Mindfulness-Based Cognitive Therapy for Depression: Effectiveness and Limitations

Abstract

Mindfulness-based cognitive therapy (MBCT) was developed by Segal, Williams, and Teasdale (2002) as a therapy for relapse prevention of major depression. The 8-week group-based program combines Kabat-Zinn's (1990) mindfulness-based stress reduction (MBSR) with components of Beck's (Beck, Rush, Shaw, & Emery, 1979) cognitive behavioral therapy (CBT). It is increasingly being offered by social workers worldwide. MBCT is based on an interacting cognitive subsystems model (ICS) replacing Beck's schema model. This new model represents the largest shift in the approach to major depression for social work in the past two decades. However, social work has been slow to incorporate it into its research agenda. In practice, MBCT teaches patients who are in remission from depression to become aware of, and relate differently to, their thoughts, feelings, and bodily sensations. This is a shift from CBT's schema theory that focused primarily on the content of thoughts and beliefs. A few reviews of MBCT research exist (Coelho, Canter & Ernst, 2007), but there has been no review of the mechanics of MBCT and how it addresses the cognitive patterns or metacognition and processes of major depression. There is no review of its use within the social work literature. This article discusses the mechanisms of MBCT in relation to the components of depression relapse/reoccurrence and reviews the literature regarding the effectiveness of MBCT. We found that MBCT has the potential to positively contribute to interventions directed at relapse prevention for patients with a history of depression.

KEYWORDS:

• Mindfulness
• Depression
• Cognitive therapy
• Mindfulness-based Cognitive Therapy

INTRODUCTION

Mindfulness-based cognitive therapy (MBCT) was developed by Segal, Williams, and Teasdale (Segal et al., 2002) to address the prevalence of major depression relapse. Social work has historically relied on problem-solving therapy (Gellis & Kenaley, 2008) or cognitive-behavioral theory (Ronen & Freeman, 2007) in treating depression. Major depression is the world's leading cause of disability (Patten & Juby, 2008) and it is often persistent and reoccurring, resulting in a chronic condition (Judd, 1997; Kennedy, Abbott, & Paykel, 2003). Major depression is characterized by recovery from the initial episode, with subsequent recurrences and recoveries (Solomon et al., 1997). Mindfulness-based cognitive therapy (MBCT) was developed specifically to address such relapses and recurrences. This article reviews the cognitive and metacognitive mechanisms of MBCT to determine congruence with the skills taught in MBCT. No studies have been done on this area. The article then reviews engagement with MBCT within the social work profession.

Only three studies have examined the metacognitive mechanisms of MBCT, but the results are encouraging (Scherer-Dickson, 2004; Teasdale, Segal, & Williams, 1995; and Kingston, Dooley, Bates, Lawlor, & Malone, 2007). They found that MBCT is an effective intervention that increases metacognitive awareness to negative thoughts and feelings including rumination, and significantly decreases relapse of major depression. Scherer-Dickson (2004) provides a comprehensive overview of Beck's schema theory and the cognitive sub-system (ICS) model—the model that underpins MBCT. She indicates that increasing metacognitive awareness within the ICS model leads to changes in the relationship between thoughts and feelings, and reduces relapse of depression rather than changing only the content of thoughts and beliefs in schema theory. Our review of studies on MBCT and the metacognitive mechanisms underlying it indicate that by changing the relationship to negative thoughts and feelings rather than trying to subdue or replace them, MBCT has an important contribution for interventions directed at relapse prevention for patients suffering with depression. This has implications for social work interventions directed at clients with reoccurring chronic depression.

THE MECHANICS OF RELAPSE/RECURRENCE

Patterns of Negative Thinking and Dysphoric Mood

In developing an intervention specifically for depressive relapses/recurrences, MBCT first needed to understand the components and causes. The literature has found that depression can begin with either negative thinking or dysphoric mood (Broderick, 2005). Depression can start with either cognitive state and, once initiated, they tend to feed off each other in a downward spiral. This tends to lead to a set of negative attitudes or beliefs that further exacerbate the depressed state.

Regarding negative thinking, two conclusions are well established in the literature: that negative thinking can cause and maintain depression (Segal et al., 2002); and, that attempts to suppress negative thoughts may increase their incidence (Beevers & Meyer, 2008). Ironic processes theory (Wegner, 1994) suggests that a thought or mood regulation strategy may actually increase negative thinking once thought suppression efforts are relinquished. A comprehensive study using meta-analysis found that thought suppression is associated reliably with a rebound of the suppressed thoughts (Abramowitz, Tolin, & Street, 2001). Segal et al. (2002, p. 28) indicate that when depressed patients are in a dysphoric mood, patterns of negative thoughts will be activated. They become more likely to recall negative memories and events. The research has found that regardless of the number of negative events versus positive events in one's life, once negative thoughts are switched on, they become the primary focus. When negative thoughts become frequent, an automatic and habitual negative thinking pattern may be formed and may lead to depression.

Other studies have found that depression can begin with a dysphoric mood. Further evidence supports that cognitive reactivity to sad mood contributes to depressive relapse following successful treatment (Segal, Gemar, & Williams, 1999; Segal et al., 2006). With the differential activation hypothesis, Teasdale ( 1999b) posited that the degree to which a negative cognition is activated in response to depressed mood may underlie the cognitive vulnerability to depression. A dysphoric mood may trigger negative attitudes (e.g., low self-worth, remorse, shame) as well as negative thinking patterns. Segal and his colleagues find that patients' negative beliefs can also be activated by a dysphoric mood. Segal et al. (2002) conclude that “‘cognitive reactivity’ [has] the tendency to react to small changes in mood with large changes in negative thinking” (p. 31).

When patterns of negative thinking and dysfunctional beliefs are activated by a dysphoric mood, often negative feelings worsen and in turn intensify and magnify more negative thoughts and feelings. This continuous chain reaction may generate even more overwhelming negative thoughts and negative attitudes. Relapse or recurrence of depression is easily set off under these circumstances.

Therefore, any social work approach or treatment intended to address relapse must address responses to negative thinking, mood shifts, and negative attitudes. Clients must learn how to effectively deal with these cognitive states. Since attempts to suppress negative thoughts may actually increase their incidence, new ways are needed to address them.

A Ruminative Mind

Another critical component of cognitive vulnerability leading to depression is rumination. Nolen-Hoeksema (2000) defines rumination as “passively focusing one's attention on a negative emotional state like depression, its symptoms, and thinking repetitively about the causes, meanings, and consequences of that state.” Papageorgiou and Wells (2004, p. 569) explain that negative automatic thoughts are relatively brief shorthand appraisals of loss and failure in depression, whereas rumination consists of longer chains of repetitive, recyclic, negative, and self-focused thinking that may occur as a response to initial negative thoughts (p. 6).

Rumination usually drives the thoughts into the past or the future, but not the present. This ruminating and self-perpetuating vicious cycle may lead depressed patients into a more depressing state. Intensification, prolongation, and relapse/recurrence are unavoidable when the ruminating mind is activated. Papageorgiou and Wells (2004, p. 44) conclude that rumination leads to “exacerbation of an existent sad mood” and is “a maintenance factor for depressive mood.” Research has found that rumination predicts the severity, duration, and recurrence of depressive symptoms (Just & Alloy, 1997; Kuehner & Weber, 1999; Nolen-Hoeksema, 2000). Several studies have determined that a vicious cycle is created whereby rumination may prolong and intensify depression is by enhancing the effects of depressed mood on negative thinking (Nolen-Hoeksema, 1991; Teasdale, 1999a, 1999b; Teasdale et al., 2000).

Both patterns of negative thinking and rumination on negative thoughts and feelings are identified as key contributing factors for relapses of major depression. For the prevention of depression relapse, it is imperative to find effective ways to change patterns of negative thinking and reduce rumination. MBCT does this in unique ways by directly addressing the cognitive patterns apparent in depression relapse or reoccurrence.

WHAT IS MINDFULNESS-BASED COGNITIVE THERAPY (MBCT)?

MBCT combines Kabat-Zinn's (1990) mindfulness-based stress reduction (MBSR) with components of Beck's (Beck et al.,1979) cognitive behavioral therapy (CBT). MBSR trains people to cultivate mindfulness through meditation techniques and self-awareness exercises. MBSR has been shown to be effective with chronic pain (Kabat-Zinn, Lipworth, Burney, & Sellers, 1987; Kabat-Zinn, 1984 & 1990), stress (Shapiro, Schwartz, & Bonner, 1998), caregiver stress (Minor, Carlson, Mackenzie, Zernicke, & Jones, 2006), disordered eating (Kristeller & Hallett, 1999), psoriasis (Kabat-Zinn et al., 1998), and cancer (Monti et al., 2006; Speca, Carlson, Goodey, & Angen, 2000), among others. CBT has also shown its effectiveness in treating depression and reducing relapses. But unlike CBT, MBCT does not emphasize changing thought contents or identifying schema or core beliefs related to depression. Instead, its emphasis is on cultivating an awareness of thoughts and feelings, accepting, and letting them be. MBCT is a group-based skills training approach delivered in 2 hour sessions over 8 weeks.

CORE THEMES: HOW DOES MBCT ADDRESS DEPRESSIVE COGNITIVE PATTERNS?

Decentering

Decentering has been defined as the capacity to take a present-focused and non-judgmental stance in regard to thoughts and feelings, and to accept them (Fresco, Segal, Buis, & Kennedy, 2007 p. 448). Studies have suggested that decentering may reduce levels of depressive rumination by teaching patients more adaptive ways of relating to their thinking (Segal et al., 2002). MBCT is designed to foster a decentered relationship (i.e., thoughts are not facts) with patients' negative thoughts. The key idea of decentering is to make radical changes in one's hidden views, beliefs, and cognitive patterns that shape the depressed patients' relationship with negative thoughts and feelings. Decentering involves distancing, stepping away from, disengaging, allowing, accepting, and letting go of negative thoughts and moods.

MBCT consists of practice components that lead patients toward decentering. Patients in an MBCT program practice decentering from thoughts and emotions (or whatever else might arise) during meditation sessions. These sessions enable a person to practice decentering in a controlled environment, usually sitting, with eyes closed in a quiet place. Once practiced, the skill is more easily sustained and integrated into the patient's daily life.

Doing Mode Versus Being Mode

Changing from a “doing mode” to a “being mode” is a key component in MBCT that helps patients to decenter. Doing mode involves a lot of thinking about the future or the past, not “being” fully in the present. Being mode is a non-striving and non-judgmental mode. Decentering corresponds to the being mode of mind. A doing mode starts kicking in when discrepancies between how things are and how they are expected or wanted are detected by the mind. The discrepancies will then automatically activate negative feelings that may trigger one's habitual thinking pattern, which leads a person into motions and actions to fill the discrepancies between the current state and the desired state. If the actions successfully reduce the gap and the desired state is reached, the doing mode will exit from one's mind. But if discrepancies remain after actions have been tried, the mind in this doing mode will keep going around, obsessively searching for possible ways to reduce the discrepancies. A “continuous monitoring and evaluation of progress” (Segal et al., 2002, p. 71) are involved. The repetitive cycle of searching, monitoring, and evaluating creates many thoughts and feelings, and these are taken to be real rather than events in the mind. At the same time, the mind may be so preoccupied with discrepancies, problem-solving, and analyzing the past and future that patients may ignore their present state or experience. Segal et al. (2002) found that the problem with the doing mode is that its processing is usually “not intentional, conscious, and planned; rather, it begins and is maintained relatively automatically, as a mental habit in the back of the mind” (p. 72). Furthermore, thoughts and feelings are evaluated as good or bad in this process, which aggravates the mind to set goals to keep the good thoughts and feelings and eliminate the bad ones. Judging and evaluating are therefore integral to rumination and the doing mode. This repetitive cycle of the doing mode will eventually increase one's sense of dissatisfaction and failure because of constant judging and evaluating.

Decentering in mindfulness is critical in helping patients to leave the doing mode and adopt the being mode so that their vulnerabilities for relapse/recurrence may be reduced. The being mode, unlike the doing mode, does not involve the search for discrepancies between the current mind state and the desired state. It also does not involve continuous monitoring and evaluating. Rather, the mind in the being mode is fully accepting and aware of experiences in the present moment. Instead of thinking about and evaluating the present, future, or past in the doing mode, the being mode is characterized by a direct, immediate, and intimate experience of the present.

With this new way of being, one's relationship with one's thoughts and feelings is changed. In the being mode, thoughts and feelings are seen as “passing events in the mind … objects of awareness, and then [they would] pass away” (Segal et al., 2002, p. 74). Decentering will be formed in this mode by disconnecting thoughts and feelings from goal-driven actions. Thoughts no longer strive to attach to pleasant feelings and eliminate or avoid unpleasant ones. This in turn strengthens one's tolerance for undesirable or unpleasant emotions or feelings without activating patterns leading to depression. Segal et al. (2002) assert that the being mode contributes to “a sense of freedom, freshness, and unfolding of experience in new ways” (p. 74).

CORE SKILLS IN MBCT

Attention and Awareness

Mindfulness is purposefully paying attention to the present moment with an attitude of openness, non-judgment, and acceptance (Hick, 2008). MBCT starts with increasing a patient's awareness of how little attention she/he pays to the present moment and to bodily sensations, thoughts, feelings, and behaviors. The patient's awareness is extended to the wandering mind, or the mind that is constantly active, evaluating, worrying, anticipating, and remembering. Through this, patients have more awareness, sensitivity, and understanding of their doing mode—how the automatic and habitual negative thinking patterns enter when their mood starts sinking (especially in a wandering mind), and how thoughts, feelings, bodily sensations, and behaviors can merge into a downward spiral of depression. In addition, patients learn how to bring their attention back to a single focus (i.e., the breath) when their mind is wandering, thereby maintaining their awareness and attention to the present.

MBCT helps patients expand their awareness and to be attentive to cognitive patterns and bodily sensations, instead of being stuck with their ruminating thoughts and obsessed feelings.

Accepting and Letting Go

After becoming aware of self-perpetuating cognitive routines in the doing mode, the next core skill in mindfulness is to step out and stay out or dissociate from these routines by letting go. Letting go means “relinquishing involvement in these routines, freeing oneself from the attachment/aversion driving the thinking pattern—the continuous attempts to escape or avoid unhappiness, or to achieve happiness that keeps the negative cycles turning” (Segal et al., 2002, p. 91).

Accepting thoughts as mental events and not as facts is a critical skill taught in MBCT. MBCT teaches patients to decenter or disengage from these thoughts and beliefs, and observe their thinking processes instead of reacting to them. Patients gradually become less attached to their own thoughts, perceptions, and beliefs. With practice, they become decentered from their old habitual negative thinking and ruminating patterns.

Furthermore, MBCT teaches patients to tune in and be aware of both pleasant and unpleasant thoughts and feelings in any moment. In the doing mode, patients often attempt to keep the “good” feelings and avoid or get rid of the “bad” ones. To recognize, approach, accept, and befriend the unpleasant and unwanted feelings and thoughts is a new way to transform patients' relationships with unpleasantness, hardship, and threat. Instead of reacting to difficult, unwanted, and painful experiences, patients respond by welcoming them with more acceptance, gentleness, and kindness. This stretches the capability of patients to not only embrace discomfort, but also develop a different relationship with their negative feelings and thoughts, unpleasantness, pain, and suffering. As a result, when patients are stuck in suffering or depressing moments, they begin to see their negative thoughts, feelings, and unpleasant experiences as passing mental events. This radical acceptance cultivates the courage to touch old wounds and current pain and suffering, and provides new perspectives and insights when looking at suffering. This enables patients to stay out of their habitual self-perpetuating negative thinking and ruminative patterns. In addition, patients are more capable of paying attention to their own unique warning signs of depression triggers. More specific action plans and skillful responses can then be made to effectively prevent potential relapse/recurrence of depression in the future.

Being mindful and aware of the present moment, and accepting and letting go are core skills in MBCT that help depressed patients to decenter and change their relationship to negative thoughts and moods.

EFFECTIVENESS OF MBCT

Existing reviews of MBCT research (Coelha, Canter & Ernst, 2007) have discussed findings and adherence to randomized controlled trial protocols. Several studies have recently shown positive outcomes of MBCT. No studies on MBCT have been conducted within the social work profession. Examinations of mindfulness within social work are just beginning (Hick, 2009). Hick's (2009) review of the social work literature on mindfulness found that mindfulness has a variety of applications within social work, including individual, groups, and communities.

The research within MBCT has much to offer social work. Segal's (Segal et al., 2002) initial study to examine the effectiveness of MBCT in relapse prevention for recurrent major depression found that for patients with three or more previous episodes of depression, relapse rates were 66% and 37%, respectively, for those receiving TAU (treatment-as-usual) and MBCT. In addition, Segal et al. (2002) found that patients in MBCT used less antidepressant medication during the research period than those receiving TAU. Similar results are found in a study by Ma and Teasdale (2004) that show significant decrease in relapse/recurrence rates for recovered recurrently depressed patients. Positive effects are more pronounced for patients with four or more episodes. Further, Ma and Teasdale (2004) found that MBCT, as a group-based treatment, averages less than 3 therapist-contact hours per patient, making it a highly cost-efficient approach (p. 38). A study by Kenny and Williams (2007) explored the use of MBCT for patients who were actively depressed and had not responded fully to standard treatments (p. 617). Results show improvements in the depression scores of patients in the study (pre-post effect size = 1.04). Another study, by Smith, Graham, and Senthinathan (2007), was done to determine the effects of MCBT on elderly people having recurring depression (p. 346). Their findings indicate that MBCT is a cost-effective and helpful intervention for older people suffering from recurring depression. Kingston et al. (2007) did a study to assess the efficacy of MBCT in reducing residual depressive symptoms in psychiatric outpatients with recurrent depression, and to particularly explore the effects of mindfulness on rumination (p. 193). Results from the study show reductions in both depressive symptoms and rumination scores at the end of MBCT. These studies present promising results for social work showing that MBCT effectively and significantly reduces the risks of relapse/recurrence in patients with major depression.

LIMITATIONS OF MBCT

Despite the effectiveness of MBCT in terms of its low costs and high success rates in reducing depression relapses, studies show that it is not equally effective in preventing every form of relapse of depression. According to Segal et al. (2002), although MBCT is effective with patients with three or more episodes, it is not with those having only two previous episodes. The relapse rate for those receiving MBCT and that for the ones receiving TAU are the same. Similar results are derived from a study by Ma and Teasdale (2004, p. 38).

Ma and Teasdale (2004) also indicate that the reduction rate in relapse/recurrence with MBCT is highest if there are no antecedent life events reported as onsets of depression, while no difference is shown between MBCT and TAU for onsets preceded by significant life events (p. 39). In other words, MBCT is effective in reducing relapse/recurrence related to autonomous and ruminative type of negative thinking patterns that are provoked internally, but ineffective in reducing relapse/recurrence associated with severe life events.

Segal et al. (2002) point out that MBCT is specifically designed for those who have been depressed in the past but are relatively well when they start the MBCT program (p. 318). Therefore, MBCT does not target patients who are acutely depressed because poor concentration and higher intensity of negative thinking among those patients would affect their focus and attention required to develop the core skills for MBCT. On the contrary, according to findings from a study by Kenny and Williams (2007), most actively depressed participants of MBCT show improvement in their depression scores (p. 617). However, even though the participants are actively depressed, their diagnosis is affective disorder rather than major depression only. Those who are qualified to participate in the study also need to have three or more episodes if their diagnosis is major depression. These two criteria essentially restrict the applicable scope of the results in this study. Therefore, the effectiveness of MBCT on acutely depressed patients is still inconclusive.

According to Coelho et al. (2007), MBCT research is in its early stage and it is premature to attempt to draw definitive conclusions about its effectiveness (p. 1000). There is a lack of research on “the unique contribution of mindfulness meditation to the outcome of MBCT” (Lau & McMain, 2005, p. 868). The specific role that mindfulness plays in MBCT to prevent relapse/recurrence of depression and its actual effectiveness is still uncertain. Further research is necessary to prove the effectiveness and efficacy of MBCT; for example, if MBCT requires fewer resources than individual social work and/or less medication (Coelho et al, 2007, p. 1004).

CONCLUSION

Depression is a persistent, debilitating, and chronic illness with long episodes and high rates of relapse and recurrence. Often the clients that social workers see suffer with depression (Olfson et al., 2000). Habitual patterns of negative thinking and rumination are found to play influential roles in relapses/recurrences of depression. Social work has historically relied on either problem-solving therapy (Gellis & Kenaley, 2008) or cognitive-behavioral theory (Ronen & Freeman, 2007) in addressing this negative thinking, rumination, and depression. MBCT is a therapy emphasizing the cultivation of mindfulness through meditation and self-awareness exercises that changes the client's relationship to negative thoughts rather than trying to replace negative thoughts with positive thoughts. Mindfulness, a non-judgmental and experiential practice, seems to fit well with social work approaches. MBCT and its engagement with the profession of social work is at a very early stage, but it appears to show promise.

With MBCT, clients learn to accept thoughts as passing mental events and let go of their habitual automatic thinking patterns and rumination. Studies find that MBCT has shown significant effectiveness in preventing relapses/recurrences for patients in certain categories, for example, three or more episodes and non-life event (i.e., death in family) onsets. It also effectively increases metacognitive awareness to negative thoughts and feelings including rumination, and significantly decreases relapses of major depression. MBCT is considered a highly cost-efficient group-based approach. However, conclusive research studies are still lacking to support the unique role mindfulness plays in MBCT and its effectiveness in relapses/recurrences of depression. Further research is needed to show how MBCT and its requisite practices might inform or shift social work practice.