CASE CONTINUED: Explaining the potential benefits
You inform Mr. A that MBCT has been shown to improve acute mild-to-moderate depressive symptoms, may decrease his risk of depressive relapse by 50%26 and could help him discontinue his medications.12 He asks how mindfulness exercises will help his symptoms.
How mindfulness works
The assumption that increased mindfulness mediates treatment outcomes4 has been addressed systematically only recently, following the development of operational definitions of mindfulness and self-report mindfulness measures, including the:
- Mindful Attention Awareness Scale (MAAS)27
- Five Facet Mindfulness Questionnaire (FFMQ)12
- Toronto Mindfulness Scale (TMS).28
Uncontrolled studies using these measures demonstrated that self-reported mindfulness increased following MBSR28,29 and MBCT15,18 in individuals with general stress, anxiety disorder or primary depression, cancer, chronic pain disorder, diabetes, and multiple sclerosis. Accumulating evidence from 1 RCT30 and 2 other uncontrolled studies28,31 demonstrates that mindfulness is associated with symptom reduction following MBSR.
Researchers have begun to focus on how mindfulness skills reduce symptoms. Baer9 proposed several mechanisms, including:
- cognitive change
- improved self-management
- exposure to painful experiences leading to reduced emotional reactivity.
Cognitive change—also called meta-cognitive awareness—is the development of a “distanced “or “decentered” perspective in which patients experience their thoughts and feelings as “mental events” rather than as true, accurate versions of reality. This is thought to introduce a “space” between perception and response that enables patients to have a reflective—rather than a reflexive or reactive—response to situations, which in turn reduces vulnerability to psychological processes that contribute to emotional suffering. Some preliminary evidence suggests that MBCT-associated increases in metacognitive awareness reduce risk of depressive relapse.32
Teaching mindfulness
Guidelines for psychiatrists who wish to become MBCT instructors suggest undergoing formal teacher development training, attending a 7- to 10-day meditation retreat, and establishing your own daily mindfulness practice ( Table 3 ).33 Segal et al2 also recommend recognized training in counseling, psychotherapy, or as a mental health professional, as well as training in cognitive therapy and having experience leading psychotherapy groups.
The recommendation that a mindfulness teacher should practice meditation derives from the view that instructors teach from their own meditation experience and embody the attitudes they invite participants to practice. In an RCT, patients of psychotherapists in training (PiTs) who practiced meditation had greater symptom reductions than those of PiTs who did not engage in meditation.34
To cultivate your own mindfulness practice, consider enrolling in an MBSR group, participating in an MBCT training retreat (see Related Resources ), or attending a mindfulness meditation retreat.
Although patient access to MBCT and MBSR programs has been increasing, formal MBSR/MBCT group programs led by trained therapists are limited. Patients can go through an MBSR/MBCT book with a trained clinician or listen to audio recordings with guided meditation instructions. Alternately, they can join a meditation sitting group or an insight meditation correspondence course ( Table 4 ).
Table 3
Recommended process for becoming an MBCT instructor
| Complete a 5-day residential MBCT training program |
| Attend a 7- to 10-day residential mindfulness meditation retreat |
| Establish your own daily mindfulness meditation practice |
| Undergo professional training in cognitive therapy |
| Gain experience leading psychotherapy groups |
| MBCT: mindfulness-based cognitive therapy |
| Source: References 2,33 |
Table 4
Useful mindfulness resources for interested patients
| Insight Meditation Society: www.dharma.org |
| Kabat-Zinn J. MBSR meditation CDs/tapes: www.stressreductiontapes.com |
| Recordings of meditation (dharma) talks: www.dharmaseed.org |
| Salzberg S, Goldstein J. Insight meditation: an in-depth correspondence course. Louisville, CO: Sounds True, Inc; 2004 |
| Williams M, Teasdale J, Segal Z, et al. The mindful way through depression: freeing yourself from chronic unhappiness. New York, NY: Guilford Press; 2007 |
CASE CONTINUED: Daily mindfulness practice
Mr. A enrolls in and completes a group MBCT program. He rearranges his schedule to include 30 minutes of formal mindfulness practice daily. During an office visit after completing the MBCT course, he describes decreased irritability and self-criticism, newfound self-acceptance, an increased ability to tolerate previously distressing affect, and the ability to set realistic expectations of himself, particularly in light of increased responsibilities at work. He also reports an increased sense of engagement in and reward in his personal life.
Several months later he requests and successfully completes an antidepressant taper and has no recurrence of depressive episodes at 18-month follow-up. He participates in monthly meditation groups to support his home practice.
- Germer CK, Siegel R, Fulton PR, eds. Mindfulness and psychotherapy. New York, NY: Guilford Press; 2005.
- Mindfulness-based cognitive therapy. www.mbct.com; www.mbct.co.uk; www.bangor.ac.uk/mindfulness.
- Center for Mindfulness in Medicine, Health Care, and Society. www.umassmed.edu/cfm.
- Neurobiology of mindfulness. www.mindfulness-matters.org.
- Siegel DJ. The mindful brain: reflection and attunement in the cultivation of well-being. New York, NY: Norton; 2007.
- University of California, San Diego Center for Mindfulness. http://cme.ucsd.edu/mindfulness.