Building Competence in Mindfulness-Based Cognitive Therapy

Transcripts and Insights for Working With Stress, Anxiety, Depression, and Other Problems

Richard W. Sears

• Publisher: Routledge
• Year: 2015
• Print ISBN:
  9780415857253
• eBook ISBN:
  9781135087227
• Topic: Psychology
• Subtopic: Education in Psychology
• Index: Psychology

Mindfulness-Based Cognitive Therapy (MBCT) is an evidence-based program that combines mindfulness and cognitive therapy techniques for working with stress, anxiety, depression, and other problems. Building Competence in Mindfulness-Based Cognitive Therapy provides the first transcript of an entire 8-week program. This intimate portrayal of the challenges and celebrations of actual clients give the reader an inside look at the processes that occur within these groups. The author also provides insights and practical suggestions for building personal and professional competence in delivering the MBCT protocol.

1
Introduction

Mindfulness-based cognitive therapy (MBCT), first developed by Segal, Williams, and Teasdale (2013), is an 8-week, evidence-based program that integrates training in mindfulness skills with cognitive-behavioral therapy (CBT) techniques for working with stress, anxiety, depression, and other problems. Mindfulness, or awareness of present-moment experience, is developed through exercises designed to strengthen attentional capacity.

Zindel Segal (2013) describes four ways mindfulness can be helpful for clients. First, it fosters awareness, which counters the “automatic pilot” mode we often fall into by bringing conscious attention to habitual patterns of thinking and reacting. Second, it helps clients come into their present-moment experiences more often rather than getting stuck in past memories and future anticipations. Third, it develops more choicefulness, that is, it fosters response flexibility, allowing clients to become more aware of the choices they have in any given moment. Fourth, mindfulness practice improves affect tolerance, which helps clients to allow their feelings to rise and fall naturally rather than struggling with them or avoiding them through maladaptive behaviors.

Interventions utilizing mindfulness are continuing to gain attention due to the effectiveness demonstrated in clinical research. On the website of Division 12 (Society of Clinical Psychology) of the American Psychological Association (www.psychologicaltreatments.org), dialectical behavior therapy and acceptance and commitment therapy, both of which have a major mindfulness component, are listed as having “modest to strong research support,” the same rating given to behavior therapy and cognitive-behavioral therapy. MBCT is listed under Cognitive Therapy for Depression, which is described as having “strong research support.” MBCT and mindfulness-based stress reduction (MBSR) are also listed and reviewed in detail on the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence-Based Programs and Practices in the United States (www.nrepp.samhsa.gov). MBCT is also recommended for depression by the UK’s National Institute for Health and Care Excellence (www.nice.org.uk).

Another reason mindfulness is gaining so much attention is due to the plethora of brain imaging studies demonstrating concrete changes in structure and functioning, even after 8 weeks of mindfulness practice, in both adults and children (e.g., Cotton, Luberto, Stahl, Sears, & DelBello, 2014; Davidson, Kabat-Zinn, Schumacher, Rosenkranz, Muller, et al., 2003; Farb, Segal, & Anderson, 2013; Farb, Segal, Mayberg, Bean, McKeon, & Anderson, 2007; Hölzel, Lazar, Gard, Schuman-Olivier, Vago, & Ott, 2011; Lazar, Kerr, Wasserman, Gray, Greve, et al., 2005; Siegel, 2007).

Clinicians are also becoming increasingly interested in mindfulness for their own self-care and clinical training (e.g., Davis & Hayes, 2011; Fulton, 2005; Shapiro, Brown, & Biegel, 2007). Interestingly, the clients of therapists who practice mindfulness have been shown to have better outcomes (Grepmair, Mietterlehner, Loew, Bachler, Rother, & Nickel, 2007).

The story of how MBCT came into being is described in the treatment manual (Segal, Williams, & Teasdale, 2013). Initially, the developers of MBCT, Zindel Segal, Mark Williams, and John Teasdale, were working to develop an effective, efficient intervention to prevent relapses of depression. The chances of becoming clinically depressed yet again increase with each episode of depression, and after two episodes of depression, there is a 70% to 80% chance of recurrence (Keller, Lavori, Lewis, & Klerman, 1983; Kupfer, 1991).

Meta-analyses of more than 40 studies demonstrate that there is no difference in negative thinking patterns between those who were between episodes of depression and those who had never been depressed (Ingram, Atchley, & Segal, 2011). It turns out that it is not negative thinking but dips in mood that lead to depressive relapse. Those who have previously experienced major depressive disorder take longer to recover from ordinary dips in mood. During this time, they are more vulnerable to reactivation of negative thinking, attitudes, and beliefs, leading to withdrawal behaviors and reduced activity levels, which can result in a downward mood spiral (Segal, Gemar, & Williams, 1999). This understanding led to a search for a new approach to preventing depression, and after consultation with Marsha Linehan, developer of dialectical behavior therapy (Linehan, 1993), and Jon Kabat-Zinn and colleagues, who developed mindfulness-based stress reduction (Kabat-Zinn, 2013), MBCT was born.

MBCT has been studied with rigorous, well-controlled clinical research, demonstrating significant reductions in depressive relapse rates, especially for those who have suffered three or more previous major depressive episodes (Hofmann, Sawyer, Witt, & Oh, 2010; Kuyken, Crane, & Dalgleish, 2012; Ma & Teasdale, 2004; Piet & Hougaard, 2011; Segal, Teasdale, & Williams, 2004; Teasdale, Segal, & Williams, 1995; Teasdale, Segal, Williams, Ridgeway, Soulsby, & Lau, 2000; Williams & Kuyken, 2012). MBCT has also been shown to be as effective as maintenance antidepressant pharmacotherapy (Kuyken, Byford, Byng, Dalgleish, Lewis, et al., 2010; Segal, Bieling, Young, MacQueen, Cooke, et al., 2010).

How Does MBCT Differ From Traditional CBT?

MBCT incorporates many cognitive-behavioral therapy (CBT) principles and techniques for working with thoughts, emotions, body sensations, and behaviors. The difference is in how clients are taught to relate to those aspects of themselves. Basically, what appears to be implicit in CBT is made explicit in MBCT.

For example, CBT methods often target change in the content of a client’s cognitions, using systematic techniques to question the logic, utility, or validity of the thinking. A CBT therapist might teach a client to notice a negative automatic thought and to question the evidence for and against that thought. Clients can then train to restructure their thinking into a more rational or functional alternative (Sears, Tirch, & Denton, 2011). However, sometimes clients get into arguments in their own minds, because it is difficult to outthink oneself. Also, according to the principle of mood state-dependent memory, when one is depressed, the brain will have much easier access to depression-related memories (Segal & Lau, 2013; Ucros, 1989). For example, when a client becomes aware of a thought such as, “I can’t do anything right,” the client then asks, “What’s the evidence?” The client may then respond with something like, “Well, I failed at school, work, and marriage.” “But your partner had a part in the failed relationship.” “But I’m the idiot who picked her.” “What about getting your college degree?” “That’s only because the instructors went easy on me.” And so it can continue, ad absurdum.

Decades ago, Hollon and Beck (1986) acknowledged that change in cognitive content may not actually be the active ingredient in cognitive therapy. Subsequent component analyses have not proven that the cognitive challenging component actually adds value to the therapeutic effectiveness of CBT interventions (Longmore & Worrell, 2007; Sears, Tirch, & Denton, 2011). It appears that noticing, writing down, and challenging thoughts actually serves to foster a process known as “decentering” (Segal, Williams, & Teasdale, 2013).

In MBCT, clients are explicitly taught to practice this decentering from thought content, effectively changing their relationship to the thoughts, uncoupling them from their affective components. Clients learn to recognize that they have thoughts, emotions, and sensations instead of overly identifying with them (being in the center of them). In other words, when a thought arises like, “I can’t do anything right,” clients practice noticing, “I am having a thought that I can’t do anything right.” Instead of engaging in internal debates with intense thoughts, clients see them as possible signs of underlying emotional states such as stress, depression, or anxiety. Clients can then shift their attention from the thoughts to explore their present-moment emotions and body sensations. This awareness opens up more opportunity for conscious responding, such as allowing the underlying feelings to pass instead of fueling them with more struggle, taking some considered action to deal with the situation, actively engaging in self-care to address the anxiety or depression, or even going back to thinking if they so choose. Conscious responding prevents the client from automatically engaging in reactions, such as avoidance and withdrawal, that might worsen their symptoms.

As will be seen in the session transcripts, MBCT incorporates a number of CBT principles and techniques, such as the ABC model (that thoughts, feelings, and behaviors affect each other), thought records, recognition of automatic and maladaptive thought patterns (catastrophizing, generalizing, mind reading, all-or-nothing thinking, etc.), and relapse prevention plans. The main difference is that MBCT emphasizes a decentered, curious approach to noticing and questioning troublesome thoughts, then choosing what to do next rather than getting caught up in debating with those thoughts. Mindfulness skills, which strengthen attentional capacity, are the vehicle for systematically developing and reliably engaging this ability to notice automatic patterns and to relate differently to challenging experiences.

Varieties of MBCT

In the wake of its success with preventing depressive relapse, MBCT is now being studied and adapted for a variety of populations and presenting issues, such as addictions (Bowen, Chalwa, & Marlatt, 2010), bipolar disorder (Deck-ersbach, Hölzel, Eisner, Lazar, & Nierenberg, 2014), cancer (Bartley, 2011), children and adolescents (Semple & Lee, 2011), eating disorders (Kristeller & Wolever, 2011), health anxiety (Surawy, McManus, Muse, & Williams, 2014; Williams, McManus, Muse, & Williams, 2011), posttraumatic stress disorder (Sears & Chard, 2015), and tinnitus (Sadlier, Stephens, & Kennedy, 2008).

Seeing the variety of conditions helped by MBCT and by mindfulness in general reminds one of the fantastic claims made by charlatans selling elixirs. However, through the development of more awareness of one’s present-moment experiences (however difficult), one can make better choices to more flexibly relate to a wide variety of life situations.

The program I present in this book is an MBCT program open to the general public, with the premise that an educational, skill-building mindfulness group will reduce stress and increase awareness, thereby helping a variety of conditions. Discussions of depression, anxiety, chronic pain, and other problems come up throughout the course or as needed based upon the particular group members. The anonymous evaluations given to participants at the end of these groups have shown that they are very important and helpful. I am currently collecting more controlled and detailed research on this approach, including data collected as part of Karen Byerly-Lamm’s doctoral dissertation.

The Need for and Purpose of This Book

While each variation of the MBCT model requires specialized training, the core components of each are the development of mindfulness skills and the teaching of CBT principles. Though the delivery methods may be refined over time, the essential skills of mindfulness have been taught for thousands of years, and this natural human state of being is timeless and already present in each client. This book therefore serves as a general guide for developing the qualities of an MBCT instructor, facilitating the process of learning the variations of MBCT delivery.

MBCT is different from other types of interventions that mental health professionals are typically trained to do. This is not something one can learn simply as academic knowledge, and it is not an intervention done “to” the client. It is crucial for the clinician to experience, practice, and embody the core skills and principles of mindfulness. Rather than engaging the participants as if they were individual therapy clients to whom one is applying the techniques of cognitive-behavioral therapy, the facilitator models mindfulness in responding to present-moment experiences in the group. This is difficult for a beginner to understand without observing examples of how this is done. Unfortunately, because so few people are well trained in MBCT, there are often not enough groups close to where one lives to provide the opportunity to experience how these processes unfold over the course of 8 weeks.

The purpose of this book is to provide glimpses of what it might be like to take a group through all eight sessions of this experiential approach through exploring important considerations and through actual transcripts. Of course, every group is a little different, just as every individual psychotherapy session is different. The goal is not to imitate my style or to make your sessions like mine but to provide a sense of the attitudes and processes that are so crucial to making MBCT work effectively.

This book is for you, the clinician. We will not go into detail about definitions and theories of mindfulness, though the transcripts contain much of that. The resource list in the next chapter offers a number of suggestions for getting more background knowledge if you are not already familiar with mindfulness and its clinical applications. Because the entire MBCT curriculum, as well as details about its evidence base, can be found in other books, the emphasis here will be on the processes involved in implementation.

Readers who are serious about learning how to implement MBCT interventions will of course need to obtain the treatment protocol manual (Segal, Williams, & Teasdale, 2013), which provides detailed instructions for how to conduct each session, as well as access to audio recordings and handouts for participants. However, this volume can also serve as an introduction to MBCT. The best way to learn, as in any treatment modality, is to experience it for oneself. Reading through the conversations and exercises in this book can give one a feel for what MBCT is all about, and if the reader chooses to learn more, the concepts in the treatment manuals will likely make more sense.

The next chapter will set the foundation by describing how to build personal and professional competence in MBCT. The chapter will describe the essential qualifications and training needed to become a competent facilitator, provide a list of resources for further study, and discuss the importance of the therapist’s own personal mindfulness practice.

The third chapter will explore important considerations for the competent delivery of the MBCT protocol. The focus will be on processes, such as how to lead the mindfulness exercises and the crucial phase of inquiry that follows. The chapter will also explore issues related to working with challenging clients, considerations for training and supervising students, and the practical issues of running an MBCT group.

The bulk of this book consists of actual transcripts of an 8-week MBCT group. Each chapter begins with a description of the important concepts of the session, followed by a transcript of the entire session with clients’ questions, comments, and reactions.

The participants in these transcripts are real people, though all identifying information has been removed or changed. They all freely gave their permission to record the sessions. Originally, I recorded several groups and considered combining them into a sort of composite for teaching purposes, but I felt that following the same individuals gives the reader a better sense of the growth process that happens. This group was smaller than usual, having only five members, resulting in a more casual, more intimate feel than is typical for a larger group.

The transcripts have undergone some minor editing to make them smoother and more natural to read. Unfortunately, listening to the recordings as I compare them to the transcripts, the words on the page seem terribly flat. The reader will miss the tone, emphases, silences, body language, aliveness, and dynamics of being present in an actual group. It is also difficult to sense the warmth and acceptance that I am modeling.

Because the mindfulness exercises take up a large part of each session and are already transcribed in the protocol books, they have been edited out to save space. One can find free recordings of the exercises on the Internet, including my own website, www.psych-insights.com. The groups are not simply a place to read transcripts of exercises, which participants can get from listening to CDs. The essential ingredient of an MBCT group is the inquiry and processing that takes place when the participants are learning to internalize the principles of mindfulness and how to integrate them into their daily lives.

Though small talk naturally emerges from an atmosphere that is warm and inviting, I have cut most of this out to save space. There are also places where we do not strictly follow the formal curriculum. For empirical studies, careful adherence to reproducible protocols is very important. For ongoing clinical work, minor adjustments for the particular group, modeling flexibility and present-moment experiencing, can be priceless. While you will find all of the elements of the protocol covered in each group, you will also find natural digressions to material relevant for the individuals in this group. However, even when the session gets “off track” in terms of content, the principles of mindfulness are still being followed, because the facilitator is joining into the developing mindfulness processes of the participants rather than automatically squelching the process artificially to rigidly adhere to content structure at every moment.

Of note, this group was conducted before the second edition of the MBCT manual was published. You may notice a few minor differences in protocol here, such as viewing the Healing From Within video, but the general format is the same.

Even in the couple of years since this was recorded, I feel that I have grown and matured as an MBCT therapist, and I endeavor to continue to do so. The participants and graduate students attending each group never fail to share and inspire new insights. I considered starting a newer set of recordings, but perhaps this will serve as a reminder to engage with reality as it is and to let go of the desire for some kind of perfection in the delivery of the group.

In each MBCT session, we open with a mindfulness exercise, which models starting with this moment before addressing challenges (Segal, 2008). Similarly, this book will start with building personal and professional competence before getting into the details of conducting MBCT groups. However, if you are relatively new to MBCT, you might choose to skip down to the actual transcripts of the groups, ideally downl...

Table of contents

• Cover Page
• Half Title page
• Frontmatter Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Figures
• Foreword
• Acknowledgments
• 1 Introduction
• I Building Competence
• II Session Transcripts
• References
• Index
• List of Contributors