Martine & Stephen

Batchelor

 

Essay/Review

of

“Mindfulness Based Cognitive Therapy for Depression”

An Eight-Week Course

 

When I lead retreats I often encounter people with depression who finds that meditation can help them in some way. I thought it might be useful to make available a review cum essay about a new method devised by Mark Williams, John Teasdale and Zindel Segal and explained in Mindfulness-Based Cognitive Therapy for Depression: A new Approach to preventing Relapse. This book describes an eight-weeks course for groups of patients who have suffered several occurrences of depression. This review is to encourage people, who are interested in this topic, to read the book in case they have not heard of it. Although relatively thorough this essay does not replace the book. It just gives a taste and an idea of what the method entails.

The eight-week course is for groups of 12 people who have had depression and have recovered from its acute phase. Each person has an initial private assessment interview of one hour before joining the group. In the class people are regularly given handouts, tapes and recommended readings or videos to watch. There are feedback, discussion and review times as empowerment is an essential component of the course. One of the core aims of the course is for people “to learn skills to help prevent depression coming back”. The skills to be learnt are: “concentration, awareness, being in the moment, acceptance, letting go, being rather than doing and bringing awareness to the manifestation of a problem in the body”. The aim of the program is freedom from self-inflicted negative depressive patterns and to see how each person can creatively engaged with them.

The first week is focused on the cultivation of mindfulness. The intention is for participants to realize that they are often on automatic pilot. The danger of living one’s life on automatic pilot is that one will also react automatically and thus be easily caught in destructive emotional and mental patterning. They are taught to pay attention in a particular way: “intentionally, in the present moment and without judgment”. This actually changes the nature of their experience. By practicing mindfulness they becomes more aware of their experience in each moment and thus can really engage with it and start to bypass the grooves of the patterns.

The participants end the first session with a short breath focus (two or three minutes) to “ground’ them after this first encounter with a lot of new material. The instructions are for them to “sit with their back straight, focus their attention on their breath as it enters and leaves the body, and notice any sensations associated with the breath”. They are also given some homework for the following week like “doing six times the body scan tape, bringing moment-to-moment awareness to one daily routine activity and eating one meal ‘mindfully’”. The homework is supported by a homework record form which is to be filled each time the patients practice and which will help them discuss their experience at the next session.

One patient reported that at first she found it difficult to concentrate as she kept thinking of other things while listening to the body scan tape. But over time she started to relax more and by not worrying about her distracted thoughts she had less of them, was able to be more present to the exercise and be aware of her body and feelings in an accepting way.

Session two deals with the difficulties people might encounter when they try to be mindful: the mind wandering, not finding the time or the right condition in which to do the exercises, being bored, feeling of irritation, falling asleep, trying too hard or re-connecting with distressing emotions. All these difficulties are discussed and investigated and it is pointed out that all these can become beneficial places for non-judgmental mindfulness.

One specific difficulty is when the body scanning re-connects one with distressing emotions one generally tries to avoid, as sometimes people “have found safer to think about emotion than to experience emotion in the body”. There the instructor suggests that “intentionally returning awareness to the body scan instructions, and then following them by focusing on the specified region of the body, as best as they can, provides patients with a way to ‘steady’ themselves, while still remaining connected to bodily experiences”. The instructors believe that this will help in allowing “completion of the unfinished work of emotional processing”. One participant was concerned that she seemed to get worse after following the instructions for two weeks but actually she found that over time the process reversed itself and she described that she felt that “it’s all been filed away now … and it actually got better”.

In session two, a ‘thoughts and feelings’ exercise is introduced. The story presented is that of a friend coming down the street and ignoring one and participants are asked to consider how they would view this incident and how it would makes them feel. This exercise is to see that “our emotions are consequences of a situation plus an interpretation, that thoughts are not facts and that negative thinking is often a warning signs of oncoming depression”. In the discussion following this exercise people realized that one situation can be interpreted in many different ways and according to different interpretations one will have different feelings, and that a negative perception will lead to a distressing feeling, specially if there is a fertile ground of depressive notions and patterns.

In this session creating a pleasant events calendar is suggested as an exercise in mindful awareness of what is and can be positive in one’s life. This can act as a counterweight to the tendency of thinking that everything is difficult and unpleasant. At the end of the session there is again a meditation focusing on the breath to develop a still and calm awareness in which thoughts, feelings and sensations can come and go. The homework for the following week is to continue to “use the Body Scan tape, to practice ten--fifteen mindfulness of breathing for six days, to fill the Pleasant Events Calendar with one entry per day and to choose a new routine activity to be especially mindful of daily”.

The third session emphasizes the focusing on the breath as a tool to steady and ground oneself in daily life. The participants do a thirty to forty minutes sitting meditation. After which they receive recommendations on the Three-Minute Breathing Space. This exercise will become one of the main tools of awareness and refuge in their daily life. The Three-Minute Breathing Space has to happen three times a day. There are three basic steps (called Awareness, Gathering and Expanding) to be done at set times: first “asking oneself “Where I am?’ or “What’s going on?”” as a means to bring oneself back to attention in the present moment. The second step consists in “bringing the attention to the breath”. The third step is “to expand the attention to include a sense of the breath and the body as a whole”. In MBCT the awareness of the body is seen as an important anchor, which steadies one and allows one to be less caught in mental ruminations.

At this stage mindful stretching and walking are introduced as well as an unpleasant events calendar. The task is to “notice as clearly as possible the thoughts, feelings and bodily sensations associated with unpleasantness” in order to “learn to relate differently to them”. The homework is “to use the Combined Breath Focus Tape three times, follow yoga instructions three times, practice the Three-Minute Breathing Space and complete the Unpleasant Events Calendar (one entry per day)”.

The fourth session is about working with the comparing mind and the mind that clings or avoids. Mindfulness of sounds and thoughts is introduced. An automatic thoughts questionnaire is given to reflect on and note the thoughts that occur repeatedly over the week and color one’s view of reality like:

  • I’m no good.
  • I’ve let people down.
  • I feel so helpless.
  • It’s just not worth it.

The questionnaire contains thirty such thoughts. The participants are also presented the Diagnostic Criteria for Major Depressive Episode – i.e. the inability to experience pleasure, sleeplessness, fatigue or feelings of worthlessness, etc –symptoms, which have lasted for more than two weeks. The instructors believe that “education about depression is essential if people are going to learn ways to deal with it more skillfully”. One of the symptoms of depression is for people to feel alone in it, by looking at these criteria as a group, patients discover the commonality of the symptoms of this illness. It is not only them who feel or experience themselves that way. The difficult with the questionnaire is that it might make people feel even sadder as they recognize and identify with some of these thoughts. Then the idea is to take a Three-Minute Breathing Space as a means to experience the sadness in a different manner.

By week four the participants are starting to feel the benefits from all this practice, their dedication and commitment. One mentioned that she felt sad because of her grandmother illness. She was able to recognize that she was tired and sad because of this condition and that this was not depression. So she could be with the feelings and the thoughts without denial and thus could let them pass through her. Another had to make a distressing phone call and instead of ruminating all day about it, at the end of it, she did the breathing space exercise and it allowed her to move on and for the worry to vanish.

The homework, that week, is to “practice the Guided Sitting Meditation Tape, six out of the next seven days, do the Three-Minute Breathing Space as a rule three times but on top of that use it to cope whenever unpleasant feelings are noticed”.

Session five focuses on acceptance and on cultivating a different relationship to experience. In the forty minutes meditation participants are encouraged to let difficulty issues come up in the mind and instructions are given to help one become aware of their effects in the body and to “let go of the aversion”. A poem of Rumi whose theme is acceptance of the whole person and of his or her experience is read.

There are further practice and homework reviews. People explore the difference between using the breath to escape, fix or avoid, which does not seem to really help, or using the breath to acknowledge fully and to accept what one is experiencing, which seems to bring a significant change. People notice that the first approach gives energy to the resistance and the latter one brings space to what one is feeling and as Michael, a patient, mentioned: “you feel that everything isn’t out of control”. The homework is to continue with the sitting practice alternating listening to a tape and just sitting in silence, and with the Three-minute Breathing Space as a regular and coping practice.

In session six negative moods and thoughts are explored and it is pointed out that “thoughts are not facts”. Meditation on thoughts is introduced. There is also a “moods, thoughts, and alternative viewpoints exercise”. The Breathing Space is presented as “the first step before taking a wider view of thoughts”. One of the difficulties with depression is that people are over-engaged with their thoughts and have long ruminative discussion with themselves. So in this session it is shown that one does not need to answer back one’s own thoughts. One participant found that she really benefited from telling herself that “thoughts are not facts even the ones that tell you they are”. It helped her to engage more playfully and light-heartedly with her ruminative thoughts.

The homework consists in meditating a minimum of forty minutes a day in different self-appointed chunks, and in continuing with the practice of the Breathing Space. Patients are also asked to notice when they “use the breath as an anchor to handle the situation as it is happening” and when they “use the mindfulness practice to deal with issues later”.

In session seven people are preparing for the future after the eight-week session ends. Now they need to focus on the positive in their life and what uplifts their moods. In order to do that they have to become aware of the connection between what they do and how they feel. It helps if they write down a list of what bring them joy and what demonstrate to them that they are good at doing something. They are encouraged to “plan how best to schedule such activities”.

They are also asked to recognize the warning signals of a future relapse – “irritability, decreasing social participation, change in sleeping or eating habits”, etc. It is essential for them to map out the actions they can undertake to prevent the recurrence of a depressive state. The homework is to decide on the form of meditation one wants to do in the next five weeks on a regular basis and to continue with the regular and coping practice of the Three-minute Breathing Space. To prevent relapse the recommendations is to “set up an Early Warning System” and to prepare an “Action Plan” reminding oneself of the tools one has cultivated during the course.

Session eight is an opportunity to review the whole course and for participants to reflect on what they have experienced and what they have learnt. People relate how the course has allowed them to learn to slow down and to find an inner safety devoid of criticism, which “helps defuse negative mental thoughts before they cause any more damage”. Some pointed how affirming it had been doing the course with other people “who know what depression is like”. Other found the breath meditation especially beneficial. One “discovered an inner strength”, another felt that doing the course “had removed a sense of shame”.

One person realized that they did not need to “worry about the future and their past failures”, that it was much more rewarding to live in the present. Now that person “could more evenly and calmly embrace the present moment” and thus learn from it to prevent further recurrence of depression. At the end of the course two handouts are given, one about “using what has been learned to deal with future moods” and the other about how to cultivate “daily mindfulness”. The core advice people are being given is to ‘KEEP BREATHING’ with awareness.

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