsive disorder: Theory, research, and treatment
. New York:

Guilford.

Rasmussen, S. A., & Eisen, J. L. (1992). The epidemiology and clinical features of

obsessive compulsive disorder.
Psychiatric Clinics of North America, 15
, 743–758.

Rhéaume, J., Ladouceur, R., Freeston, M. H. & Letarte. H. (1994). Inflated responsi-

bility and its role in OCD. II Psychometric studies of a semi-idiographic measure.

Journal of Psychopathological Behaviour, 16
, 265–276.

Robins, L., Helzer, J., Weissman, M., Orvaschel, H., Gruengerge, E., Burge, J., et al.

(1984). Lifetime prevalence of specific psychiatric disorders in three sites.
Archives

of General Psychiatry, 41
, 949–958.

Rogers, R. D., & Monsell, S. (1995). Costs of a predictable switch between simple

cognitive tasks.
Journal of Experimental Psychology, 124
, 207–231.

Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New

York: Basic Books.

Salkovskis, P. M. (1983). Treatment of an obsessional patient using habituation to

audiotaped ruminations.
British Journal of Clinical Psychology, 22
, 311–313.

Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural

analysis.
Behaviour Research and Therapy, 23
, 571–583.

Salkovskis, P. M. (1996). The cognitive approach to anxiety: Threat beliefs, safety

seeking behavior, and the special case of health anxiety and obsession. In P. M.

Salkovskis, (Ed.)
Frontiers of Cognitive Therapy
(49–74). New York: Guilford.

Salkovskis, P. M., Richards, C., & Forrester. E. (2000b). Psychological treatment of

refractory obsessive-compulsive disorder. In W. K. Goodman, M. V. Rudorfer & J. D.

Maser (Eds.),
Obsessive-Compulsive Disorder: Contemporary Issues in Treatment
.

Mahwah, NJ: Elbaum.

Salkovskis, P. M., Shafran, R., Rachman, S., & Freeston, M. H. (1999). Multiple path-

ways to inflated responsibility beliefs in obsessional problems: possible origins

and implications for therapy and research.
Behaviour Research and Therapy, 37
,

1055–1072.

218

Fabrizio Didonna

Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mind-

fulness.
Journal of Clinical Psychology, 62
, 373–386.

Sher, K. J., Frost, R. O., & Otto, R. (1983). Cognitive deficits in compulsive checkers:

An exploratory study.
Behaviour Research and Therapy, 21
, 357–363.

Schwartz, J. M. (1998). Neuroanatomical aspects of cognitive-behavioral therapy

response in obsessive-compulsive disorder: An evolving perspective on brain and

behavior.
British Journal of Psychiatry, 173, Supplement 35
, 39–45.

Schwartz, J. M. (1999). A role for volition and attention in the generation of new

brain circuitry: Toward a neurobiology of Mental force. Special issue of Journal

of Consciousness Studies, Libet, B., Freeman, A. & Sutherland, K. (Eds.): The Voli-

tional Brain: Towards a neuroscience of free will.
Journal of Consciousness Stud-

ies, 6
(89), 115–142.

Schwartz, J., & Begley, S. (2002).
The mind and the brain: Neuroplasticity and the

power of mental force
(1st ed.). New York: Regan Books.

Schwartz, J. M., & Beyette, B. (1997).
Brain lock: Free yourself from obsessive-

compulsive behavior
. New York: Harper Collins.

Schwarz, N. & Bless, H. (1991). Happy and mindless, but sad and smart? The impact

of affective states on analytic reasoning. In J. Forgas (Ed.),
Emotion and social

judgements
. 55–71. London: Pergamon.

Schwartz, J., Gullifor, E. Z., Stier, J., & Thienemann, M. (2005a).
Mindful aware-

ness and self directed neuroplasticity: Integrating psychospiritual and biolog-

ical approach to mental health with focus on obsessive compulsive disorder
:

Haworth Press.

Schwartz, J. M., Stoessel, P. W., Baxter, L. R., Martin, K. M., & Phelps, M. E. (1996).

Systematic changes in cerebral glucose metabolic rate after successful behavior

modification treatment of obsessive-compulsive disorder.
Archives of General Psy-

chiatry, 53
, 109–113.

Segal, Z. V., Williams, J. M., & Teasdale, J. D. (2002).
Mindfulness-based cognitive

therapy for depression: A new approach to preventing relapse
. New York: The

Guilford Press.

Simon, G., Ormel, J., VonKorff, M., & Barlow, W. (1995). Healt care costs associated

with depressive and anxiety disorders in primary care.
American Journal of Psy-

chiatry, 152
, 352–357.

Singh, N. N., Wahler R. G., & Winton, A. S. W. (2004). A mindfulness-based treatment

of obsessive-compulsive disorder.
Clinical Case Studies, 3
(4), 275–287.

Snelling, J. (1991).
The Buddhist
handbook. Rochester, VI: Inner Traditions.

Steketee, G., & Shapiro, L. J. (1995). Predicting behavioural treatment outcome for

agoraphobia and obsessive compulsive disorder.
Clinical Psychology Review, 15
,

317–346.

Teasdale, J. D. (1999). Metacognition, mindfulness and the modification of mood dis-

orders.
Clinical Psychology and Psychotherapy, 6
, 146–155.

Teasdale, J. D., Segal, Z. V., Williams, J. M. G., & Mark, G. (1995). How does cognitive

therapy prevent depressive relapse and why should attentional control (mindful-

ness) training help?
Behavior Research and Therapy, 33
, 25–39.

Teasdale, J. D., Segal, Z. V., & Williams, J. M. (2003). Mindfulness training and problem

formulation.
Clinical Psychology: Science and Practice, 10
, 157–160.

Trobe, T., & Trobe, G. D. (2005).
From fantasy trust to real trust
. Amsterdam: Osho

Publikaties.

Weissman, M. M., Bland, R. C., Canino, G. J., Greenwald, S., Hwu, H. G., Lee, C. K.,

et al. (1994). The cross-national epidemiology of obsessive-compulsive disorder.

Journal of Clinical Psychiatry, 55
, 5–10.

Wells, A., & Papageorgiu, C. (1998). Relationships between worry, obsessive-

compulsive symptoms and meta-cognitive beliefs.
Behaviour Research and Ther-

apy, 36
, 899–913.

Chapter 11 Mindfulness and Obsessive-Compulsive Disorder

219

Wilhelm, S., & Steketee G. (2007). Recent Advances in the Assessment and Cognitive

Treatment of Obsessive Compulsive Disorder. Workshop presented at the World

Congress of Behavioural and Cognitive Therapy. Barcelona, July, 2007.

Williams, J. M. G., Mathews, A., & MacLeod, C. (1996). The emotional Stroop task and

psychopathology.
Psychological Bulletin, 120
(1), 3–24.

World Health Organization (1996).
The Global burden of disease
. Geneva: WHO

Zylowska, L., Ackerman, D. L., Yang, M. H., Futrell, J. L., Horton, N. L., Hale, T. S.,

C. Pataki, and S.L. Smalley (2008). Mindfulness Meditation Training in Adults and

Adolescents With ADHD:A Feasibility Study.
Journal of Attention Disorders, 11

(6), 737–746

12

Mindfulness-Based Cognitive

Therapy for Depression

and Suicidality

Thorsten Barnhofer and Catherine Crane

I find hope in the darkest of days, and focus in the brightest. I do not

judge the universe.

XIV Dalai Lama

Introduction

Major depression is one of the most prevalent and most disabling emotional

disorders. Its impact is pervasive, affecting social, individual, and biologi-

cal functioning. For individuals with depression, negative thinking pervades

views of the personal past, the current self and the personal future while

lack of interest and anhedonia reduce engagement in activities that used

to be experienced as enjoyable. These psychological symptoms are accom-

panied by dysregulations in a number of physical systems, with symptoms

such as fatigue and difficulties concentrating undermining the ability to deal

actively with the challenges of everyday life. Individuals experience the state

of depression as painfully discrepant from their usual or desired level of func-

tioning and depressed mood is often perpetuated by the responses it evokes:

attempts at coping that often remain passive and a tendency to engage in

either avoidance or repetitive and analytical, ruminative thinking, which fur-

ther increase the likelihood of deteriorations in mood. In a significant num-

ber of cases the hopelessness associated with this condition escalates into

suicidal ideation and behavior.

The prevalence of depression in Western countries is extremely high. Cur-

rent estimates of 1 year prevalence for major depression in Europe are around

5%
(Paykel, Brugha, & Fryers, 2005),
similar to recent estimates from North America, where the 2001–2002 replication of the National Comorbidity Survey showed a 1-year prevalence of 6.6%
(Kessler et al., 2003).
These rates are projected to increase even further as demographic studies have shown consistent increases in rates over the past decades (Compton, Conway, Stinson,

& Grant,
2006),
with major depression predicted to become the second leading cause of disability worldwide by the year 2020
(Murray & Lopez, 1996).

In about 25% of depressed individuals in the community (Goldney, Wilson,

Del Grande, Fisher & McFarlane,
2000)
and 50% of depressed inpatients
221

222

Thorsten Barnhofer and Catherine Crane

(Mann, Waternaux, Haas, & Malone, 1999)
depression is accompanied by
suicidal ideation
or behavior.

What makes these high rates of prevalence particularly concerning is that

for most of those affected, an episode of depression is not a singular event.

Individuals who have suffered from one episode of depression are very likely

to suffer from further episodes. For example the collaborative depression

study (CDS;
Katz & Klerman, 1979)
identified rates of recurrence of 25–40%

after 2 years, increasing to 60% after 5 years
(Lavori et al., 1994),
to 75%

after 10 years, and to 87% after 15 years
(Keller & Boland, 1998),
suggesting that risk for relapse remained even after prolonged periods of recovery. For

individuals who become suicidal when depressed the picture is equally con-

cerning. Perhaps the best predictor of death by suicide is a history of prior

suicidal behavior and where suicidality has been a feature of one episode of

depression it is very likely to recur as depression recurs (Williams, Duggan,

Crane, & Fennell,
2006).
Treating depression in general and suicidal depression in particular therefore requires a focus not only on alleviating current

symptoms but also on reducing risk of relapse in those who have experi-

enced depression in the past.

Mindfulness-based cognitive therapy (MBCT), developed by Zindel Segal,

Mark Williams, and John Teasdale
(2002),
was specifically designed to target vulnerability processes that cognitive research has identified as playing

a causative role in depressive relapse. The eight-week program combines

training in mindfulness meditation, following the approach developed by

Jon Kabat-Zinn (1990),
with interventions from cognitive-behavior therapy (CBT) that have been used successfully in the treatment of acute depression. In common with other “third-wave” cognitive-behavioral therapies the

emphasis of treatment is on acceptance as well as change, its general aim

being to help participants become more aware of and respond differently

to negative thoughts and emotions that might trigger downward cycles of

thinking and mood. More recently research has begun to adapt MBCT for use

specifically with patients who experience serious suicidal ideation or suici-

dal behavior when depressed. The aim of this overview is to describe the

rationale for MBCT and explore how treatment is delivered. We then briefly

review current research on the effectiveness of MBCT and present a case

example to illustrate the treatment approach. Finally we describe why MBCT

may be particularly suitable for patients with a history of suicidal depres-

sion and outline some initial adaptations to the programme for this high-

risk group.

Theoretical Rationale

As discussed, risk of relapse to depression increases dramatically with num-

bers of previous episodes (e.g.,
Solomon et al., 2000).
It is now generally assumed that risk for relapse after a first episode of depression is approximately 50%, rising to about 70% with a second, and about 90% with a third

lifetime episode (DSM-IV TR). This has important implications both for the

understanding of the factors which determine vulnerability to depression

and the development of effective treatments, because models of depression

must take into account the increase in risk of recurrence across episodes