Mindfulness Based Cognitive Therapy (MBCT) (My Favorite Therapy)
Many modalities and therapies are available for patients in order to help them with mood and reduce stress. One in particular, is Mindfulness. Mindfulness-based practices originated in eastern parts of the world and has rapidly spread due to the known benefits and ease of application (R). During mindfulness, the goal is to consciously pay attention to thoughts and feelings without placing judgement on them. When doing this form of practice, one may combine a cognitive therapeutic technique, namely, cognitive behavioral therapy (CBT), which, when combined with mindfulness, is called mindfulness-based cognitive therapy (MBCT). In CBT, the premise is that thoughts precede mood and false beliefs lead to unwanted emotions. The goal is then to eventually replace negative thought patterns with positive thinking. Having patients participate in both forms of therapy may produce an additive effect with regard to positive outcomes, in theory. It stems from earlier research and success with treatment resistant major depressive disorder and cognitive processes (R). As with cognitive behavioral therapy (CBT), emphasis with MBCT is on psychoeducation and changing maladaptive thought patterns to facilitate the relaxation response. Homework is also undertaken as well as individual practice.
Theory
The theory originated in the 1970’s and is a hybrid of mindfulness and cognitive therapy, which was thought to be more effective than one technique alone. It’s theorized that once someone has a history of depression, the individual is more likely to return to those automatic thought patterns. Mindfulness philosophy is to make observation and identify feelings, where cognitive therapy teaches one to interrupt those automatic thought processes that happen in depression, but also other forms of psychopathology. MBCT has then evolved to become a technique or practice to essentially lower the consumption of medications and provide a safe, psychosocial intervention for patients suffering.
Mechanisms
The most common conditions in psychiatry are depression and anxiety while 50% of high-cost users of the American healthcare system have some form of a mental health condition (R). One may separate depression from anxiety where depression is generally reflecting on past failures, where those with anxiety tend to dread and worry about the future. When the focus is on either of these states, the individual has less attention on the present moment. By practicing non-judgmental awareness and becoming more present, MBCT may interrupt the emotional reactivity and depression symptomology. Functional imaging shows centers in the brain that regulate compassion becoming more active, compared to non-controlled subjects. The other main mechanism of MBCT includes cognitive flexibility through attentive processes. All thoughts compete in theory, and threatening, unwanted, negative, or self-defeating thoughts may take priority, instead of less threatening thoughts. MCCT can change this, which is exciting. MBCT has been proven to have comparable outcomes to maintenance antidepressant medication, and targets cognitive reactivation. According to Kuyken et al., mindfulness skills are taught to embrace distressing thoughts and feelings, hold expertise of awareness, and cultivate acceptance and self-compassion. (R) I can relate here, as I make every attempt to practice daily mindfulness. Over the years, it’s become easier to enter a state of compassion, gratitude and introspective analysis of my life. It perhaps allows me to accept myself for who I am, and not become so distracted with unwanted thoughts or negative thinking. It has also allowed me to become productive and feel relaxed, yet energized with short, 15-minute daily sessions. The intent of attention is learned in the first three MBCT sessions through various techniques; the body scan, mindful movement, and mindfulness of breath. Initial sessions for participants identify forms of reactivity, racing thoughts and self-defeating, critical thoughts, and eventually participants learn to not respond to states of self-judgment but rather foster compassion instead. Other studies have showed mindfulness to change prefrontal functioning and thickness on imaging (R). In Buddhism texts, mindfulness mechanisms may be described by acceptance and compassion, attentional regulation, ethical practice, non-attachment and non-aversion.
Mindfulness vs. CBT
Using both cognitive behavioral therapy and mindfulness together makes for a powerful therapeutic technique. CBT is rooted in understanding and changing maladaptive thought patterns, which then changes emotions, and then behaviors. An example may be a person who thinks a dog may bite them if it’s coming near. The emotion may be fear and the physiological response may lead to their heart racing. The behavior in the situation is running away or avoidance. This differs than the individual who thinks the dog is cute and has an emotion of happiness and a behavior of petting the dog, for example. Mindfulness, on the other hand, allows one to be more present and aware to their surroundings through purposeful attention. CBT is thought focused, and promotes a new way of identifying circumstances. Further, CBT will seek to challenge dysfunctional beliefs, and offer behavioral interventions focused on healthy, more realistic thought patterns. With this technique, the therapist is the instructor. Contrary to this, Mindfulness, has more emphasis on structure and is focused on thought processes. This practice allows thoughts and feelings to enter one’s mind, without changing or avoiding them. They’re essentially free flowing and receptive in nature where one welcomes all thoughts.
Mindfulness
From a Buddhist and perhaps philosophical perspective, mindfulness is the life of awareness, but also lends itself to free forgetfulness and become more present. Mindfulness enables one to live fully, to breath deep, where breath is the bridge which connects life to consciousness, uniting body and thoughts. Further, Buddhism suggests that everyone learns to breathe as a tool to stop mental dispersion and to build the power of concentration, which comes with time and is the ultimate strength leading to awakening. As one practices this repeatedly, one may feel refreshed and restored, as I can attest to and mentioned earlier with my personal practice of mindfulness. In practice, I make every attempt to include mindfulness as a strategy to combat psychological symptoms such as stress, low self-esteem, anger, regret and other maladaptive thought patterns and emotions which hinder one from living optimally. It seems, according to my observation in clinical, most have unfortunately never tried mindfulness or relaxation techniques. I also discuss the practice of breath work, guided imagery, or doing progressive muscle relaxation, all which allow for attention to breathing and relaxation, each with some intricate differences. Surprisingly, 40% of Americans use CAM therapy, and some use mindfulness, especially for chronic pain and mood disorders. In general, people that meditate seem to report differences in a number of psychological measures, namely, self-compassion and overall well-being, but also significantly lower levels of psychological symptoms, rumination, thought suppression, fear of emotion, and emotion regulation (R). Most refer to mindfulness as attentional awareness, and may be viewed as two components: self-regulation of attention, and adoption of a particular orientation towards one's experiences, observational awareness of sensations, thoughts, or feelings in every moment. The reference of orientation is to experience, specifically an attitude of curiosity, openness, and acceptance, with acceptance meaning one shall experience without obsession or suppression of an idea. To distinguish from western practice, Buddhism practices mindfulness as part of a combination of practices that are necessary to minimize suffering, the ultimate state or end goal prescribed to spiritual practitioners in the tradition. Further, mindfulness as a trait has been seen to enhance life satisfaction, agreeableness, conscientious, vitality, self-esteem, working memory, short term memory, spatial abilities, and focused attention to name some (R). Useful forms of meditation include mindfulness of breathing (using breath in the present moment), and compassion-focused meditation (having kindness, and awareness of others and introspective analysis of our own suffering to be in the present moment), and lastly, the body scan, where one focuses on different body parts. Other forms of meditation include the use of mantras or phrases to focus attention to the present moment, and even walking meditation. All forms may be appropriate and supporting those in isolation as a low-cost solution to reduce anxiety and depression among other mental health conditions such as substance abuse, which have increased since the pandemic began. And perhaps most interesting, mindfulness changes epigenetics where this practice may up-regulate and down regulate certain genes.
Cognitive Behavioral Therapy (CBT)
Originated by Aaron Beck, this form of therapy dates back to the 1960’s, and was originally called cognitive therapy. The therapy aims to ignite cognitive but also emotional and behavioral change, and does present similarities to other modalities and therapeutic techniques. The basic premise of CBT is to alter patients’ beliefs about themselves, the world, and other people (Beck, 2011). The following are the principles of CBT as described by Beck:
1. CBT is based on an ever-evolving formulation of patient’s problems and unique understanding of the patient in a cognitive context
2. CBT requires a sound therapeutic alliance
3. Requirement of collaboration and active participation between therapist and patient
4. Goal oriented and problem focused
5. Emphasis on the present, instead of past or future
6. Is educative and aims to teach the patient to be their own therapist with focus on relapse prevention
7. Aims to be time limited
8. Sessions are structured
9. Teaches’ patients to identify and evaluate their thought patterns while responding and changing their dysfunctional thoughts and beliefs. This is occasionally called “behavioral experiments”
10. Uses a variety of techniques including Socrative questioning and guided discovery, both which I currently use in my practice
MBCT for Depression
Major depression can be defined by either being sad, or experiencing a lack of interest in everyday activities. Other features include, trouble sleeping, changes in appetite, lack of concentration, fatigue, restlessness and guilt. (APA, 2013). Most people suffering from depression are treated in primary care with anti-depressants, even though guidelines suggest a combination of counseling and medication to yield better results, especially for mild depression. In regard to recurrent depression, patients have to stay on their antidepressant for 2 years following remission and many experience unpleasant side-effects (Kuyken et al., 2008). With this in mind, an alternative would be psychosocial therapies and mindfulness, which MBCT was created for. With MBCT, groups are typically 8-15 members and require an 8-week program, although again, this can be done in the practice setting with a therapist. In one trial, sessions were 2 hours, videotaped and and delivered over 8 weeks, with four additional follow up sessions. Sessions include various forms of meditation, review of homework, and teaching/discussion of cognitive skills. Daily 40-minute mindfulness sessions were suggested on off-days. After the completion of the program, results indicate MBCT has comparable outcomes for people using anti-depressant medication, with regard to relapse and cost. Reductions in medication within the treatment group utilizing MBCT was substantial with 75% adherence rate (Sipe & Eisendrath, 2012).
MBCT for Anxiety
Anxiety is one of the most common forms of mental illness usually starting early in life. Generalized anxiety disorder (GAD) is chronic in nature lasting over 6 months, and characterized by excessive worry. Common symptoms include fatigue, trouble concentrating, trouble sleeping, and restlessness. (APA, 2013). The estimated lifetime prevalence of GAD is 5.7%, impacting women more than men. (Evans et al., 2008). In regard to therapy, cognitive therapy remains the gold standard in detecting maladaptive thought patterns and internal and external cues to manage the symptoms. Full remission is hardly seen, however. Certain psychotherapies happen to include mindfulness as a vital component such as acceptance and commitment therapy (ACT) and dialectical behavioral therapy (DBT), the latter which is designed around borderline personality disorder. MBCT does however have trials around anxiety. For example, an 8-week trial was carried out where subjects with co-morbid diagnoses were excluded such as major depression, substance abuse, psychosis, and suicidal and homicidal states. Each session among the 8 focused on different themes or topics including but not limited to cognitive exercises. At the end of the 8 sessions, there were statistically significant reductions in various objective measures including the Beck Anxiety Inventory, and Penn State Worry Questionnaire. Subjects had a decrease in their worry, tension, and depressive symptoms (Evans et al., 2008). The authors also noted other benefits including increased mindfulness while eating, an improved marital relationship, better awareness of self, and improved self-acceptance and emotional regulation. The benefits of mindfulness and CBT are also apparent in clinical as I’ve been incorporating it with patients. Some have reported subjective improvements with feeling at ease, better concentration, less worry, and even better scores on the GAD-7 when we repeat the form.
Many psychotherapeutic techniques exist and help patients such as MBCT, a combination of mindfulness and CBT. Both therapies, or better yet, practices have compelling research which when combined offers an additive benefit for patients. Mindfulness has spread globally from its’ origin in eastern regions and strategically combined with CBT for enhanced emotional regulation and improved thought patterns. When practiced, those that engage in MBCT have a plethora of benefits that translate to better mood, less depression and less stress and anxiety.
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