Clinical Handbook of Mindfulness (69 page)

important. Additionally clinical experience suggests that some individuals

spend considerable amounts of time ruminating about suicidal plans and fan-

tasies, with suicidal ideation eliciting both distress and comfort and occur-

ring in the context of broader deficits in effective problem solving (Schotte,

Cools & Payvar,
1990).
Thus the ability to disengage from ruminative thinking, and as a result to see suicidal thoughts and fantasies, like other thoughts

and fantasies, simply as mental events, has the potential to be extremely ben-

eficial for suicidal patients. Finally suicide-related cognitions and behavioral

deficits appear to be subject to the same cognitive reactivity processes as

other features of depression (Williams, van der Does, Barnhofer, Crane &

Segal., in press;
Williams, Barnhofer, Crane & Beck, 2005).
As such, developing the ability to spot early warning signs of suicidal crisis and to remain

mindful and make wise choices about how to respond may be critical in

determining whether crises become suicidal crises, or whether individuals

experiencing suicidal ideation go on to engage in suicidal behavior.

240

Thorsten Barnhofer and Catherine Crane

Pilot work in Oxford suggests that MBCT is acceptable to formerly suicidal

patients, and a number of modifications have been incorporated into pilot

groups to tailor MBCT more closely to the needs of individuals with a his-

tory of suicidality. These include (1) a greater emphasis on orienting partic-

ipants’ attention outward, through formal meditation practices (e.g., seeing,

hearing meditations) and through encouragement to attend to and notice

small things in everyday life (e.g., the sight of a bird, the sound of traffic).

The aim of this is to enhance participants’ ability to ground themselves in

the present moment at times of intense negative affect, intrusive thoughts

or memories, (2) a greater emphasis on the use of active meditation prac-

tices (yoga, stretching, walking) for participants experiencing difficulty with

sitting meditation practices, for example due to agitation or overwhelming

intrusive cognitions, (3) reflection in class on the cognitions which accom-

pany suicidal states of mind and participants’ own relapse signatures for sui-

cidal crisis, to increase metacognitive awareness of these, (4) development

of a crisis plan to enable participants to take wise action in the event that

their mood deteriorates in the future, incorporating action to take in the

event of suicidal ideation, (5) limited individual contact outside of classes (by

telephone or face-to-face) between the instructor and any participants who

are experiencing particular difficulties, to discuss how these might be man-

aged through modification of the meditation practice or use of alternative

strategies.

In running groups for individuals who had experienced suicidal ideation

or behavior, there was an initial reticence about directly exploring suicidal

cognitions in class, for fear of “giving people ideas.” However the experience

has been that the effects of raising these issues directly in class are posi-

tive, helping to reinforce an attitude of openness to
all
experiences, and the

benefits of taking a metacognitive approach to even those thoughts which

are perceived to be most powerful, shameful, dangerous or compelling. The

pilot classes have been encouraging, suggesting that MBCT may hold bene-

fit for at least some individuals with a history of suicidal depression. Whilst

there is very little data in this area one recent pilot study from our group

has suggested that MBCT may exert protective effects on prefrontal alpha

asymmetry in resting EEG in formerly suicidal patients, a neurophysiologi-

cal indicator of emotional functioning
(Barnhofer et al., 2007).
Interestingly the study by
Kenny & Williams (2007)
which examined MBCT in currently depressed patients also found equivalent results for patients whose depression had suicidal features as for those whose did not.

Summary and Conclusions

Mindfulness-based cognitive therapy is a skills training programme which

teaches participants “to recognize and to disengage from mind states charac-

terized 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. Meditation practice, exercises from cognitive therapy and guided

enquiry facilitate this process. Further research is needed to explore the

mechanisms of action of MBCT and to examine its efficacy when compared

Chapter 12 Mindfulness-Based Cognitive Therapy for Depression and Suicidality

241

to plausible alternative psychotherapeutic interventions, but initial findings

suggest that it is a promising treatment for individuals with recurrent depres-

sion and may also be applicable to those whose depression has suicidal fea-

tures and those with ongoing symptoms.

Acknowledgements:
This work was supported by a grant from the Wellcome

Trust, GR067797.

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