You may have heard of the Eastern-influenced practice of mindfulness, with roots in Buddhist traditions extending back over 2500 years (Sipe & Eisendrath, 2012). You undoubtedly know about – and are probably at least somewhat familiar with – the (Western) psychotherapeutic approach of CBT, or cognitive behavioural therapy, as proposed by Aaron Beck (2011). MBCT is an adaptation of MBSR (mindfulness-based stress reduction) developed at the University of Massachusetts Medical Center by Jon Kabat-Zinn and his colleagues (Kabat-Zinn, 1990) which brings mindfulness and CBT together. In this article we provide a definition of MBCT, along with an overview of its historical background and development.

Definitions

Mindfulness-based cognitive therapy (MBCT) is a psychological therapy designed to help prevent the relapse of depression, especially for those individuals who have Major Depressive Disorder (the principal type of depressive disorder defined by the DSM-5). It employs traditional CBT methods and adds in mindfulness and mindfulness meditation strategies.

Cognitive behaviour therapy (CBT) is a form of psychotherapy originally developed to treat depression, but which is now used for a number of mental illnesses. It works to solve current problems and change unhelpful thinking and behaviour (Beck, 2011).

Mindfulness has been defined, particularly for participants of MBCT, as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to things as they are” (Williams, Teasdale, Segal, et al, 2007).

Mindfulness-based stress reduction is a mindfulness-based program designed to assist people with pain and a range of conditions and life issues that were initially difficult to treat in a hospital setting. It uses a combination of mindfulness meditation, body awareness, and yoga to help people become more mindful and has been shown in clinically-controlled trials to have beneficial effects such as stress reduction, relaxation, and improvement to quality of life. Although it has roots in spiritual teaching, the program is secular (Greeson, Webber, Smoski, Brantley, Ekblad, Suarez, & Wolever, 2011).

Background and development of MBCT

Major depressive disorder (MDD) is one of the most prevalent psychiatric disorders, characterised by high relapse rates. In addition to the grim statistic that 80 percent of those who have an initial depressive episode will relapse, psychologists have also observed that each successive episode increases the risk of recurrence by 16 to 18 percent (Solomon et al, 2000; Kingston et al, 2007; Mueller et al, 1999). Given the high psychological as well as social and economic burden associated with MDD, relapse prevention must have high priority. The most commonly used strategy to prevent relapse is maintenance treatment with antidepressant medication, but even though it has an established effectiveness, its disadvantages have clinicians and clients alike searching for a different solution. For one thing, many clients are unwilling to take it for the recommended two years following r emission of depression. Even for those who sign up to do that, adherence is low. Many clients experience disturbing side effects and some people prefer a psychological solution to a pharmacological one (Cairns & Murray, 2015).

Cognitive behavioural therapy has for some time been considered the “gold standard” among therapists for treating depression, and over the past three or four decades has enjoyed a position on centre stage as research studies to demonstrate its efficacy have proliferated. More than for any other therapeutic approach, an extensive literature base has documented how well CBT works, especially for depression (e.g., Butler, Chapman, Forman & Beck, 2006; DeRubeis, Gelfand, Tang, & Simons, 1999; Dobson, 1989; Gloaguen, Cottraux, Cucherat, & Blackburn, 1998; Hollon, Shelton, & Davis, 1993; Jakobsen, Hansen, Simonsen, Simonsen, & Gluud, 2012; U.S. Department of Health and Human Services (USDHHS), 1993; Wilson, Mottram, & Vassilas, 2008).

The frustrating reality about even approaches deemed to be effective, however, is that not all clients respond well to a given treatment. Meta-analyses have shown that generally only about half the patients treated with cognitive therapy demonstrate improvement clinically significant enough to meet strict U.S. Department of Health and Human Services standards (USDHHS, 1993). Moreover, even though clients receiving cognitive therapy have typically demonstrated lower relapse rates than those who receive medication (29.5 percent versus 60 percent, respectively), over one- to two-year follow-ups, some patients have still relapsed after cognitive therapy (Gloaguen et al, 1998).

Thus a crucial question has taunted clinicians and researchers alike, eventually motivating the development of MBCT. That question is this: if cognitive therapy is effective sometimes for some clients, how can we make this good thing even better, improving response rates and decreasing relapse rates?

Eastern meditative practice added to cognitive approach inspires MBCT development

An attempt to meet the above challenge was published in Segal, Williams, and Teasdales’s (2002) work proposing the use of mindfulness in cognitive therapy for the express purpose of preventing depressive relapse. The authors did not merely pluck the notion of adding mindfulness to cognitive therapy out of thin air, however.

Mindfulness-based stress reduction (MBSR) appears first

Eleven years prior to Segal and associates’ publication, the U.S.-based MacArthur Foundation asked Dr Segal to develop a maintenance version of cognitive therapy. Its goal would be to prevent relapse in patients who had already been treated for and recovered from depression. The journey to development would turn out to be a fairly lengthy one, with numerous twists and turns in the road. Early on Segal and his colleagues broke new ground by hypothesising that, when cognitive therapy worked against depression relapse, it did so not by modifying the content of a client’s cognitions as Beck (1976) had argued. Rather, it was now proposed that the relapse was avoided because individuals changed their relationship to their feelings: a process shift (Rohan, 2003).

Upon identifying negative thoughts, individuals could stand back and evaluate the thoughts, creating a shift in perspective in which thoughts could be viewed as passing events: possibly valid, but possibly not, and certainly separate from the individual thinking them. Such shifts are called “decentering” or “distancing” by Beck (1979) and “disidentifying” by Psychosynthesis practitioners (Assagioli, 1965). Using them suggested that mindfulness, particularly defined as we have above: “paying attention on purpose, in the present moment… to things as they are” (Williams, Teasdale, Segal, et al, 2007) would be a valid addition to cognitive therapy.

Beck’s cognitive model and response styles theory form foundation of new approach
Segal, Williams, and Teasdale based their maintenance therapy on a model of depression relapse which borrowed from both Beck’s work (1976) and also that of response styles theory (Nolen-Hoeksema, 1987). Individuals who had recovered from depression, said the model, would find that their sad moods reactivated a negative cognitive style, one associated with their previous dysphoric mood. This reactivation would occur, argued Segal and cohorts, because of a learned association between the two. Once re-activated, the negative cognitive style would run around well-worn “mental grooves” (much like those on old phonograph records), triggering a long-standing pattern of rumination, and reinforcing negative thoughts, feelings, and physical states. These vicious maintaining cycles were hypothesised to escalate a transient sad mood into full-blown depression if not checked (Rohan, 2003).

Clinical trial of DBT and reluctant contact with Kabat-Zinn

When the authors saw a clinical trial of dialectical behaviour therapy (DBT) for borderline personality disorder which included mindfulness meditation (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991), they became intrigued with the notion of mindfulness. It did not sit comfortably within their CBT-centric world view, however, so it was only with reluctance that they contacted Dr Jon Kabat-Zinn at the University of Massachusetts Medical School Centre for Mindfulness in Medicine, Health Care, and Society. Arranging a visit to the Stress Reduction Clinic there, they were able to observe chronic pain patients and others using mindfulness meditation to respond to stress over eight weekly group sessions of around 2.5 hours each.

The authors then developed their first course of maintenance cognitive therapy-attentional control training combining mindfulness with cognitive therapy techniques (Teasdale, Segal, & Williams, 1995, in Rohan, 2003). They believed that mindfulness could serve as an early-warning system for depressed mood, cut off rumination before it could escalate, and strengthen decentering from negative thoughts, whereby cognitive restructuring could be used. Unfortunately for the development of MBCT, however, the MacArthur Foundation reviewers did not approve the eight-week, group format attentional control training. It diluted the CBT program components, they said, in favour of mindfulness, which was as yet unproven (Rohan, 2003).

At this juncture, the authors revisited the Massachusetts Stress Reduction Clinic, this time observing sessions towards the middle of the program, which focused on difficult physical and emotional problems. The authors noted with curiosity that the problems were not fixed. Rather, the patients were bringing their problems to awareness and breathing into them. Instead of seeing them as “the enemy”, the mindfulness training helped the patients to disidentify, bringing a “kindly awareness” to the problems, which they viewed nonjudgmentally. This second set of observations inspired Segal, Williams, and Teasdale to change the structure of the attentional control training. Exiting “therapist mode” – helping clients to solve problems – the authors now moved toward “instructor mode”, a stance of empowering patients to be mind ful of their moment-to-moment experience. The treatment manual was re-drafted to embrace the eight-session group format used at the Stress Reduction Clinic and it retained some cognitive therapy elements. Mindfulness-based cognitive therapy was born (Rohan, 2003).

So, what is included in a course of MBCT?

Meditation and mindfulness. The original course of Segal et al (2002) consisted of eight consecutive weekly sessions of about two hours each. It contained both formal and informal meditation practices, including guided body scans, sitting and walking meditations, Hatha-yoga-based mindful movement, three-minute breathing spaces, and focused awareness on routine daily activities. There was a general progression from early attention to breathing or bodily sensations in guided meditations to later sessions which emphasised developing an independent practice and holding mindful awareness of mental events, such as emotions and thoughts which the client may have previously avoided.

Homework. From their inception, MBCT courses have featured homework as a central element. Clients are encouraged to spend 45 minutes daily practicing mindfulness activities; some of these would be led by guided meditation recordings.

Psychoeducation and cognitive therapy. The educational portion of the original MBCT courses included aspects of cognitive therapy. There was also psychoeducation, during which clients learned that feelings of distress might intensify and actually perpetuate their depressed mood rather than help resolve it if they attempted to resist or avoid unwanted thoughts. Clients were supported to include mindful activities toward well-being, such as taking a bath, going for a walk, or listening to nice music. Action plans typically completed the suite of assignments; these would identify early warning thoughts or feelings that signalled worsening symptoms, along with steps they had agreed to take in the face of imminent relapse (Sipe & Eisendrath, 2012).

This article was adapted from the upcoming Mental Health Academy’s CPD course “Mindfulness-Based Cognitive Therapy: An Overview”.

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