Clinical Handbook of Mindfulness (68 page)

this. The first class finished with the “body scan,” a lying down meditation in

which participants bring attention to every part of the body in turn.

Doing the body scan during the first week of homework proved challeng-

ing for Fiona. At the second class she reported that she “could not do” the

body scan. She said she had been crying more during the week after the

first class and it emerged that she had experienced feelings of panic on sev-

eral occasions during the body scan, finding it extremely unpleasant. The

instructor explored with Fiona the bodily sensations she had noticed during

the body scan at the start of the second class. However she was unable to

clearly describe them, simply repeating that she felt “panicky.” The instruc-

tor encouraged Fiona to approach the sensations with curiosity should they

arise again, looking in detail at what she experienced in her body during

these periods. He also emphasized to the class that there was no right or

wrong way to feel during the body scan. In the second session of the pro-

gram, themed “Dealing with Barriers,” addressing reactions to the first week

of practice such as Fiona’s is an important feature. Many participants have

questions about whether they are doing the practice right, or expect to find

the meditation relaxing, getting bored and frustrated when this is not their

experience. At this point in the classes it is necessary to emphasize to partic-

ipants that just doing the practice and observing their experiences whatever

they are, is all that is required. It is also critical at this stage that the instructor

models an openness and curiosity toward participants’ experiences, in order

to encourage them to maintain their practice of the body scan for a second

week. The second session is also used to introduce the cognitive model in

order to demonstrate the strong relation between interpretations and emo-

tions.

During the third class participants were introduced to both sitting medita-

tion, and to walking meditation and yoga. Fiona had continued to experience

unpleasant sensations during the body scan meditation but also reported

what she was beginning to relax to some degree in her attempts to control

her emotions. During exploration of her experiences during the sitting medi-

tation in class, Fiona was more able to describe the qualities of the sensations

she experienced (tension in her chest, irregular breathing, sadness). How-

ever after her initial enthusiasm she also reported increasing doubts about

the helpfulness of the classes as she was not yet starting to feel “better.”

This response is not unusual as participants, through their practice, tend

to experience negative thoughts, feelings and body states more clearly or

more strongly. At the same time, they begin to realize how their usual ways

of responding often entail avoidance or ruminative thinking. In contrast to

these habitual tendencies, MBCT teaches participants to become more aware

of difficult aspects of experience. In the third session, themed “Mindfulness

of the Breath,” the focus is on learning how attention to the breath and body

sensations can serve to stabilize the mind and return the focus to the experi-

ence of what is present, even when the mind is drawn toward difficulties.

A big shift came for Fiona as she began to practice the sitting meditation.

She described a period of sitting meditation during which she felt a great

Chapter 12 Mindfulness-Based Cognitive Therapy for Depression and Suicidality

237

sense of relief in response to the occurrence of the thought “its ok to be

me.” She said that she had realized that she had previously avoided spending

time alone and so had tried to surround herself with other people because

she did not like herself. This contributed to her sense of anxiety and aban-

donment in the face of perceived rejections. Through the sitting meditation

she began to explore her experiences of “being with herself” in this new way.

Spontaneous insights like this frequently arise as the MBCT classes progress

and participants begin to observe the workings of their mind and their reac-

tions to events from a new perspective. Up to session 3, participants are

instructed to respond to mind wandering by noticing where their mind has

gone and then simply returning attention to the object of the meditation.

From session 4 onwards, there is a change in emphasis in that participants are

instructed more explicitly to turn toward difficult experiences and explore

them with gentleness, curiosity and interest. Fiona’s greater sense of compas-

sion for herself nicely reflects this shift in emphasis. The focus in session 4

is on “Staying Present” with difficult experience. Session 5, themed “Allow-

ing/Letting Be,” explores ways of bringing a sense of acceptance to such

experiences, particularly through staying with and exploring the body sen-

sations that come with negative thoughts. Session 6 makes explicit the core

theme of the program, that “Thoughts are Not Facts,” and that they occur

as transient mental events which individuals can choose to attend to or not.

As part of the sitting meditations in these sessions, participants deliberately

bring to mind a difficulty in order to practice these different ways of relating.

Fiona, at first, found it difficult to see the benefit of deliberately approach-

ing difficulties. However, over time it became possible for her to stay with

the distress she experienced when bringing a difficulty to mind, focusing

her attention on the bodily sensations accompanying what she experienced

(tightness in the chest, difficulty breathing, sadness) and the gradual change

in these as she continued to observe them. Hearing other participants of

the class talk about similar experiences helped her to develop compassion

both for herself and others. Many of the participants reflected on the way

that they judged themselves and the consequences this had for their mood

and well-being. The instructor encouraged participants to bring mindfulness

to the occurrence of difficult thoughts during their meditation practice, for

example noting “here is guilt,” “here is judgement” when familiar thoughts

arose. Participants were also encouraged to experiment with techniques to

facilitate de-centering including imagining thoughts as leaves gliding down a

stream, or projected on a cinema screen.

The theme of session 7 is “How Can I Best Take Care of Myself.” In this ses-

sion, participants reflect on the balance of nourishing and depleting activities

in their lives. As often occurs, Fiona realized that she spent very little time

on activities that lifted her mood or improved her well-being, often being so

concerned to meet the needs of others and avoid rejection that she failed

to meet her own needs adequately. In common with other members of the

group Fiona recognized a typical spiral of depression in which, as her mood

deteriorated, she increasingly gave up activities that might give her a sense

of mastery or pleasure. A key part of her relapse planning was therefore to

identify the early warning signs of this process, to take a breathing space

and reflect on an appropriate course of action, and to deliberately engage in

nourishing activities at times of low mood.

238

Thorsten Barnhofer and Catherine Crane

Session 8, themed “Using What Has Been Learned to Deal with Future

Low Mood,” is used to both look back at what has been learned and for-

ward to how what has been learned can be maintained and used to pre-

vent relapse and increase well-being. Fiona identified several areas in which

she had made progress. She was more able to recognize her tendency to

react to social stressors “online” and was able to use meditation, including

short 3-minute breathing spaces, to become aware of her reactions and make

choices. For example Fiona described a situation in which she had been sit-

ting on a train and had smiled at the person opposite who promptly got up

and walked away. Her initial reaction was to assume that the person opposite

had thought her strange and that others had also noticed the situation and

his departure, leading to feelings of embarrassment. However, rather than

triggering a cycle of rumination Fiona was able to stay with her immediate

experiences and observe her thoughts and bodily reactions in response to

the event. Shortly after the person opposite returned to their seat from the

restroom! This experience and others illustrated to Fiona the benefits of stay-

ing in the present moment. and allowing events and experiences to unfold,

rather than getting trapped in habitual but unhelpful patterns and reaction.

Research Findings

Two randomized controlled trials have evaluated the effectiveness of MBCT

for recurrent depression. In an initial multi-center trial by
Teasdale et al.

(2000),
145 recovered depressed patients were randomized to MBCT or treatment as usual and followed up over a period of 60 weeks. MBCT significantly

reduced relapse rates in patients with three or more previous episodes of

depression, with 66% of those in the treatment as usual group compared

to 40% of those in the MBCT group suffering from relapse. A later study

by
Ma and Teasdale (2004)
replicated this finding in a smaller sample of 73

recovered patients, 55 of whom had suffered from three or more previous of

depression. Of this latter group, 78% of those who had continued treatment

as usual relapsed within the one-year follow-up compared to only 36% in the

MBCT group.

The results from both of these trials advocate the use of MBCT to help

reduce risk of relapse in individuals with recurrent depression. The fact that

MBCT reduced relapse rates to about half in individuals with three or more

episodes of depression, but did not produce significant effects in those with

one or two previous episodes, is consistent with its focus on cognitive reac-

tivity and rumination and the assumption that through associative learning

these processes come to be increasingly relevant for relapse as individuals go

through repeated episodes.

Studies explicitly investigating effects on relevant cognitive parameters

and hypothesized mechanisms of action are only beginning to emerge.

Williams, Teasdale, Segal and Soulsby (2000)
found that MBCT can reduce

deficits in autobiographical memory specificity, a phenomenon that has

been shown to be play a central etiological role in depression. In a pre-

post comparison study,
Ramel, Goldin, Carmona, McQuaid (2004)
found

that mindfulness-based stress reduction (MBSR), the generic mindfulness

Chapter 12 Mindfulness-Based Cognitive Therapy for Depression and Suicidality

239

program developed by John Kabat-Zinn, reduced ruminative tendencies in

previously depressed patients, (2007).

While specifically developed for preventing relapse to depression, the pro-

grams’ focus on changing cognitive reactivity and rumination suggests that

it may also have some beneficial effects for patients currently suffering from

depression. Some preliminary evidence that this may be the case comes from

a pre-post comparison of MBCT
(Kenny and Williams, 2007),
which found

significant reductions in symptoms in individuals with treatment-resistant

depression who were treated with MBCT after CBT. The possibility of deliv-

ering MBCT to patients with ongoing symptoms of depression is welcome

since individuals with highly recurrent depression may experience signifi-

cant residual symptoms and fail to meet the strict recovery criteria that have

been imposed in existing clinical trials (12 weeks symptom free). However,

further randomized controlled trials exploring the use of MBCT for individ-

uals with current depressive symptoms will be required before we can have

confidence in the suitability of the approach for this group.

MBCT for Individuals with a History

of Suicidal Depression

There are several reasons to suspect that the skills acquired during MBCT may

be particularly suitable for patients who become suicidal when depressed

(Williams et al., 2006;
Lau, Segal & Williams, 2004).
First, avoidance tendencies, targeted by MBCT, appear to be critically important in understanding

suicidal ideation and behavior. The desire to escape from an unbearable situ-

ation is one of the most commonly reported motivations for suicidal behav-

ior (e.g.,
Hjelmeland et al., 2002)
and prominent psychological theories of suicidality converge on the suggestion that suicidality can be understood

as an attempt to escape, from aversive self-consciousness (e.g.,
Baumeister,

1990),
unbearable “psychache” (e.g.,
Schneidman, 1997)
or intolerable circumstances in which the opportunity to escape by other means or to be

rescued is perceived to be remote (e.g.,
Williams & Pollock, 2000;
Williams,

2001).
Thus the capacity to remain open to and stay with difficult expe-

riences, responding with self-compassion and acceptance may be critically