Editor’s Note: Zindel V. Segal, Ph.D. is a clinical psychologist and Head of the Cognitive Behavior Therapy Unit at the Center for Addiction and Mental Health and Professor of Psychiatry at the University of Toronto, where he is also Head of the Psychotherapy Program. He is the co-author of The Mindful Way Through Depression: Freeing Yourself From Chronic Unhappiness
The clang of the meditation bells slowly faded into a silence punctuated by the sounds of bodies moving on chairs and cushions. It was our seventh session, and by now, group members were comfortable with just sitting and watching their breathing for 40 minutes, while all manners of thoughts, feelings and sensations came into their minds with a searching insistence. It hadn’t always been this way. Right at our first session, these folks had asked lots of questions and were unsure exactly how meditation was going to help them prevent depression from returning. Attending to sensations in their toes, or taking five minutes to eat a raisin and then discussing the experience, didn’t seem, even to the most adventurous in the room, to be close to what they needed. Nonetheless, they were learning firsthand about the powerful connection between attention and emotional balance. Each of the participants had suffered from depression in the past, but recognizing that it could easily return, had signed up for a program in which meditative practices featured predominantly.
In the late Sixties, meditation gained popularity as a vehicle for exploring altered states of consciousness and experience. Today’s therapeutic uses of meditation are orientated toward cultivating a particular form of awareness known as mindfulness. The practice of mindfulness originated in the meditation traditions of Asia has been part of Buddhist culture for millennia. Mindfulness describes a moment-by-moment, non-judgmental attending to experience without automatically reacting to what is being noticed. When mindful of ordinary activities such as eating, we may do things to deliberately keep our focus on the act itself, such as putting our spoon down between tasting and swallowing each mouthful of soup. Within the realm of emotion, we may note the presence of disturbing ideas or sensations, and be less drawn into responding with an habitual defense of outburst, sense of sleight or reflexive withdrawal.
Mindfulness, Cognitive Therapy and Mood Disorders
Over ten years ago, my colleagues, John Teasdale, Mark Williams and I adapted the teaching of mindfulness meditation for use in preventing depressive relapse. In our program, Mindfulness Based Cognitive Therapy, these practices are taught without a particular religious or philosophical belief orientation, as a basic awareness technique or a way of looking at things that anyone, no matter what their fate, could utilize. Participants attend eight weekly two-hour classes of between 10 to 12 people, in which the primary work is intensive training in mindfulness meditation as it relates to regulating thoughts and feelings.
Participants in MBCT practice mindfulness meditation through the body scan, mindful stretching, mindful walking, and alternating the focus of attention by shifting between mindfulness of the breath, the body, sounds and thoughts. And of formal practices that encourage close attending to common, seemingly mundane experiences are one way in which participants can apply mindfulness skills in their everyday lives (e.g., eating a meal mindfully, monitoring the physical sensations such as brushing one’s teeth, noticing how hard one grips the steering wheel while driving on the highway). Taken as a whole, the mindfulness practices in the program help participants take a wholly different approach to the endless cycles of mental strategizing that often drive depression’s return. They do so by helping us get back in touch with the full range of inner and outer resources for learning, growing, and healing, resources that they can access on a daily basis and may not even believe they have.
One vital inner resource that is often ignored is the body itself. When people get lost in thoughts or try and jettison their feelings, they pay very little attention to the physical sensations from their bodies. Yet, those sensations provide immediate feedback about what’s going on at an emotional and mental level. Group members explore this possibility by monitoring every day pleasant or unpleasant events, firstly noting body sensations that are present before going on to record their thoughts and feelings.
The cognitive therapy aspects of MBCT include psychoeducation about depressive symptoms and the dark thinking styles that often accompany them. To many participants, the only ‘legitimate’ symptoms of their depression are the ones that dysregulate them physically. If they have turned into harsh and critical judges of themselves or feel like giving up, somehow this is not seen in the same light. It is just a sign of their lack of mental toughness or character. Discussing this material helps participants acquaint themselves with the ‘territory of depression’ so that if they notice these changes occurring, then it will be easier to take action earlier.
The second cognitive therapy emphasis comes in helping participants to see their thoughts as creations of the mind and not as facts. Through simple exercises that emphasize the relationship between thinking and feeling and how certain roads bring with them familiar negative ruminations, participants developed the ability to dis-identify from their thoughts as reflections of themselves and see them as part of a larger ‘package’ of depression. Very often this recognition, almost saying to oneself, ‘Oh here comes another round of judgement’, for example, can help people take a step back from it without resorting to disputation or challenging. In cases where certain thoughts or beliefs still have a strong pull on awareness, participants practice questioning them with an attitude of investigation, curiosity and kindness.
Finally, all participants are provided with The Mindful Way Through Depression, the book that describes the program and contains a CD of guided meditations similar to the ones they practice in the class.
To date, MBCT has been evaluated in three randomized clinical trials, each showing a significant protective advantage for patients receiving the treatment. Recently, the UK National Institute of Clinical Excellence (NICE) has recently endorsed MBCT as an effective treatment for prevention of relapse. Research has shown that people who have experienced multiple episodes of depression can reduce their chances that depression will return by 50 percent.