Clinical Handbook of Mindfulness (62 page)

Chapter 12 Mindfulness-Based Cognitive Therapy for Depression and Suicidality

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either by assuming changes in factors meditating risk, or at least changes in

their relative contribution to determining risk. One example of this is the

observation that the relationship between negative life events and onsets of

depression is much stronger for first as compared to later episodes (for an

overview see
Monroe & Harkness, 2005).
This research suggests that across episodes, depression is more likely to be triggered either autonomously or

by increasingly minor or idiosyncratic stressors. Why might this occur and

what might its treatment implications be?

From a cognitive science perspective these findings have been explained

within the framework of differential activation (Segal, Williams, Teasdale,

Gemar,
1996).
The theory of differential activation suggests that across depressive episodes associations are formed between low mood and other

emotions (e.g., anger, hopelessness), cognitions (e.g., dysfunctional atti-

tudes), and behaviors (e.g., passivity, risk taking), which occur in depressed

states. Although these patterns of response are likely to differ from individ-

ual to individual, forming the individual’s unique “relapse signature,” it is sug-

gested that they will nevertheless be relatively stable for the same individual

over time. Indeed across episodes of depression the associations between

these different aspects of the depressed “mode” are thought to be strength-

ened (due to co-activation), such that they become increasingly coher-

ent, with a reduced threshold for activation. Thus depressive episodes are

more and more easily triggered, increasing the likelihood of recurrence and

reducing the association between major negative life events and depressive

onsets.

Another factor that has been found to be of particular importance with

regard to vulnerability to depression is rumination. Research over the last

decades has shown that those who are at risk for depression tend to respond

to symptoms, negative cognitions and unpleasant body states by engaging

in repetitive, abstract-analytical thinking
(Nolen-Hoeksema, 2004).
While initially instigated as a means to solve problems and reduce self-discrepancies,

this ruminative thinking, in particular aspects characterized by brooding,

has a range of negative effects (e.g.,
Treynor, Gonzalez, & Nolen-Hoeksema,

2003).
Rumination causes further deterioration in mood, increases biases in negative thinking and undermines cognitive functions crucial for effective

coping including the ability to retrieve specific memories of autobiographi-

cal events
(Raes et al., 2006)
and the ability to solve interpersonal problems

(Watkins & Moulds, 2005).
Paradoxically, previously and currently depressed individuals report predominately positive beliefs about its usefulness as a

coping strategy
(Papageorgiou & Wells, 2004),
which are likely to contribute to the fact that ruminative thinking often persists despite its deleterious consequences.

As current mood worsens, individuals may oscillate in their attempts at

coping between ruminative monitoring and avoidance of negative thoughts

and body states. As with rumination, the effects of avoidance are predomi-

nately negative. Attempts to suppress negative thoughts, for example, have

been shown to paradoxically increase the frequency of intrusions rather than

reduce them
(Wenzlaff & Wegner, 2000).
Furthermore, avoidance precludes both engagement in more active forms of problem solving and habituation

to distressing mental content. Teasdale, Segal, and Williams have argued that

it is these and other processes that lead to a situation in which the very

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Thorsten Barnhofer and Catherine Crane

responses depression evokes serve to perpetuate the condition, a mecha-

nism which they refer to as “depressive interlock.”

Mindfulness-Based Cognitive Therapy: Overview

MBCT was developed specifically to target the above vulnerability processes.

It teaches as its core skill the ability “to recognize and to disengage from mind

states characterized by self-perpetuating patterns of ruminative, negative

thought”
(Segal et al., 2002,
p. 75) and to adopt a stance toward experience, which is characterized by openness, curiosity and acceptance, rather than

experiential avoidance. Like cognitive therapy, MBCT aims to give patients

the ability to see thoughts as mental events rather than facts, to decouple the

occurrence of negative thoughts from the responses they would usually elicit

and, eventually, to change their meaning. However, while cognitive therapy

maintains a strong focus on the content of thoughts and the re-evaluation of

their meaning, the main aim in MBCT is to teach patients to take a differ-

ent perspective on thinking and awareness itself. By consistently practicing

bringing awareness to present moment experience, participants shift into a

mode of functioning that is incompatible with the self-focused and analyti-

cal cognitive processes that perpetuate depressive states.
Segal et al. (2002)

describe this as change from a “doing” mode, in which the main focus is on

the reduction of discrepancies between the current state and ideas of how

things should be or ought to be through problem-solving behavior, to a mode

of “being,” in which the individual is in immediate and intimate contact with

present moment experience, whatever that experience might be.

Mindfulness has been described as “paying attention in a particular way: on

purpose, in the present moment and non-judgmentally”
(Kabat-Zinn, 1994,

p. 4). As such mindfulness is both a means of becoming aware of and switch-

ing from “doing” to “being” mode as well as a central characteristic of the

“being” mode itself. In the MBCT program, participants train mindfulness

through regular formal meditation practice and through exercises designed

to generalize the effects of meditation to everyday life. In the early stages of

the program participants are taught to become aware of and recognize the

doing mode in its different manifestations and to cultivate the being mode

as an alternative state. The increased awareness this facilitates is an essential

foundation for the prevention of depressive relapse since without it individ-

uals are poorly equipped to spot the relatively subtle changes in mood and

body state that signal the activation of depressive modes of mind. In the

later stages of the programme, as this foundation strengthens, the focus of

the training moves toward recognizing the occurrence of negative emotions,

negative cognitions (for example self-criticism and judgment) and triggers

of negative moods in daily life. Practice during this stage cultivates the abili-

ties to disengage from responses such as rumination which characterize the

doing mode, and to be with difficult and aversive thoughts and emotions

in more skillful ways, adopting an attitude of acceptance rather than avoid-

ance. The final sessions emphasize the integration of learned skills to prevent

future relapse.

MBCT is first and foremost a training of skills. A regular formal medita-

tion practice between sessions and the practice of mindfulness in everyday

Chapter 12 Mindfulness-Based Cognitive Therapy for Depression and Suicidality

225

life are essential components of the program. During the eight weekly ses-

sions the focus is, as much as possible, experiential rather than didactic,

apart from some psychoeducational elements in which participants learn

about the symptoms of depression and vulnerability mechanisms leading

to relapse. Most of the time in sessions is spent in the practice of medita-

tion and subsequent enquiry, primarily reflections on current practice, but

also on difficulties that participants may have encountered with their med-

itation practice during the week. The role of the instructor, in general, is

that of a facilitator and a model, inviting participants to open to and reflect

on their experiences. Through this dialogue and reflection MBCT encour-

ages both the development of greater metacognitive
awareness
, for exam-

ple an increased ability to observe the occurrence of mental events such

as thoughts, emotional responses, bodily sensations “online”; and the aris-

ing of metacognitive
insight
, into the nature of the mind, the relationship

between thoughts, emotions and bodily states, and the experience of suf-

fering. The attitude the instructor brings to this enquiry is one of curiosity,

and particularly one in which difficult thoughts and feelings are observed

and accepted without having to resort to problem solving and “fixing.” The

instructor incorporates in the class process the same principles of openness

and compassion that participants are taught to bring to their own meditation

practice. In this way, enquiry serves as a continuation of the meditation prac-

tices. It is both because of the need to guide meditations from within, that is,

from own meditation experience, and because instructors need to be able to

bring their own ability to relate differently to negative affect into the class,

that a developed regular mindfulness meditation practice is a prerequisite for

teaching MBCT classes.

The Programme

MBCT consists of eight weekly sessions of 2 hours length, each of which fol-

lows its own theme and curriculum. Prior to the first class participants meet

individually with the class instructor to give time for the instructor to ori-

ent them toward the treatment approach, develop an understanding of the

participant’s presenting problems, establish realistic expectations for treat-

ment, and answer any questions the participant might have. Class sizes vary

according to facilities but are often of around 12 participants. Sessions 1–4

emphasize learning to pay attention. Participants become aware of how their

minds often take them away from present moment awareness and increase

concentration and awareness of thoughts, feelings and bodily sensations as a

means to being in the moment. Sessions 5–8 shift emphasis toward dealing

with difficult thoughts and feelings. Participants learn to decenter as a means

of becoming aware of their thoughts, feelings, and body sensations, to bring

acceptance and kindly awareness to their sensations and to let go of thoughts,

reducing the tendency to get entangled in ruminative thinking, ultimately

leading to a general shift toward functioning in present moment awareness.

Across the eight sessions different guided meditation practices, including an

eating meditation, “body scan,” yoga stretches, walking meditation, and sit-

ting meditations are introduced to participants. Toward the end of the treat-

ment participants are encouraged to develop a home practice which fits their

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Thorsten Barnhofer and Catherine Crane

needs and which can be maintained in the longer term. Table
12.1
outlines the meditation practices and CBT components introduced in each session,

the skills developed and insights supported by these components and the

activities suggested to participants as homework.

The Eight Sessions: A Case Example

We outline the progression of the eight classes of the program with a case

example: Fiona, a 37-year-old single woman with one daughter, worked as a

retail assistant. She referred herself to MBCT having read information about

an ongoing programme of mindfulness research in the local newspaper. She

had experienced several prior episodes of major depression accompanied by

suicidal ideation and was still experiencing periodic episodes of anxiety, low

mood and more fleeting suicidal thoughts. She described a typical “down-

ward spiral” of depression. This would usually be triggered by a perceived

rejection, either by someone at work or a social acquaintance and would lead

to feelings of abandonment, agitation, depression and worthlessness, as well

as physical reactions such as tightness in the chest and crying. Fiona reported

that she would tend to withdraw from social situations as these feelings

developed, reinforcing her sense of isolation, instead spending time on her

own ruminating about her current situation and past rejections. As depres-

sion and worthlessness escalated she would experience thoughts of suicide,

feeling that no one would care if she died. These sometimes progressed to

specific plans for suicide, but she had never acted on these thoughts.

At her pre-class interview the instructor asked Fiona questions about her

previous experiences of depression and factors that might be involved in

relapse and maintenance. Fiona learned more about the general background

of MBCT and how, more specifically, mindfulness meditation could help with

her recurrent problems. Potential benefits discussed included the possibility

of becoming more aware of the sequence of events and experiences which

typically led to suicidal ideation and to respond differently; for example notic-