Mindfulness and Mental Health

Psychotherapy and spirituality have mingled with one another since the early development of talk therapy. Early psychotherapists relied on their philosophical and spiritual beliefs as they worked towards an understanding of the soul, the spirit and the self. With the development of more concrete therapeutic techniques, the use of religion and spirituality in psychotherapy has fallen out of favor (especially with the growing interest in evidence-based practice). One exception to this is the major influence that meditation has had on modern day psychotherapy. Meditation has been a part of many different religious traditions (e.g., Hinduism, Taoism); however, I believe that most of us associate it with Buddhism. As a beginning point for my research, I conducted an online search using only the term “Mindfulness”. The results pointed to Jon Kabat-Zinn, a physician who has dedicated his career to highlighting the benefits of the use of meditation in health care. The results also helped to clarify the definition of the term “mindfulness” as a reference to the therapeutic application of meditation. This helps in understanding the interchangeable relationship between the terms meditation and mindfulness.

Understanding the use and benefits of mindfulness required more in-depth research, much of which lead to resources rather than answers. For example, Dr. Daniel Seigel has written several books on the process of incorporating mindfulness based practice with psychotherapy: Mindsight and The Mindful Brain.

Jon Kabat-Zinn, mentioned earlier, has written extensively on the use of mindfulness in reducing stress and anxiety. His books include: Full Catastrophe Living, The mindful Waythrough Depression, and Wherever You Go, There You Are.

Common to both these authors is their emphasis on the relationship between mind and body. Many who practice mindfulness in psychotherapy believe that awareness of the self in the present moment (including past repressed emotions and memories) is the pathway towards successful living. Through mindfulness, a clinician can help a client move away from the avoidance strategies implemented in the past. The goal, in this type of therapy, is to help a client gain awareness of the self by understanding and processing feelings throughout the body – notably while processing painful affect and memories. In essence, mindfulness is the opposite of mindlessness. This idea is rooted in the belief that negative emotions need to be processed before an individual can move towards successful living.

Now to the ultimate question, “Does Mindfulness Work?” For this question I moved away from “Google” research and utilized other resources (e.g., PsychInfo and PsychArticles databases). The results led to many articles with only a few catching my attention. For instance, an article titled “The Effect of Mindfulness-Based Therapy on Anxiety and Depression: A Meta-Analytic Review” reviewed 39 studies with participants receiving mindfulness-based therapy for a range of conditions (i.e., cancer, generalized anxiety disorder, depression, and other psychiatric or medical conditions). The researchers found that mindfulness-based therapy was moderately effective for improving anxiety and mood symptoms, concluding that mindfulness-based therapy is a promising intervention for treating anxiety and mood problems in clinical populations. It is important to note that this study is a summary of 39 other studies on the topic of mindfulness. This is a convenient way of capturing a wide-range snapshot of the available research.

A study titled “Mindfulness-Based Stress Reduction and Health Benefits: A Meta-Analysis” concluded that Mindfulness-Based Stress Reduction (MBSR, “…a structured group program the employs mindfulness meditation to alleviate suffering associated with physical, psychosomatic and psychiatric disorders…”) may help a broad range of individuals to cope with their clinical and nonclinical problems. Finally, a study titled “The Effects of Mindfulness-Based Stress Reduction Therapy on Mental Health of Adults with a Chronic Medical Disease: A Meta-Analysis” concluded that the same intervention (MBSR) has small effects on depression, anxiety and psychological distress in people with chronic somatic diseases. They add that integrating MBSR in behavior therapy may enhance the efficacy of mindfulness based interventions. Here below is a link to the first MBSR article and an abstract of the second MBSR article: 

So, back to the question “Does mindfulness work?” In my opinion, the answer is that it does work, however (like all other interventions/techniques), not across all populations, conditions or contexts. Current research is primarily focused on understanding which populations, conditions and contexts would benefit most from mindfulness. The first meta-analysis covered above showed that the use of mindfulness is moderately effective while the following two studies resulted in less positive findings (e.g., “may help…” and “…has small effects…”). I think this speaks to the need for a more detailed understanding of mindfulness as a technique in psychotherapy. For instance, it may be the case that mindfulness successfully compliments certain traditional forms of psychotherapy while conflicting negatively with others. It may also be the case that mindfulness fits well when it comes to certain psychological/psychiatric conditions but not others. For now, it does seem that mindfulness based psychotherapy is a useful practice for addressing general anxiety and depression. 

By Ous Badwan

Ous is a Psy.D. Student from the University of Denver’s Counseling Psychology program  currently doing a research internship at MHCD.

More about neuroplasticity

Last week we described briefly some research about the relationship between bran plasticity and emotional wellbeing. This week, we would like to talk about another area where there is some very exciting research that links brain plasticity and mental wellbeing. In addition to the symptoms usually associated with schizophrenia (hallucinations, delusions, disordered thinking; see NIMH’s website for a description of schizophrenia and its symptoms, there are other symptoms which are as important but hardly mentioned and include: inability to understand information, trouble focusing attention, and problems with memory (in particular, maintaining and using information which is known in behavioral research as “working memory”). The reason why this is an important deficit, is because there is evidence that shows that cognitive deficits like those described, will have an impact on more functional outcomes; things like employment, education, social interaction, and even ability to live independently.

There is some very recent research that focuses on some of the brain mechanisms that may be involved in this deficit (some neurochemicals and their receptors that do not work as intended). Also, there is some research that tries to tackle these deficits from a different point of view: Cognitive Remediation Therapy (CRT), whose main goal is to teach individuals some strategies to improve their cognitive skills go here and here  for links to some of these studies). These skills include things like rote memorization, and/or the use of strategies to memorize/pay attention to key pieces of information.  Regarding CRT, one study that we found is a meta-analysis by McGurk and others. Meta-analysis is a great tool for research, because it helps summarize in a scientific way the information contained in many studies. In this case, the authors summarized and compared the results of 26 studies to explore whether the use of CRT helped individuals with schizophrenia not only to have better memory, attention and problem solving, but also better functional outcomes. The analysis showed great promise in several areas: improvement in cognitive areas like attention, verbal learning and memory, ability to process information faster and ability to solve problems. Interestingly, the analysis also showed that at least within these studies, there seems to be no relationship between the length of the program (number of hours spent learning the techniques and practicing) and the improvements observed. It seems that as long as the individuals practiced between 5 and 15 hours (the program with the maximum length was 15 hours), there were no differences in improvement, with one exception: Verbal learning and memory. However, it is possible that this relationship does not seem to be important, because the studies did not go far enough in time to observe changes. Only six programs assessed changes in the individuals 8 months after the program ended. Therefore there will be no way to know if the effect of number of hours helped change or maintain the improvements after 8 months.

There were two other interesting findings. One is that the CRT programs seem to have minor impact on the more traditional symptoms of schizophrenia (though there are some other studies that suggest improvements in mood and self-esteem).  The other finding is also a minor improvement on the functional outcomes; things like working on competitive jobs, improvement in the individual’s social relationships and ability to solve interpersonal problems. However, for the second finding, the researchers also found that studies that combined CRT with psychiatric rehabilitation had a stronger effect than those studies that used only CRT.

Although the results are not conclusive, this time, the bottom line seems to be that the combination of clinical therapy, psychiatric rehabilitation and some type of cognitive improvement program holds the most promise as far as being able to improve memory, attention, concentration, and also improve functional outcomes like maintain employment, and have meaningful relationships with other individuals (go here for similar conclusions).

Is it possible that the results found are just like a “sugar pill” (i.e., a placebo effect)? It does not seem likely. Some of the studies compared CRT versus more clinician’s attention and found that individuals who attended CRT showed much more improvement than those who received only more clinician’s attention.

Some factors still need further study. For example, since only a few studies reassessed individuals a few months (8 at most) after the program ended, it is unclear if the number of hours of practice will have a significant impact on maintaining this cognitive improvement longer. Similarly, only a few studies try to relate changes in the more cognitive tasks (memory, attention, problem solving) with functional outcomes (going back to –and maintaining—employment, improvement in social relationships). This is an area where the Mental Health Center of Denver (MHCD) and the MHCD Research institute are currently working to further understand the relationship. Stay tuned for forthcoming blogs where we will talk about mental health research using functional outcomes.

Research on brain plasticity

There has been some recent research that seems to point toward the fact that the brain is much more pliable than what we used to think. This is part of a field known as Neuroplasticity. Just to check, I decided to run a quick search on Google of the word “neuroplasticity”. According to Google, I got “about 838,000 results”, and it only took “0.20 seconds”. This can be a little overwhelming, if you want to learn about what neuroplasticity can do for you. There are a few blogs where the term neuroplasticity can be found, but someone who has written a lot is  beyond meds . Many of the posts related to neuroplasticity can be traced back to a book written by Norman Doidge: The brain that changes itself. In his book , Dr. Doidge had stories about different individuals who have been able to overcome challenges by “rewiring their brain”. Some of the individuals and stories were related to some major issues, like having a stroke and having to relearn how to walk or talk. But there were a couple of chapters dedicated to emotional imbalances. One that tries to explain sexual disturbances and one related to mental illness. If you have a chance to read this, it is highly entertaining, and is highly exciting to learn about everything that in theory can be achieved by just rewiring our brains. However, be warned that it may be too easy to assume that everything can be achieved if we just try to rewire ourselves. Life is never that easy.
In a more recent story, at science daily we found a description of recent research with a more direct relationship between brain plasticity and mental illness coming out of the University of Oregon. The original research tries to link the relationship between changes in emotional wellbeing (such as reduction in stress, anxiety and depression) and changes in neuroplasticity. What the research seems to show is that if we meditate, (as opposed to just learn to relax) using a technique called Integrative Body Mind Training, and if we train in these technique long enough, our brain eventually learns how to keep this state of mind and changes its structure so it can respond to stressors in a more adequate way. For example, in the same article,  it is explained how students who learned those techniques, “showed lower levels of anxiety, depression, anger and fatigue than students in a control group” before a math test. The changes were associated with a specific part of the brain (the anterior cingulate cortex, which is connected with the amygdala and other midbrain structures usually associated with emotions). To make matters more interesting, it is explained that the anterior cingulate cortex is associated with several mental illness and emotional disturbances like attention deficit disorder, dementia, depression and schizophrenia.

Does this mean that we need to stop doing whatever we are doing and just start learning Integrative Body Mind Training? Probably not; I am sure we can use it in addition to whatever other medications/therapies/strategies are currently being used to recover from mental illness, but I do not think that anyone at this point will endorse shifting to this therapy while forgetting other options. There are many reasons why shifting is not a good idea. First of all, different individuals seem to respond in different ways to some therapies. I am sure many of us have experienced with medications or other types of home remedies in our daily encounters with fevers, cold or other illnesses, just to find out that what works fine for some individuals, do not necessarily work for us. Further, the research is still considered preliminary, and much more testing needs to be done to be considered as an alternative to other types of therapies. Why more testing? It could be possible that the individuals who were in the study were somehow predisposed to show better outcomes, because they knew that they were in a study. This is similar to the type of precautions that are taken when pharmaceutical companies are testing medications, and they found out that a sugar pill has the same effect that this very expensive medication that has taken years of research. Furthermore, if you have a chance to read Dr. Doidge’s book you’ll notice that his stories are based on individuals and not groups of people. If we want to be able to generalize to more than single individuals, we need to replicate the studies in multiple settings and across different types of people, to determine that the effects are not restricted to a specific type of people, or even worse, to some very unique characteristic that can only be found on a few individuals.

Although more testing needs to be done, this does not undermine the importance, excitement and potential that some of these findings bring to the field of mental health. Clearly, there is so much that we still need to learn about the brain and its connection to behavior, that it can be a little bit intimidating and perhaps overwhelming, especially when you feel that you need to know that now for your own personal reasons. On the other hand, it can be exciting to think about how much more we can learn about the relationship between our genetic makeup, the brain and the environment and how all three shape our behavior.

There are other types of meditation such as "sitting meditation" also called "mindfulness meditation" or "vipassana"/insight meditation that have long been utilized to address both emotional issues and health issues. We will discuss these practices in a future blog as they relate to both mental and physical health.

Research on Mental Health and Recovery from Mental Illness

We are the Research Institute at the Mental Health Center of Denver, and although technically we were just funded on May 2010, we have been doing research on mental health for the last 10 years.

We have been doing research in many areas associated with both Adults and Children's mental health. More recently however, we have concentrated our research on Recovery, Resiliency and Wellness in general. We have found that people outside the field of mental health, sometimes can confuse recovery from mental illness with recovery from substance abuse therefore, we are beginning to shift toward the word "wellness", which captures a lot of what is meant by recovery from mental illness.

Part of our research duties include to search for research in many places (including the internet), and since sometimes it is difficult to find good information, we decided to start this blog that will try to bring together research that we find interesting in areas associated with in mental illness and Recovery, Resiliency and Wellness.

We also maintain another blog where we speak much more about recovery from mental illness and substance abuse. If you are interested in learning more about those topics, and the impact it may have on everyday’s life, we invite you to visit our blog. If you are interested to learn about our research, we invite you to visit two of our websites: http://www.outcomesmhcd.com/ where we describe our work at MHCD in recovery, resiliency and wellness in both adults and children, as well as a current list of our publications and presentations. Or you can visit http://mhcdresearch.org/ where we present more of the services we can offer to centers and other entities interested in doing research and evaluation in recovery, resiliency and wellness, improving clinical practices, creating more effective and efficient use of clinical resources, mining clinical data, etc