Mindfulness Based Cognitive Therapy (MBCT) is a treatment program for prevention of relapses in depression and the treatment of anxiety disorders.
Is MBCT an acceptable intervention to patients with depression and anxiety?
The course exercises
There was a wide range of views on the course exercises, in particular the body-scan and walking meditation. While some participants found the body-scan a pleasurable, relaxing experience others found it a difficult practice.
“I liked the body-scan. That was the one bit that I really liked. I’ve got an awful lot of pain with the arthritis and when he was going through the body-scan and all that saying breathe into the pain, it was actually taking the pain away.”-P3
“What I did find about the body scan when we were doing it whether at home or in here I became very aware of small itches and things like that irritated by them and really that was part of what I found quite hard to do. If it was my foot throbbing or itchy or just if I start to feel I’ve got to get out you know I’ve got to get up”-P7
One woman with a history of childhood sexual abuse found the body-scan made her aware of “horrible feelings through my body that I had never felt before“. She found this exercise and the longer meditation exercises too difficult to practice at home.
Despite this, she found the 3-minute breathing space a useful exercise and continued to use it regularly, three months after the course had finished.
In contrast, one of the other participants with a history of childhood sexual abuse had no such problems with the body-scan and continued to practice the longer meditation practices several times a week three months after the course finished.
One man had a traumatic flashback of an accident he had witnessed while doing the body-scan for the first time. This flashback, the first for a number of months, provoked considerable anxiety and claustrophobia.
Another participant with severe generalised anxiety disorder found the body-scan an effective way of reducing her anxiety and found it more effective than her previous experiences using a progressive muscle relaxation technique.
“I couldn’t believe the way I was feeling after doing the body-scan…when you are doing (progressive muscle) relaxation you are sort of concentrating just on muscles or different parts of your body but it’s outside your body but I felt the meditation was going inside the body…as if I’ve got into the root, is probably the best way to describe it. And I can get right to the nucleus of it and I can feel it”-P9.
There was a wide variation in the amount and type of homework done, with some participants only practicing the occasional breathing space and other spending 30 minutes a day practicing meditation.
One woman felt that making the time to practice the longer meditation was ‘too much of a luxury’ when she had 6 children at home an instead practiced mindfulness of washing the dishes and mindful walking.
“you are doing the dishes…actually take the time, look at the shape, the shape of the dishes and the water temperature. Calm down and actually take notice of what you are doing and relaxing instead of automatically jumping, as I do, onto the next couple of things maybe for the whole day, you know”.-P2.
Some participants described struggling with the meditation exercises;
“I have great difficulty in keeping on the line of the meditation, getting used to it, I had great difficulty but I still persevered and I still have great difficulty with it”-P1
“The one where you meditate sitting, I can’t do it for 25â€“30 minutes because I’ve got a bad spine and I found it, I get agitated I cant sit for that length of time”-P8
Others adopted a more flexible attitude towards practice;
“Sometimes I would start doing it (the body-scan) and maybe I didn’t feel myself relax. I fought against it at the start. I thought this isn’t working but what I started doing was if I didn’t feel that I could relax right away I would put it off and then later on go back and do it”.-P5
The same participant later she describes letting go of trying to force the relaxation
“I let go of those feelings and it just all started to come naturally.“-P5
Another woman described a similar process whereby her ability to sit with her anxiety depended on her own meditation skill and the degree of anxiety;
“I find it (sitting meditation) very, very good but I must say that when I am very, very anxious and uptight about something I find it very hard, very, very hard to sit with my anxiety…. that’s a definitely a skill”.-P11
In general, those in the group that were able to let go of expectations of results and focused simply on the meditation methods, were more likely to persist with the exercises and feel benefit from the course.
Benefits and on-going practice.
Most of the course participants continued to use some of the mindfulness exercises three months after the course ended, suggesting that they found some benefit from these practices.
The majority continued to use the three-minute breathing space, finding it an effective method for regaining composure in the face of difficult emotions, particularly anxiety.
Five participants continued to have a regular formal meditation practice 2â€“3 times per week three months after finishing the course.
Other participants, while not continuing formal periods of meditation, integrated mindfulness practices into ordinary activities such as walking the dog or washing the dishes.
Several participants spoke about the difficulty in motivating themselves to continue practicing, after the course had ended.
In total 4 participants dropped out of the course and two of these were interviewed. One man had kept the material with the intention of one day trying it.
The other, who dropped out after the first session said the course had acted as a trigger for her to engage in her own form of meditation/relaxation practice.
Of the two drop outs that were unavailable for interview one had a history of alcohol abuse and dropped out after only 2 classes. The other, a woman whose husband had walked out on her half way through the 8-week program was too upset to continue with the course, had since moved out of the area.
The group described a wide range of benefits that came from the course. These included an
â€¢ increased ability to relax,
â€¢ <em>a decreased tendency to jump to negative conclusions,
â€¢ learning to take time out,
â€¢ learning new ways of dealing with difficult emotions
â€¢ greater self acceptance.
“I am able to deal with my emotions…I am not scared of things any more…I don’t want to turn about and walk away from things…I’ll take the time out to sit down and face up to it…“-P5
“Well I think it must have helped because I usually land up in hospital and I didn’t this time…I’m just being more relaxed about what I am thinking”-P2
“I don’t panic the same, eh, I still have negative thoughts about things, I worry a lot and I always see the pessimistic point of view but I don’t go into tizzies…the course has helped. I wish I had that course years ago”-P8
“its helped me look at things in a different way…just accept it”-P3
Two participants who had been off work because of psychological difficulties believed the course had helped them get back to work.
One of these participants had been out of work for almost a year because of depression and difficulty coping with stress at work. He felt the course helped him get back to work.
The other participant had been off work for 9 months due to a combination of physical and psychological problems.
“I do the 3 minute thing when I’m at work…and to be honest with you I feel that if I didn’t do it I would have to go home, you know, I would have to leave my work”-P9
One woman who found the course especially useful, and whose depression resolved completely, described how she had discovered self-worth and joy.
“I feel more worthwhile now. I’m beginning to feel now that there is something out there for me. I’m going to go back to work as well…My outlook has changed. The kids have even noticed it”-P5
“I had tried anti-depressants and that and I’m not really one for taking medication if I can help it and I think something like this, it doesn’t make you be in control of your life, but it certainly helps and I think that is the thing, if something can help you. Whereas the anti-depressants I just felt as if I wasn’t in control anymore. They made me feel different. The same problems were there. So when I stop taking the tablets I still had the emotional baggage and everything that I had stopped feeling when I started taking the pills. It was waiting for me at the end of the course whereas I feel with this, this is a different course. I’ve dealt with everything myself and at the end of the course the feelings are still there but I can deal with them so I would definitely feel that this is an alternative“-P5.
For one woman with generalised anxiety disorder the course gave her a method of managing her anxiety when having a medical procedure;
“I got a lot out of the body-scan. There was an incidence where I had went to the hospital for an endoscopy and you hear all the horror stories about what is going to happen and whatever and normally with things like that I would be physically shaken, you know I would be so uptight but because I had this, under my belt if you like, I thought no I’ve got to use it, that is what it is there for, so I did use it and I wasn’t shaken and I was so proud of myself”-P9.
Several participants found their sleep improved when they practiced mindfulness meditation and one man found that mindfulness meditation techniques helped him with cope with restless legs syndrome.
One woman describes how techniques learned for dealing with anxiety helped her give up smoking.
“But this time I stopped smoking…and I have still stopped and I’m sure that course helped me…I don’t know if you know anything about the patches, the last month we go on a low dose, it really is quite hard then because you are coming off the nicotine and I get really, really anxious. And I really do think if it hadn’t been for that meditation that 8 weeks I maybe would have started smoking again”-P11
Learning to live in the present moment was seen as a way of letting go of anxiety and re-discovering joy. One woman, saw the course in spiritual terms:
“Because what its (meditation) actually accentuating is the five senses…taking in what your seeing, what your hearing, to when your eating something; you notice the texture. I walk my son’s dog and I really had a lovely calming experience. It was a lovely day and I was watching the lovely breeze in the trees and I was watching the flowers and the river and your really more conscious of creation so I felt that the spiritual connotations were what was different,-P8
While some members of the group described very positive changes in mood and attitude as a result of completing the 8-week course, other participants found the course less helpful.
One participant, who had suffered from anxiety and depression for more than 30 years, had hoped meditation would provide a ‘miracle cure‘ and was disappointed this had not been the case. She spoke about on going family problems, expressing feelings of rejection and isolation and continued to experience high levels of anxiety.
While she enjoyed the classes and found the ‘thoughts and feelings’ exercise very informative, at times she felt overwhelmed by the amount of new information.
Importantly, she tended to conceptualise mindfulness practice in terms of relaxation alone and remained goal oriented while practicing meditation.
Because of this she found herself judging her practice as successful if it induced relaxation and unsuccessful if she was tense or distracted.
During the classes she found herself able to relax, but at home she spoke about becoming easily distracted by noises which she felt interfered with her practice and so in her opinion made the practices less effective.
“Nothing has got worse. Just I know meditation would be a good thing and I would enjoy it if I could get into it. It’s very beneficial and I think it would have helped if it had gone on longer but it just wasn’t long enough. I have still been putting the tape on but I’m not putting into it, you know, it doesn’t seem to be working, I think it’s because I know I’m not coming back to the class”-P3
Another participant with posttraumatic depression and anxiety, found the course interesting but not particularly useful to him.
While he found attending the group a hugely normalising experience, he found the meditation practices irritating and difficult. He spoke about becoming irritated with the audio instructions on the CD and giving up on the guided meditations early on in the course.
Occasionally he meditated on sound, which he found calming, but admitted that since the course had ended this practice was diminishing. He continued to struggle with difficult emotional states and believed that while the mindfulness approach was helpful, it was only helpful to a certain degree:
“How much that degree is I couldn’t quite fathom at the moment, it’s not been long enough. There are so many hurdles that you’ve got to jump over. It’s so easy to trip up, so unbelievably easy to get yourself back into the rut…I think perhaps it makes you recognise that you are on the edge of the rut quicker rather than falling into it and saying how the hell did I get here. And it gives you some methods of holding a better balance.”-P1
In the present study four research questions were considered;
1. Is MBCT an acceptable intervention to patients with depression and anxiety?
2. What benefit, if any, do patients derive from the mindfulness approach?
3. Do patients continue to employ mindfulness techniques to cope with adverse mental states, three months after the course has finished?
4. Does an 8-week course result in improved mood as measured on Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory
The majority of the participants found the MBCT course acceptable, enjoyable and beneficial. However most of the group also felt the course was too short and thought that some form of follow up was essential.
For many of the participants, being in a group was an important normalising and validating experience.
Their description of the facilitator as an empathic listener who taught from his own experience contradicts the notion that mindfulness training is a detached therapy.
Duration and severity of illness, avoidance of medication and desire to engage in a form of self-help, were cited as factors that motivated participants to complete the course.
Interestingly two of the three patients who did not complete four sessions had relatively mild mental health histories compared with the rest of the group. This is in keeping with previous findings that found a significant increase in drop out rates for those with two episodes of depression compared with three or more.
This would support the hypothesis that duration of illness is an important motivating factor for engaging with mindfulness based cognitive therapy.
What benefit, if any, do patients derive from the mindfulness approach?
Analysis of the interviews suggests a correlation between the amount of effort participants invested in developing their own mindfulness practice and improvements in psychological well-being. This is in keeping with previous findings that suggest strong links between consistent practice (therapy ‘homework’) and the process of change.
The reported benefits of mindfulness training in this present study included an increased ability to relax, improved mood, greater self-awareness and self-worth, improved sleep and new ways of working with negative thoughts and emotions.
Two participants who went back to work and one woman who gave up smoking attributed these changes to skills they had developed as a result of partaking in the group.
Several factors appeared to influence participants’ commitment to mindfulness training including initial experiences of mindfulness, time pressures, individual characteristics and on-going personal and interpersonal difficulties.
Two members of the group who had difficult initial experiences with the body-scan, one with a history of post-traumatic stress disorder, the other with childhood sexual abuse, did less formal meditation practice during the course than the rest of the group and gave up on the longer meditation practices once the course had ended.
Positive initial experiences could also be an obstacle to mindfulness practice if they created expectations that were not subsequently fulfilled: one woman for example, became frustrated and demoralised because she could not achieve the degree of relaxation she initially experienced while doing the exercises in the group.
Conversely, participants who found the initial exercises relatively straightforward and who were able to adopt a relaxed, non-striving, non-judgemental approach to mindfulness practice tended to enjoy the exercises and persist with them after completing the course.
Do patients continue to employ mindfulness techniques to cope with adverse mental states, three months after the course has finished?
Three months after the course had ended the majority (8/11) of the participants continued to use mindfulness techniques such as the breathing space.
Five participants who completed the MBCT course continued to do some formal mindfulness meditation practice 2â€“3 times per week.
Finding the time to practice and lack of group support were highlighted as obstacles to on-going practice. The lack of ongoing support was a common theme, and we would suggest that the establishment of ongoing support groups may be a very important part of long-term effectiveness.
In the present study, participants who described improvements in mood not only continued to practice mindfulness meditation on a regular basis, but also made changes in other areas of their lives.
Behavioural changes included going back to work, giving up smoking and increasing exercise.
Cognitive changes included recognising and disengaging from worrisome, unhelpful and self-critical thinking.
Participants whose depression and anxiety resolved also had more social support and fewer ongoing interpersonal problems.
Individuals with significant post-course depression symptoms tended to have decreased levels of activity (one woman continued to spend much of her day in bed), were more socially isolated and had significant histories of unresolved trauma such as childhood sexual abuse, early emotional neglect and domestic violence.
Although participants continued to use the breathing space to cope with anxiety, there appeared to be a marked difference in the application of this technique.
Two of the participants used the breathing space to recognise, welcome and disengage from worrisome thinking.
This is in contrast to some other members of the group who continued to engage in active worry and use the breathing space as a way to cope with physiological symptoms of anxiety.
This suggests that for these patients mindfulness training did not change the way they related to unhelpful beliefs about worry (“worry is protective”/”worry will help me cope”/”worry is not controllable”) known to play a significant role in maintaining generalised anxiety disorder.
Unlike CBT, the mindfulness-based approach does not explicitly aim to challenge beliefs about worry and instead focuses on changing participants’ way of relating to worry itself.
In theory, the repeated application of non-judgemental attention to the process of worry (watching thoughts come and go without either blocking or following them) reduces habitual worrying and the distress associated with worrisome thoughts. However this is a rather subtle process and as this study shows is the easily open to misinterpretation.
Although it is possible that the course was simply too short, and indeed the majority of participants thought that this was the case, the above examples indicate that for some patients MBCT may not affect significant change in key domains that maintain depression and anxiety.
Interestingly, while Baer’s review suggest that mindfulness training has benefits across a wide range of disorders, Teasdale et al remain cautious about attempts “to apply mindfulness training indiscriminately, as if it were a simple, general-purpose therapeutic technology”.
Instead they suggest that mindfulness training “is best conducted by practitioners who have adequately formulated views of the disorders they wish to treat and of the ways that mindfulness training can be helpful to clients with those disorders”.
In the case of relapsing depression the problem is conceptualised in terms of ruminative thinking induced by low affect, which can turn brief periods of low mood into prolonged episodes of depression.
It must also be remembered that the authors of the MBCT manual tailored the mindfulness exercises to non-depressed clients with a history of relapsing depression, teaching them to recognise and remain ‘open’ to difficult emotions without engaging in ruminative thinking.
However, the results from this study suggest that MBCT may be of benefit to a wider range of patients than non-depressed patients with a history of relapsing depression.
At the same time it is also plausible that some patients may benefit more from a course that placed less of an emphasis on mindfulness training (at least initially) and more of an emphasis on cognitive behavioural strategies (problem solving, assertiveness training, challenging maladaptive beliefs, etc.).
Further research in the form of randomised controlled trials comparing group CBT to group MBCT would help address these important issues.
A number of questions remain unanswered.
1) For individuals with affective disorders how does MBCT compare with group or individual CBT in terms of efficacy, acceptability and cost-effectiveness? A randomised controlled trial using both qualitative and quantitative research methods would be especially helpful in determining which elements of both mindfulness training and CBT clients use as antidotes to emotional distress.
2) When is the best time to introduce mindfulness training for patients with depression and anxiety? Should brief mindfulness training be introduced to patients with severe depression/anxiety right from the start of therapy or is it more effective for these patients to engage in individual/group cognitive behavioural therapy, deferring mindfulness training until some improvement in their mood?
3) Does long-term training in mindfulness meditation confer additional benefits for mental health compared with CBT?
A strength of the present study was that it was conducted in a routine primary care setting, involving patients from a range of socio-economic backgrounds.
Most of the participants had not practiced mindfulness meditation previously, and did not have fixed ideas about what to expect. The use of mixed methods in the evaluation of the study was also a strength.
However, there are several limitations to this exploratory study. This was a small study with no control group. Because there was no control group reductions in mean depression and anxiety scores cannot be directly attributed to the intervention.
Only two quantitative measures were used and data was collected at only 2 points, one at the beginning of the group and the second three months after completing the course.
The follow up duration was relatively short so it is not clear whether mindfulness training produces long term changes in affect.
The author who led the group (Andy Finucane) had no previous experience of running MBCT groups and a more experienced facilitator may have achieved better results.
However, it should be noted that the participants felt that the facilitator was very empathic and understanding, and it was clear that a good therapeutic relationship developed between the facilitator and the group members.
Mindfulness Based Cognitive Therapy, originally developed for non-depressed patients with a history of relapsing depression, may be acceptable and beneficial to patients with active depression and anxiety.
Depression and anxiety are amongst the commonest problems seen by primary care professionals and group based interventions have the potential to offer cost-effective treatment to larger numbers of patients than individual therapy, alleviating the existing pressure on psychology services.
However, if group based mindfulness approaches to mental health are to play a role in primary care then careful attention must be paid to training, capacity building and quality assurance. Further research is warranted that compares group based MBCT to other group based psychological interventions.
Andy Finucane and Stewart W Mercer. An exploratory mixed methods study of the acceptability and effectiveness of mindfulness -based cognitive therapy for patients with active depression and anxiety in primary care. Copyright Â© 2006 Finucane and Mercer; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the (http://creativecommons.org/licenses/by/2.0).
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