Clinical Handbook of Mindfulness (27 page)

Stone, A. A. & Shiffman, S. (1994). Ecological momentary assessment (EMA) in behav-

ioral medicine.
Annals of Behavioral Medicine, 16
, 199–202.

Teasdale, J. D. (1999). Emotional processing, three modes of mind and the prevention

of relapse in depression.
Behaviour Research and Therapy, 37
, 53–77.

Thompson, E. (2007).
Mind in life: Biology, phenomenology, and the sciences of

mind
. Cambridge, MA: Belknap Press.

Thompson, E. & Zahavi, D. (2007). Philosophical issues: Phenomenology. In P. D.

Zelazo, M. Moscovitch, & E. Thompson (Eds.),
The Cambridge handbook of con-

sciousness
(pp. 67–87). New York: Cambridge University Press.

Tsoknyi, D. (1998).
Carefree dignity: Discourses on training in the nature of mind
.

Hong Kong: Rangjung Yeshe Publications.

Tyssen, R., Vaglum, P., Gronvold, N. T., & Ekeberg, O. (2001). Factors in medical

school that predict postgraduate mental health problems in need of treatment. A

nationwide and longitudinal study.
Medical Education, 35
, 110–120.

Uchiyama, K. (2004).
Opening the hand of thought
. Somerville, MA: Wisdom

Publications.

Urry, H. L., van Reekum, C. M., Johnstone, T., Kalin, N. H., Thurow, M. E., Schaefer,

H. S., et al. (2006). Amygdala and ventromedial prefrontal cortex are inversely cou-

pled during regulation of negative affect and predict the diurnal pattern of cortisol

secretion among older adults.
Journal of Neuroscience, 26
, 4415–4425.

Varela, F. J. & Depraz, N. (2003). Imagining: Embodiment, phenomenology, and trans-

formation. In B.A. Wallace (Ed.),
Buddhism and science: Breaking new ground

(pp. 195–232). New York: Columbia University Press.

Varela, F. J. & Shear, J. (1999).
The view from within: First-person approaches to the

study of consciousness
. Bowling Green, OH: Imprint Academic.

Wachs, K. & Cordova, J. V. (2007). Mindful relating: Exploring mindfulness and emo-

tion repertoires in intimate relationships.
Journal of Marital and Family Therapy,

33
, 464–481.

Walach, H., Buchheld, N., Buttenmuller, V., Kleinknecht, N., & Schmidt, S. (2006).

Measuring mindfulness: The Freiburg Mindfulness Inventory (FMI).
Personality

and Individual Differences, 40
, 1543–1555.

Wallace, B. A. (1999). The Buddhist tradition of
Samatha
: Methods for refining and

examining consciousness. In F. J. Varela & J. Shear (Eds.),
The view from within:

First-person approaches to the study of consciousness
(pp. 175–187). Bowling

Green, OH: Imprint Academic.

Wilson, T. D., Lindsey, S., & Schooler, T. Y. (2000). A model of dual attitudes.
Psycho-

logical Review, 107
, 101–126.

Wupperman, P., Neumann, C.S., & Axelrod, S.R. (in press). Do deficits in mindfulness

underlie Borderline Personality features and core difficulties?
Journal of Personal-

ity Disorders
.

Part 2

Clinical Applications: General Issues,

Rationale, and Phenomenology

5

Mindfulness and Psychopathology:

Problem Formulation

Nancy L. Kocovski, Zindel V. Segal, and Susan R. Battista

There is no greater impediment to progress in the sciences than the

desire to see it take place too quickly.

Georg Christoph Lichtenberg (1742–1799)

Mindfulness-based interventions are currently being used with a variety of

populations to treat a wide range of physical and psychological disorders.

For example, Mindfulness-Based Stress Reduction (MBSR;
Kabat-Zinn, 1990)

has been used to treat chronic pain and anxiety, among other conditions.

Mindfulness-Based Cognitive Therapy (MBCT;
Segal, Williams, & Teasdale,

2002)
has been used for the prevention of relapse in depression. Accep-

tance and Commitment Therapy (ACT;
Hayes, Strosahl, & Wilson, 1999)

includes elements of mindfulness and has been used with a wide variety

of patients. Finally, Dialectical Behavior Therapy (DBT;
Linehan, 1993)
incorporates mindfulness as a core skill in the treatment of borderline personality

disorder.

With the growing number of mindfulness-based interventions, and the

growing evidence supporting the use of some of these interventions, clin-

icians are understandably interested in continuing to apply mindfulness to a

wide variety of concerns. However, the danger of over-applying mindfulness

as a treatment for psychopathology exists. Additionally, the application of a

generic mindfulness program to a wide variety of complaints may not be as

efficacious as tailoring the mindfulness intervention to a specific problem.

In addition to tailoring a mindfulness intervention to a specific complaint, an

integrative approach, one in which evidence-based interventions are retained

and mindfulness is incorporated in a theoretically consistent manner, may

lead to the most favorable outcomes.

The primary goal of this chapter is to highlight the importance of taking

a problem formulation approach in the development and use of mindfulness

interventions. Related to this, a secondary aim of this chapter is to review cur-

rent theory and research on mechanisms of change of mindfulness interven-

tions in the reduction of psychological distress and also to encourage further

research in this area. A clear understanding of how mindfulness interven-

tions lead to positive outcomes is essential for therapists, as it will enhance

problem formulation.

85

86

Nancy L. Kocovski, Zindel V. Segal, and Susan R. Battista

Problem Formulation

The evidence supporting the efficacy of mindfulness interventions across a

wide variety of populations might lead some to conclude that mindfulness

groups are a cost-effective “general-purpose therapeutic technology” (Teas-

dale, Segal, & Williams,
2003,
p. 157). Teasdale and colleagues posit that while there have been favorable findings for mindfulness interventions, often

these studies have had instructors who “embodied, sometimes implicitly,

quite specific views of the nature of emotional distress and ways to reduce

that distress” (p. 157). They further argue that for mindfulness interventions

to be successful, it is necessary for practitioners to have a clear formulation

of the disorder being treated and how a mindfulness intervention may be

helpful for that disorder. We further believe that understanding mechanisms

of change is necessary for a problem formulation approach to the use of

mindfulness interventions.

Teasdale et al.
(2003)
outlined six considerations related to mindfulness that require further investigation. Many of these considerations involve or

would be enhanced by an understanding of the mechanisms of change of

mindfulness interventions for a particular disorder. First, mindfulness train-

ing can be unhelpful. There are some conditions that may not benefit from

mindfulness meditation or may worsen. For example, early research on the

use of meditation in patients with psychotic disorders was not promising

(e.g.,
Walsh & Roche, 1979);
however, later research using ACT for psychosis found lower rehospitalization rates compared to a control group (Bach &

Hayes,
2002).
The
Melbourne Academic Mindfulness Interest Group (2006)

reviewed other adverse effects that have been reported in the literature; typ-

ically these adverse effects have been found with transcendental meditation

(TM) and longer-term meditation retreats, and they include an increase in

depressive and anxious symptoms. Relatedly, mindfulness interventions can

be a significant time investment, often involving a two-hour group meeting

weekly for at least eight weeks, possibly involving significant travel time

to and from the group meetings, and a significant homework commitment

(i.e., 45 minutes per day). Some programs also include a full day of mind-

fulness practice as a group. This large time commitment can be considered

an adverse consequence if a patient has not benefited from the intervention

(Melbourne Academic Mindfulness Interest Group, 2006).

Second, sharing a clear formulation with clients is important, and this

involves having an understanding of how mindfulness might lead to change

for that particular client’s problem. Some clients may have preconceived

notions of what mindfulness entails and may judge it as an unsuitable

approach. A discussion of how mindfulness may be an appropriate interven-

tion may help to counteract these preconceived notions.

The third consideration relates to the apparent simplicity of mindfulness.

Mindfulness appears to be a simple procedure, but the style is as impor-

tant as the technique. Understanding mechanisms of change for a particular

problem can inform the specific mindfulness exercises chosen for the inter-

vention, the style of delivery, and the emphasis for the inquiry.

Fourth, mindfulness was originally developed as part of a multifaceted

approach, not as an end in and of itself. Often there are well researched and

supported techniques for a particular disorder that can be integrated with

Chapter 5 Mindfulness and Psychopathology

87

mindfulness interventions. However, leaving out previously established tech-

niques in favor of a pure mindfulness approach may result in a disservice to

patients. Often there are traditional cognitive and behavioral therapies that

are empirically supported for specific populations. One of the challenges of

integrating mindfulness with these interventions is that the acceptance-based

underpinnings of mindfulness can be at odds with the change-based focus of

traditional cognitive and behavioral interventions (see
Lau & McMain, 2005,

for a review). However, this challenge can and has been met (e.g., MBCT;

Segal et al., 2002),
highlighting that, while it may seem difficult, it is possible to achieve theoretical integration with seemingly very different approaches.

Therefore, rather than abandoning empirically supported treatments in favor

of a pure mindfulness intervention, integration may be the most effec-

tive approach. Additionally, understanding the mechanisms of change will

enhance the development of multifaceted approaches that include mindful-

ness interventions.

Fifth, some components of mindfulness training may be more relevant for

some conditions than for others. Understanding mechanisms of change for a

particular disorder will inform which components of mindfulness are most

relevant for that disorder.

The sixth and final consideration outlined by
Teasdale et al. (2003)
is that while mindfulness training may affect processes common to many disorders,

indiscriminate application of mindfulness techniques across disorders is not

optimal. There is still room for specificity even if the process is similar across

several disorders.

MBCT as an Example of the Problem Formulation

Approach

The development of MBCT
(Segal et al., 2002)
is an example of the problem formulation approach. Segal and colleagues sought out to develop a program

to target the recurrent nature of depression. Patients who have one episode

of depression have a 50% probability of becoming depressed a second time,

and those who have had two episodes of depression have a 70–80% prob-

ability of having a third episode. Segal and colleagues developed MBCT, an

eight-week group intervention, for patients who have been depressed but are

currently well. They integrated aspects of cognitive therapy for depression

with mindfulness training, following a clear rationale of what they expected

would be helpful, given current data on depression and mindfulness. The

emphasis in MBCT is on changing the relationship with thinking, rather than

changing the content of thought.

MBCT has been found to help patients with three or more episodes of

depression, but not those who only had two depressive episodes (Teasdale,

Segal, Williams, Ridgeway, Soulsby, & Lau,
2000;
Ma & Teasdale, 2004).
Ma and Teasdale found that those with a history of only two episodes reported a

later onset of depression and less childhood abuse in their histories, suggest-

ing that they may have represented a unique population, compared to those

who had a greater number of depressive episodes. This illustrates the need

to study exactly how mindfulness techniques work in specific populations

as they may not be beneficial in all cases
(Teasdale et al., 2003).
Additionally, while MBCT was developed for formerly depressed patients who

88

Nancy L. Kocovski, Zindel V. Segal, and Susan R. Battista

are currently well, there is growing evidence that MBCT can be effective

for actively depressed and anxious patients in a primary-care setting (Finu-

cane & Mercer,
2006)
and for treatment-resistant actively depressed patients

(Kenny & Williams, 2007).