Mindfulness and Psychotherapy

The practice of mindfulness is a practice that is finding increased attention in the application of psychotherapy. What exactly is mindfulness as it relates to psychotherapy? The term mindfulness comes from the word sati, taken from the Buddhist tradition of meditation and psychology. This word suggests awareness, attention and remembering. According to Dr. Ronald Siegel, Psy.D, Assistant Clinical Professor of Psychology at the Harvard Medical School, mindfulness as it relates to psychotherapy is assisting a person to learn to cultivate a practice of awareness of a present emotional experience. In the book co-edited by Dr. Siegel (2005), Mindfulness and Psychotherapy, New York: Guilford Press, Dr. Siegel suggests that it is also very important that the person is able to practice acceptance of that emotional state as it arises. As used in psychotherapy, mindfulness is a practice that systematically teaches the patient how to accept their emotional experience. This is similar to the use of mindfulness in Marsha Linehan’s Zen-inspired dialectical behavior therapy (DBT). Linehan, M. (1993). Cognitive-behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press. As emphasized in DBT, emotions can become overwhelming, and this may impact one’s behaviors and thoughts in a negative or destructive manner. Mindfulness as utilized in dialectical behavioral therapy attempts to break this pattern by helping the patient better manage these emotions.
  While mindfulness has most often been related to Buddhist or religious/contemplative practices, mindfulness is now also being integrated into what we might call the more traditional forms of psychotherapy as what is now being called the third wave in behavior therapy. The first wave was Operant and Classical Conditioning and the second one is Cognitive Behavioral Therapy. The third wave now incorporates mindfulness into the well know evidence based practice of Cognitive Behavioral Therapy as Mindfulness-Based Cognitive Therapy, (MBCT).
 Mindfulness-based cognitive therapy was developed by Zindel Segal, Mark Williams and John Teasdale (2001), Mindfulness-Based Cognitive Therapy for Depression: a New Approach to Preventing Relapse, New York: Guilford Press. Their work was largely influenced by the work of Jon Kabat-Zin whose work was discussed in a previous article found on this blog site regarding the work of Kabat-Zin and the development of the Mindfulness-Based Stress Reduction Program at the University of Massachusetts Stress Reduction Center.
Mindfulness-based cognitive therapy is a blend of cognitive behavioral therapy (CBT) which focuses on changing our thoughts in order to change our behaviors, and the meditative practice of mindfulness, a process of identifying our thoughts on a moment-to-moment basis while trying not to pass judgment on them and experience them with acceptance as suggested by Dr. Ronald Siegel. While cognitive behavioral therapy has always emphasized the end result of change of one’s thoughts, mindfulness really looks at how a person thinks — the process of thinking — to help one be more effective in changing negative thoughts. What does some current research suggest about the effectiveness of this newer form of psychotherapy?
Coelho et. al. looked at research about mindfulness-based cognitive therapy and found four relevant studies that examined the effectiveness of this approach. Coelho, H.F. (2007). Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. J Consult Clin Psychol., 75(6):1000-5.
The current evidence from the randomized trials suggests that, for patients with 3 or more previous depressive episodes, MBCT has an additive benefit to usual care. It is important to note here that MBCT is designed to help people who suffer from repeated bouts of depression. Coelho found however, because of the nature of the control groups, these findings cannot be attributed to MBCT-specific effects. The researchers did suggest that MBCT has found some positive results for those with a more chronic depression but they could not say that this was as a result of specifically MBCT alone.
It is clear that there is an ever increasing mindfulness oriented model of psychotherapy. Treatment strategies can be derived from the basic elements of mindfulness – awareness of present experience, with acceptance. A review of the empirical literature by Baer (2003); Baer,R. , Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10(2), 125-142, suggests that mindfulness based treatments are “probably efficacious” and en route to becoming “well established”.
The possible emerging model of mindfulness as integrated into psychotherapy can be seen to have promise in many areas of psychology and psychotherapy and has indeed become well established. Similarly empirical research in this area has seen a significant increase. In 2003 at the time of the review by Baer, there were several hundred empirical research articles on mindfulness and psychotherapy and now, 2010, one can find several thousand. Mindfulness is beginning to move into other areas such as brain science, health/medical psychology and positive psychology. It seems that the clinical literature is promising and psychologists and mental health clinicians have the opportunity to integrate a form of mental practice that is based on a 2,000 year old contemplative practice of bringing the mind to the present state, experiencing this state and accepting this state. Additional Resources
University of Massachusetts Medical School, Center for Mindfulness and Medicine
www.NICABM.com
Dr. Ronald Siegel, (2010), The Mindfulness Solution: Everyday Practices for Everyday Problems, New York: Guilford Press
By Marcia Middel, Ph.D.
Dr. Middel is the chief psychologist at the Mental Health Center of Denver. She is also the Director of the Center for Integrated Psychological Services (CIPS) and team associate with MHCD Evaluation and Research team
 

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.