Mindfulness-Based Cognitive Therapy for Bipolar Disorder: A Feasibility Trial

Mindfulness-based cognitive therapy (MBCT) studies generally focus on what’s sometimes called unipolar depression. The term “unipolar” is just a fancy way of distinguishing clinical depression from depression experienced in people with bipolar disorder. People with bipolar disorder may alternate between periods of depression and periods of elation called mania or hypomania (hypomania is less extreme than mania).

In earlier studies of MBCT, people with bipolar depression were screened out. More recently, researchers from Geneva University Hospital in Switzerland set out to determine if MBCT may be helpful for people with bipolar disorder.  They hypothesized that mindfulness may help break the vicious cycles of depression and mania.  This study is the first to pilot the use of MBCT for a sample comprised entirely of people with bipolar disorder.

.

The intervention consisted of weekly, 2-hour, MBCT sessions for a total of 8 weeks. Each group met three months after the end of the 8-week program for a 2-hour refresher session. Little was changed to the program except that mania and hypomania were discussed in sessions and mentioned in handouts. Participants were assessed a month before the MBCT class, a month afterward, and at the 3-month follow-up. Of 23 participants, only 15 attended enough sessions to be included in the analyses, and only 9 were assessed at follow-up.

Overall, there were no significant improvements in mindfulness, depression, and hypomania between the beginning and end of the MBCT program. Interestingly, it didn’t look like the researchers included the 3-month follow-up in their analyses. Statistical analyses indicate no significant changes in depressive symptoms, mindfulness, and mania during the study. According to a table in the article, it even looks like depression may have increased at the follow-up! The good news is that 82% of the participants reported having benefited from the program. This point is emphasized by the authors.

A big limitation of this study is sample size: it’s hard to detect changes when working with such a small sample. That said, the study is spun a bit. The authors seem to downplay the nonsignificant changes in symptoms and mindfulness in favor of the participants’ self-report that they found the program beneficial. People says they liked the program, but there's no evidence it impacted depressive symptoms or mania, or that people improved in mindfulness.

In sum, the study suggests that people with bipolar disorder can participate in MBCT, but it provides little evidence that they benefited from it. However, because the sample size was small, it may be worth running another MBCT study for people with bipolar disorder with a larger sample.

The full citation is below:

Weber, B., Jermann, F., Gex-Fabry, M., Nallet, A., Bondolfi, G., & Aubry, J.-M. (2010). Mindfulness-Based Cognitive Therapy for Bipolar Disorder: A Feasibility Trial. European Psychiatry, 25, 334-337.

If you're interested in learning more about MBCT, the original book is one of the more readable therapist manuals out there:

Segal, Z.V., Williams, J.M.G., & Teasdale, J.D. (2001). Mindfulness-Based Cognitive Therapy for Depression: A New Aproach to Preventing Relapse. New York: Guilford.

The core MBCT originators also created a self-help book called The Mindful Way Through Depression.

I'd like to thank Molly Ellis for her help with this post.

Comparison of Motivational Interviewing with Acceptance and Commitment Therapy: A Conceptual and Clinical Review

Motivation Interviewing (MI) is not an a mindfulness and acceptance-based treatment; however, it is consistent with many of same principles and can be used in conjunction with a number of treatments. MI is a type therapy in which the primary aim is increasing motivation for change. It was originally developed for addiction but has since been adapted for all sorts of things, including health-related behaviors. Rooted in Carl Roger's person-centered approach, MI is not a stand alone therapy in itself, but a way to prepare someone for change. The therapist accepts the client where she is while helping to guide the individual towards talking about change.

Dr. Jonathan Bricker--who also piloted the telephone smoking cessation study I posted about last year--co-authored a recent article exploring the conceptual similarities and differences between MI and Acceptance and Commitment Therapy (ACT). The article highlights three ways in which both approaches overlap:

1. Both seek to increase commitment to changing behavior.

2. Both draw upon values to enhance commitment. In particular, MI and ACT therapists strive to help people contact long-term goals and life directions to increase the motivation for behavior change.

3. Both look at processes of language to help facilitate change. In MI, there's an emphasis on helping people engage in "change talk" (e.g., openly verbalizing what they want to do). By contrast, ACT seeks to undermine verbal self-rules (e.g., unhelpful ideas that keep people stuck) and help people make commitments towards valued goals and directions.

The article does a nice job summarizing both treatments. According to the Acknowledgments section, the authors received feedback on the manuscript from Drs. Bill Miller and Steve Hayes, core originators of MI and ACT, respectively. There's no new data, but the article provides a balanced view of MI and ACT and offers suggestions for how they may complement one another. Even if you've never heard of MI, the article provides a concise introduction.

The article hasn't been officially published yet but is available online. To download a copy click on the full citation below:

Bricker, J., & Tollison, S. (in press). Comparison of Motivational Interviewing with Acceptance and Commitment Therapy: A Conceptual and Clinical Review. Behavioural and Cognitive Psychotherapy.

If you'd like to read further about MI, I encourage you to check out the core MI book:

Miller, W.R., & Rollnick, S. (2002). Motivational Interview, Second Edition: Preparing People for Change. New York: Guilford Press.

For a book with chapters on an ACT approach to substance use, check out:

Hayes, S.C., & Strosahl, K. (Eds.) (2004). A Practical Guide to Acceptance and Commitment Therapy. New York: Springer.

Living with Your Fears

A friend sent me a link to the cartoon below at 9GAG. I think it's a cute illustration of mindful acceptance.

http://9gag.com/gag/99399/

Therapist and Client Perceptions of Therapeutic Presence: The Development of a Measure

This post isn't directly related to mindfulness, but the topic overlaps. Most psychotherapists would agree that the therapeutic relationship with clients is very important. There is less agreement, however, in a definition of what makes up a good therapeutic relationship and how it can be measured.

The lab of Dr. Les Greenberg, the core originator of Emotion Focused Therapy, has taken some initial steps to address this issue more empirically. The first author is Dr. Shari Geller.

These researchers from York University in Toronto have developed two measures of what the call therapeutic presence. Therapeutic presence, according to their definition, involves "bringing one’s whole self into the encounter with clients, by being completely in the moment on multiple levels:  physically, emotionally, cognitively, and spiritually."

Therapeutic presence differs from mindfulness, according to the authors, in two ways. The authors consider mindfulness a technique used to cultivate presence rather than presence itself. They also suggest that mindfulness--at least how it's presented in the research literature--is a way of engaging the internal world of one's self and another person, whereas "therapeutic presence is an internal and relational therapeutic stance that includes the therapist's present-centered sensory attention in direct relation to the client's in-the-moment experience.

I found the authors terminology a little imprecise for my tastes. There seemed to be a blurring of technical terms with vaguely defined descriptions; however, it could be that they're drawing from a research literature I'm not all that familiar with. Regardless, I believe it's clinically useful to define therapuetic presence as something separate from mindfulness.

The study went through a series of stages, beginning with creating items and, eventually, using them in an actual clinical setting with clients who met criteria for depression. The researchers developed two versions of a measure they call Therapeutic Presence Inventory. In one version (TPI-C), clients rate the presence of their therapist; in the other (TPI-T), therapists rate themselves.

The client measure predicted the therapeutic relationship and improved outcomes. The therapist version wasn't predictive of either. This supports a long line of research showing that psychotherapists aren't a very good judge of how well therapy is going. Psychotherapists tend to overestimate how much their clients like them! Consequently, the findings for the therapist measure are not too surprising.

The client version, though, is potentially really useful. It's short (only 3 items), and it can give therapists feedback about how clients perceive their relationship. Moreover, this feedback appears to be related to how clients change and improve.

In my own practice, I often give clients the option of filling out a feedback form about how well the session went. When I get the chance, I intend to revise my form to incorporate these three items.

To download the article, click on the full citation below:

Geller, S.M., Greenberg, L.S., & Watson, J.C. (2010). Therapist and Client Perceptions of Therapeutic Presence: The Development of a Measure. Psychotherapy Research, 20(5), 599-610.

Neural Correlates of Focused Attention and Cognitive Monitoring in Meditation

A former classmate from graduate school sent me a nifty neuroimaging study by a group of researchers in Italy. The article compared 8 Buddhist monks against 8 novice meditators. The monks were part of the Thai Forest Tradition founded by Ajahn Chah. They averaged 15,750 hours of meditation experience! By contrast, the novice sample were people who expressed an interest in meditation but had no prior meditative experience. They were given 10 days of meditation practice prior to the study.

Using an fMRI (e.g., functional brain scans), the researchers recorded brain patterns during an hour block involving alternating periods of focused attention (FA) and open monitoring (OM). For those familiar with Buddhist practices, FA corresponded to Samatha meditation (Pali: calm abiding) and OM was a form of Vipassana (Pali: clear seeing or insight), according the researchers. (Our garden variety mindfulness meditation is more or less based on Vipassana meditation.) Participants alternated between 6 minutes of Samatha and Vipassana with 3 minutes of non-meditative rest preceding and following these conditions.

The article is pretty technical. Since I can't really do it justice, I won't parrot back the specific results (e.g., which parts of neuroanatomy relate to which forms of attention). Overall, results suggest that meditation practice reorganizes brain activity. More simply, experienced meditators showed a different pattern of brain activity than novices on these tasks.

Reorganization of brain processes is called neuroplasticity. Previously researchers believed the brain doesn't change much after we're born. Recent research has shown that this isn't so--the brain can and does change--and regular meditation practice can re-map the way the brain processes stuff.

For the full citation:

Manna, A., Raffone, A., Perrucci, M.G., Nardo, D., Ferretti, A., et al. (2010). Neural Correlates of Focused Attention and Cognitive Monitoring in Meditation. Brain Research Bulletin, 82, 46-56.