Mindfulness Based Cognitive Therapy and the prevention of relapse in depression
Professor Mark Williams
Mindfulness-based Cognitive Therapy has been developed with the aim of reducing relapse and recurrence for those who are vulnerable to episodes of depression.
It is needed because the risk of relapse and recurrence in those who have been depressed is very high, and the amount of triggering required for each subsequent episode becomes lower each time depression recurs. Research by Zindel Segal (Toronto), Mark Williams (Oxford) and John Teasdale (Cambridge) has been investigating how meditation may help people stay well after recovery from depression.
Their work is based on the observation that, once a person has recovered from an episode of depression, a relatively small amount of negative mood can trigger a large amount of negative thoughts (eg. ‘I am a failure’, ‘I am weak’, ‘I am worthless’) together with bodily sensations of weakness or fatigue or unexplained pain. Both the negative thoughts and the fatigue often seem out of proportion to the situation. Patients who believed they had recovered may find themselves feeling ‘back to square one’. They end up inside a rumination loop that constantly asks ‘what has gone wrong?’, ‘why is this happening to me?’, ‘where will it all end?’. Such rumination feels to the person as if it ought to help find an answer, but it only succeeds in prolonging and deepening the mood disturbance.
Why do people remain vulnerable to relapse?
During an episode of depression, negative mood occurs alongside negative thinking and bodily sensations of sluggishness and fatigue. When the episode is past, and the mood has returned to normal, the negative thinking and body sensations tend to disappear as well. However, during the episode an association has been learned between the various symptoms. This means that when negative mood happens again (for any reason) it will tend to trigger all the other symptoms in proportion to the strength of association (this is called ‘differential activation’). When this happens, the old habits of negative thinking will start up again, negative thinking gets into the same rut, and a full-blown episode of depression may be the result.
The discovery that, even when people feel well, the link between negative moods and negative thoughts remains ready to be re-activated, is of enormous importance. It means that sustaining recovery from depression depends on learning how to keep mild states of depression from spiralling out of control.
Mindfulness-based cognitive therapy (MBCT)
Based on Jon Kabat Zinn’s Stress Reduction program at the University of Massachusetts Medical Center, Mindfulness-based Cognitive Therapy includes simple breathing meditations and yoga stretches to help participants become more aware of the present moment, including getting in touch with moment-to-moment changes in the mind and the body. In eight weekly classes (the atmosphere is that of a class, rather then a therapy group), and by listening to tapes at home during the week, class participants learn the practice of mindfulness meditation. MBCT also includes basic education about depression, and several exercises from cognitive therapy that show the links between thinking and feeling and how best participants can look after themselves when depression threatens to overwhelm them. These more structured exercises make MBCT different from mindfulness meditation as it is normally taught at retreat centres, but the approach is embedded within, and seeks to remain true to the insight meditation tradition that has been taught for two and a half thousand years.
Mindfulness-based cognitive therapy helps participants in the classes to see more clearly the patterns of the mind; and to learn how recognise when their mood is beginning to go down. It helps break the link between negative mood and the negative thinking that it would normally have triggered. Participants develop the capacity to allow distressing mood, thoughts and sensations to come and go, without having to battle with them. They find that they can stay in touch with the present moment, without having to ruminate about the past, or worry about the future.
Evaluation of MBCT
In a multi-centre RCT conducted in Toronto, Cambridge and Bangor, 145 participants were allocated to receive either treatment-a-usual (TAU), or, in addition to TAU, to receive eight classes of MBCT. All the participants in the study had been symptom free for at least 3 months, and off antidepressant medication, when they entered the trial. They were known to be vulnerable to future depression because they had had at least two episodes in their past that met criteria for DSM Major Depression (the final episode having occurred within 2 years). The sample was stratified on entry by the number of previous episodes (2 only, or more than 2). The researchers followed them up for twelve months after the eight weeks classes.
The results showed that MBCT helped most those who had suffered the most number of previous episodes. It had no effect on those who had only 2 episodes in the past (the minimum criteria for entry to the trial – about a quarter of the trial sample). By contrast, it substantially reduced the risk of relapse in those who had three or more previous episodes of depression (from 66 per cent to 37 per cent). Participants reported being able to develop a different (‘decentred’) relationship to their experience, so that their depression-inducing thoughts could be viewed from a wider perspective as they were occurring. (For a report of this trial see: Teasdale, J.D., Segal, Z.V., Williams, J.M.G., Ridgeway, V., Lau, M., & Soulsby, J. (2000) Reducing risk of recurrence of major depression using Mindfulness-based Cognitive Therapy. Journal of Consulting and Clinical Psychology, 68, 615-23. For other data from the trial, see Williams, J.M.G., Teasdale, J.D., Segal, Z.V. & Soulsby, J. (2000) Mindfulness-Based Cognitive Therapy reduces overgeneral autobiographical memory in formerly depressed patients. Journal of Abnormal Psychology 109, 150-155.)
These findings have now been replicated in a study by Helen Ma and John Teasdale in Cambridge. It found the same pattern of results, with MBCT reducing the rate of relapse from 78% in those with three episodes or more, to 36%. The treatment was, once again, found not to affect those who had experienced only 2 episodes, and for a discussion of this, see both the book (Segal et al., 2002, below) and the report of the trial (Teasdale et al., 2000).
In Oxford, Mark Williams, Melanie Fennell and their colleagues will be piloting the use of MBCT with people who have had a suicidal crisis, and now recovered, with the aim of reducing the risk of further self-harm. It is too early to say how many patients will find this approach useful.
If someone is depressed, we still recommend that they receive cognitive therapy from a trained therapist. MBCT was designed to be used to prevent relapse and recurrence of depression in those who are in recovery. If you want to learn more about the use of the mindfulness approach for people who remain vulnerable to depression, the approach is described in Zindel Segal, Mark Williams and John Teasdale’s book (Segal, Z.V., Williams, J.M.G., & Teasdale, J.D. (2002) Mindfulness-based Cognitive Therapy for Depression: a new approach to preventing relapse. Guilford Publications, New York.) Written in a practical and accessible manner, it tells the story of how the authors came to develop MBCT using clinical transcripts that bring to life the challenges and promise of the approach.
Segal et al, 2002 (chapter 15), also gives a number of recommendations for those who wish to learn more about mindfulness meditation in healthcare, and some of these are summarised here.
Jon-Kabat-Zinn's own book, Full Catastrophe Living (1990; New York: Delacorte) describes the UMass Mindfulness-based Stress Reduction program in a very engaging way. It is an excellent introduction to clinical applications of mindfulness training (e.g. chronic pain, anxiety, stress-related physical illness) and is essential reading for anyone wishing to explore this approach further. This book is an important resource that is used in the MBCT program.
Jon Kabat-Zinn has also written Wherever you go, there you are: mindfulness meditation in everyday life. (1994; New York: Hyperion, published in the UK as "Mindfulness Meditation for Everyday Life"). This is a book that conveys the spirit of bringing mindfulness to everyday experience, together with suggestions for practice.
Another excellent source for a more detailed description of insight meditation, the tradition from which clinical applications of mindfulness are most directly derived, is "Seeking the Heart of Wisdom : The Path of Insight Meditation" by Joseph Goldstein and Jack Kornfield (1987; Boston: Shambala).
And if you decide you would actually like directly to sample the practice of mindfulness?
There are many different forms of meditation. It is therefore important to choose a tradition and teacher that are compatible in spirit and form with the MBCT program. In practice, this is likely to mean exploring the teachings offered by centres related to the westernised insight meditation tradition. Information about these centres can be obtained from Gaia House, West Ogwell, Newton Abbot, Devon, TQ12 6EN, UK. Information on where there are other such centres worldwide is available, directly or via links, from www.dharma.org
Training in Mindfulness-based approaches in healthcare, including an introduction to MBCT, is offered at the University of Wales, Bangor. See www.bangor.ac.uk/mindfulness for details.
Finally, the material that is actually used in the MBCT program can be used to provide both an excellent introduction to meditation practice, as well as direct sampling of the exercises that were used for the patients in the research program described earlier. The tapes come in two series, both recorded by Jon Kabat-Zinn. Series One consists of two 45 minute tapes (also used on the University of Massachusetts Mindfulness-based Stress Reduction program) that narrate a guided body scan, a guided meditation on the breath, body, sounds, thoughts, and choice-less awareness, together with two different sessions of guided mindful hatha yoga. Series Two consists of five tapes (each from 10 to 30 minutes long) specifically designed for those with a more general (rather than clinical) interest in learning mindfulness meditation. Both series can be ordered from: Stress Reduction Tapes, P.O. Box 547, Lexington, MA 02173, USA; or from the website: www.stressreductiontapes.com. A video of some of Jon Kabat-Zinn’s work has been made, Mindfulness
and Meditation: Stress Reduction, and the price is $19.98 from amazon.com.