Why Mindfulness May Enhance Exposure Therapy for Anxiety Disorders

I realize I’ve been neglecting Scientific Mindfulness of late. It’s not that I’ve stopped blogging. Instead, I’ve shifted my focus to two other blogs: The Art and Science of Living Well and Science-Based Psychotherapy. Recently, I came across an article that bridges SM and Science-Based Psychotherapy.

University of Massachusetts’ Michael Treanor, who is a grad student I think, published a review of the overlap between mindfulness and exposure therapy. Exposure therapy is a topic I have a particular interest in, and I think there’s great potential for ways in which mindfulness can enhance exposure-based interventions.

Treanor’s article is pretty technical, and there’s no way I could offer a basic summary. However, it’s a very important article, in that it examines how mindfulness may be used to improve exposure-based treatments for anxiety disorders. For example, mindfulness may help develop awareness of multiple cues, both internal (e.g., bodily sensation) and external (e.g., situations, places), which may help with generalizing exposure treatments. The effectiveness of exposure-based treatments has plateaued in recent years; although it’s not certain mindfulness may change that, it does offer one avenue for exploration.

As I mentioned, this article is not for the faint of heart. However, I encourage you check it out if you’re interested. It could help to jump start several labs.

Treanor, M. (2011). The Potential Impact of Mindfulness on Exposure and Extinction Learning in Anxiety Disorder. Clinical Psychology Review, 31, 617-625.

US Congressman Authors Mindfulness Book

A colleague passed on this tidbit from The Plain Dealer. Tim Ryan, an Ohio Congressman and Democrat, has authored a book an mindfulness that will hit the shelves in March. It's entitled, A Mindful Nation: How a Simple Practice Can Help Us Reduce Stress, Improve Performance, and Recapture the American Spirit.

That's all I know about it!

ACT for Zombies

The Acceptance and Commitment Therapy people try not to take each other too seriously. Each year at the main ACT conference--the Association for Behavioral Contextual Science--they hold a "Follies night" where people poke fun aat ACT and some of the key ACT people. Created by Joe Oliver and Eric Morris, this video was unveiled at the most recent conference.

WARNING: There's some graphic violence, so it's not for the faint-hearted!

Watch the wide-screen version on YouTube.

Mindfulness Journal

A posting on a professional journal reminded me of this: there's a journal called Mindfulness that's been around since March 2010. The journal is dedicated to mindfulness-based research. The reason why I mention it is that you can download all the articles for free. That's right--free!

Most scientific journals require that you pay--either by the article or through a subscription. Colleges and universities usually have subscription packages, as do some public libraries, although the public libraries tend to be more limited.

I don't know how long Mindfulness will be offered for free. My guess is that when it becomes popular enough to charge for, the publisher will start charging. In the meantime, download what you want.

You can check out Mindfulness here.

NYT Article on Marsha Linehan and Dialectical Behavior Therapy

We've written in the past in Scientific Mindfulness about Dialectical Behavior Therapy (DBT), one of the early pioneers in mindfulness-based treatments. DBT is also hugely important in providing effective treatment for extremely suicidal people who how have difficult regulating their emotions--often diagnosed as borderline personality disorder. These are the kind of clients that many therapists in Portland still shy away from.

In this New Yorker Times article, University of Washington professor and core DBT originator Dr. Marsha Linehan talks about her own struggles with suicidality. This is the first time she's publicly come out about being hospitalized for 26 months when she was a teenager. During this time she was placed in seclusion, strapped down, and given electroconvulsive therapy. Dr. Linehan eventually devoted her life to helping people with the types of problems she had struggled with. As she says, 

“I decided to get supersuicidal people, the very worst cases, because I figured these are the most miserable people in the world — they think they’re evil, that they’re bad, bad, bad — and I understood that they weren’t,” she said. “I understood their suffering because I’d been there, in hell, with no idea how to get out.”

It's a stunning, public revelation from a very important researcher, clinician, and figure in psychology. To read the full article, click here.

Mindfulness-Based Attention as a Moderator of the Relationship Between Depressive Affect and Negative Cognitions

Here’s another study in the growing body of research suggesting that mindfulness changes how we experience depression.

Researchers at Pacific University collected self-report measures of mindfulness, depression, and negative thinking from a sample of 278 undergraduates. Analyses suggest that there is a weaker relationship between negative thinking and depressive symptom for people higher in mindfulness than for people lower in mindfulness.

What might this mean?

The authors conclude that being more mindful may serve a protective function against becoming depressed when someone experiences negative thoughts. Conversely, less mindful people may be more likely to become depressed when they have negative thoughts.

The results are pretty limited. For one, this was a convenience sample of undergraduate students, not a sample of people with clinical depression. Also, because the results are correlational, we can’t draw any firm conclusions that one thing causes another. We can't tell from these results whether increasing mindfulness actually serves as a prophylactic against becoming depressed.

However, if you're interested in studies that tell us more about how mindfulness may impact how we experience depression, check out some of the past posts from Scientific Mindfulness on Mindfulness-Based Cognitive Therapy and Mindfulness-Based Relapse Prevention. Additionally, a longitudinal study showed that less mindful police officers showed greater increases in depression over time compared to their more mindful counterparts.

For the full citation:

Gilbert, B.D., & Christopher, M.S. (2010). Mindfulness-Based Attention as a Moderator of the Relationship Between Depressive Affect and Negative Cognitions. Cognitive Therapy and Research, 34, 514-521.

You might also be interested in some of these other books about mindfulness and depression: 

I’d like to thank Molly Ellis for her help with this post!

Meditation Experience Predicts Less Negative Appraisal of Pain: Electrophysiological Evidence for the Involvement of Anticipatory Neural Responses

In a recent study, researchers in the United Kingdom examined the impact of meditation experience and the anticipation of and experience of pain. The control group consisted of 15 people with no previous experience in meditation. They were compared with 12 people who came from a variety of Buddhist and non-Buddhist meditative backgrounds. It was a pretty heterogeneous sample of meditators.

The researchers encountered difficulty developing a reliable estimate of meditation experience. They eventually disregarded the amount of hours per week of practice and instead looked at the overall lifetime experience with meditation. These ranged from less than 1 year to more than 30 years experience.

The researchers used a laser to induce a painful burning sensation in the participants. Anticipation of pain was created through a visual stimulus that indicated to the participants that they would be exposed to the laser within 3 seconds.  Because of the design, the researchers suggest they may have over-estimated the impact of the anticipation of pain on the actual pain response. In addition to self-report by the participants, the researchers used an EEG (e.g., brain scan) to measure participants' anticipation to and experience of pain.

Initially, the researchers found no significant difference in perceived pain between the mediation and control groups. Once the researchers dropped participants with less than 6 years of meditation experience from the analyses, however, participants with more meditation experience showed a lower response to anticipated pain unpleasantness.  This relationship was accounted for by the age of the meditators.  However, there was no correlation in the control group between pain response and age.  Although the relationship is not entirely clear, it appears that meditation experience may impact anticipation of pain.

In looking at the EEG results, an interesting pattern emerges. The researchers suggest that those with meditation experience were more likely to process and contextutalize the experience of pain before responding to it emotionally.

In summary, the researchers suggest that the cultivation of acceptance through practicing attentional control (i.e., through regular meditation practice) may allow people to show more equanimity in both in their anticipation of pain and their actual experience of it.

There are some limitations with the pain assessment in this study. As noted, researchers admitted that they had a difficult time determining if the pain assessment was in fact influenced by the anticipation of the pain. Also, because of the design of the study, we can't completely rule out that people who take up meditation are inherently different from those who don't meditate, and that these differences--rather than the actual meditation practice--better explain the results.

To download a  copy of the article, click on the full citation is below:

Brown, C.A., & Jones, A.K.P. (2010). Mediation Experience Predicts Less Negative Appraisal of Pain: Electrophysiological Evidence for the Involvement of Anticipatory Neural Responses. Pain, 150, 428-438.

I’d like to thank Molly Ellis for her help with drafting this post!

Sesame Street: Monster in the Mirror

I discovered this Sesame Street clip after a therapist posted it on a professional listserv. As the poster noted, it's a clever illustration of the ease that can come from accepting parts of us that we experience judgment towards. I'd like to thank Jonathan Kandell for sharing it!

BOOK REVIEW: Self-Compassion: Stop Beating Yourself Up and Leave Insecurity Behind

I recently finished reading Kristin Neff's new book, Self-Compassion: Stop Beating Yourself Up and Leave Insecurity Behind. As I've mentioned before in Scientific Mindfulness, I've been following Dr. Neff's work on self-compassion for several years now. This new book is the first written for a lay audience.

A researcher at the University of Texas - Austin, Dr. Neff discovered self-compassion when she began attending a local Buddhist center while she was a graduate student at the University of California at Berkley. According to her book, she was really struck by the Buddhist view of compassion and devoted much of her professional career to defining and studying it. In Neff's conceptualization, self-compassion has three component: 1.) being kind to one's self, as opposed to harsh and judgmental; 2.) feeling part of the human condition, as opposed to alone and isolated; 3.) and being mindful of the present moment.

Research on self-compassion has really snowballed of late, and changes in self-compassion are being increasingly studied in mindfulness and acceptance-based research. There's also a growing body of literature suggesting that self-compassion is a more useful construct than that of self-esteem. Despite it's widespread use, our understanding of self-esteem is very problematic, as Dr. Neff discusses in her book.

Dr. Neff's book is an enjoyable mixture of theory, research, and personal anecdotes. It has elements of self-help but is not primarily a self-help book. Each chapter has exercises the reader may use to help develop self-compassion. I bookmarked several of them to use with clients. The exercises become a little weaker in the second half of the book, in my opinion--less specific, more abstract and vague--but I really liked many of them.

Dr. Neff does a great job incorporating research in a very readable and accessible style. Nothing is presented very technically, and the reader can easily find the studies cited in the "Notes" appendix in the back if he or she wants to seek out the original source material. I found myself flipping to the back frequently.

What I found most brave and unique about this book is Dr. Neff's willingness to speak candidly about her own life. In her book, she leads by example and shows a startling openness in sharing her own struggles. From an ex-husband who has never forgiven her for cheating on him to the difficulties of raising a child with autism, Dr. Neff offers incredibly personal anecdotes from her own experience and other people she knows. She doesn't present herself as an expert on self-compassion in the sense that she has it all figured out; rather, she vividly describes her own successes and struggles in incorporating self-compassion into her life.

Overall, I highly recommend the book. For people who'd like to know more about self-compassion and the research behind it, the book is a very up-to-date primer. For those interested in bringing more self-compassion into their lives, the book has a number of exercises and useful illustrations of self-compassion in action. As the book demonstrates and research increasingly shows, there is much to be gained in learning to treat ourselves more kindly.


Neff, K. (2011). Self-Compassion: Stop Beating Yourself Up and Leave Insecurity Behind. New Yorker: HarperCollins.

You might also check out Dr. Neff's website at www.self-compassion.com.

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.

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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.

Open, Aware, and Active: Contextual Approaches as an Emerging Trend in the Behavioral and Cognitive Therapies

In recent post, I wrote about how Dr. Steven Hayes coined the term "third wave" to describe the recent crop of mindfulness and acceptance-based treatments. In a new paper, Dr. Hayes and his colleagues at the University of Nevada-Reno explore this notion further.

The article examines the theoretical underpinnings of the current generation of mindfulness and acceptance-based psychotherapies, and at the published empirical data supporting the theory. This article provides a fantastic overview of the current state and development of many of these treatments.

Towards the end of article, Hayes and colleagues suggest abandoning the term "third wave" in favor of what they call "contextual cognitive behavioral therapy" or contextual CBT. According to the authors, contextual CBT differs from traditional CBT in several important ways:

1. Contextual CBT emphasizes changing the context and function of psychological events (e.g., thoughts, emotions, physical sensation) rather than the content, accuracy, and frequency. For example, a contextual CBT therapist is more interest in changing how someone relates to self-critical thinking than in changing the thoughts themselves.

2. Contextual CBT focuses more on what the authors call a "transdiagnostic approach to mental health." What this means is that, rather than treat specific diagnoses (e.g., generalized anxiety disorder), contextual CBT therapists focus more on processes (e.g., emotion regulation).

3. Contexutal CBT therapists are encouraged to apply these methods to themselves. For example, leaders of Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy groups are encouraged--even required--to maintain their own mindfulness practices.

4. Contextual CBT is less about throwing away techinques and interventions from other treatments than in taking what is useful and applying it in ways that are consistent with the theories underlying contextual CBT.

5. In their final distinction, the authors suggest contextual CBT is being applied to a much broader and deeper range of problems within the human conditions, such as spirituality and values. (The authors admit that this point is more of a "judgment call" than an accepted fact.)

I highly recommend this article for readers of Scientific Mindfulness. It's a great review article for much of what we write about in this blog.

To download a copy of the article, click on the full citation below:

Hayes, S.C., Villatte, M., Levin, M., & Hildebrandt, M. (2011). Open, Aware, and Active: Contextual Approaches as an Emerging Trend in the Behavioral and Cognitive Therapies. Annual Review of Clinical Psychology, 7, 141-168.

The Strange Powers of the Placebo Effect

This video isn't about mindfulness specifically, but I think it's a wonderful illustration of one of the reasons why scientific research is so important. Without controlled studies, it's hard to discern active treatments from placebo because placebo by itself can an effective treatment. It's important to assess whether treatments work for the reasons we think they work; otherwise, we can become lost in a sea of pseudoscientific cures. (If you're interested, click here for a blog post I did about pseudoscience in psychotherapy.)

In Memory of Alan Marlatt's Passing

For those of you who haven't heard, University of Washington professor and researcher Dr. G. Alan Marlatt passed away from melanoma on Monday (3/14/2011). He was 69. My understanding is that the diagnosis was unexpected, and Dr. Marlatt was told he had only days left to live. By report, he passed away in the company of his family.

I've previously talked about Dr. Marlatt's work with Mindfulness-Based Relapse Prevention here in Scientific Mindfulness. Dr. Marlatt has a 30-year history practicing mindfulness and meditation. He started by with Transcendental Meditation hoping it would help lower his blood pressure (it did), and eventually began exploring different Buddhist meditative traditions.

Even if Dr. Marlatt had never incorporated mindfulness into his research, he would be well-known for his other contributions to the study of addictions and substance abuse. He is well-known for his work on harm reduction: the notion that some people who don't want to give up alcohol entirely may learn to drink moderately. He made significant contributions towards understanding relapse.

I had a few brushes with Alan in my career. Early on in my graduate studies, I emailed him a question about problems with alcohol abuse in Buddhist teachers. Not only did he respond, but he suggested we talk about by phone! He was extremely kind and supportive during our brief chat. A year or two later, he was the discussant at a symposium I participated in. I introduced myself again but felt too shy to make an effort at engaging him, as there were others calling for his attention. Everyone I've spoken with about Alan has commented on his kindness and gentleness, an impression I shared.

Alan Marlatt will be missed. We've lost an exceptional researcher, a great contributor towards understanding mindfulness and acceptance-based treatments, and a wonderful man.

Time has a brief article on Dr. Marlatt. To check it out, click here.

For those interested in knowing more about him, Dr. Marlatt wrote a very touching portrait of his history with mindfuless that's worth tracking down:

Marlatt, G. A. (2006). Mindfulness Meditation: Reflections from a Personal Journey. Current Psychology, 25(3), 155-172.

Psychology Today: Bringing ACT to Sierra Leone

In a blog post today on the Psychology Today website, Dr. D.J. Moran, author of ACT in Practice, writes of a recent trip to war-torn Sierra Leone with two other psychologists. Together, they taught two workshops on Acceptance and Commitment Therapy (ACT) to local mental health practitioners. Dr. Moran writes:

In January 2011, my colleagues Beate Ebert and JoAnne Dahl and I set out to present two workshops in evidence-based behavior therapy and Acceptance and Commitment Therapy (ACT).  Beate is a dedicated psychologist and the founder of Commit + Act, the non-governmental agency that planned this trip.  JoAnne has extensive understanding of using ACT with the chronic pain population, but also has experience with bringing ACT to populations that have limited access to mental health care.  Our first five (5) day workshop was in Freetown, S.L. and the second three (3) day workshop was in Serabu, S.L..  Each workshop had over 30 mental health practitioners in attendance.   They were very eager to hear how they could address Post-Traumatic Stress Disorder with behavior therapy and ACT.

Dr. Moran offers a touching sketch of their efforts to bring an evidence-based mindfulness and acceptance-based treatment to therapists in a country that has witnessed unimaginable horror. I can't do it justice to through summary; to read the full post, click here.

How Does Mindfulness-Based Cognitive Therapy Work?

Mindfulness-Based Cognitive Therapy (MBCT) has demonstrated it reduces depressive relapse in those with three or more depressive episodes across several studies now. But why--what changes occur in MBCT that reduce relapse? The theory behind MBCT suggests increased mindfulness leads to reduced chance of relapse; however, treatments may be effective for reasons having little to do with why we think they're effective.

A recent article by Kuyken and colleagues examines processes of change in MBCT in order to assess the theory behind underlying it. The researchers used what are called mediational analyses. Mediational analyses look at whether changes in one factor (e.g., mindfulness) lead to changes in another (e.g. lower depression).

The authors used data from a previous study (Kuyken et al., 2008) in which 123 people with 3 or more depressive episodes who were currently prescribed antidepressant medication were randomly assigned to either 8-weeks of MBCT or were placed on a wait list. Those in the MBCT condition were weaned off their medication while those not assigned to MBCT remained on their meds. Participants were assessed every 3 months up to a 15 month follow-up. (In the original study, there was no difference in rate of relapse between MBCT and antidepressant meds; however, people in MBCT exhibited fewer depressive symptoms by the 15-month follow-up.)

Results of this study suggest increases in mindfulness and self-compassion mediated the effect of MBCT on depressive symptoms at follow-up. Researchers also looked at what they called cognitive reactivity. Cognitive reactivity was defined as changes in depressive thinking before and after a short piece of "sad" music (i.e., Prokofiev).

Curiously, people who participated in MBCT exhibited greater cognitive reactivity than those who remained on antidepressant medication. Here's the interesting part, though: whereas cognitive reactivity was associated with poorer outcome for people taking antidepressants, participation in MBCT appears to erase this relationship. Said another way, for people who participated in MBCT, cognitive reactivity no longer appeared to impact depressive symptoms. This reminds me of the Mindfulness-Based Relapse Prevention study in which the researchers found the relationship between depression and relapse appeared to disappear for those who participated in the program.

These results of the current study offer further evidence that mindfulness doesn't change patterns of thinking so much as it changes how people relate to thinking. Additionally, this is another study showing the useful in self-compassion in understanding mechanisms of change in mindfulness based treatments. (For another study indicating the importance of self-compassion, click here.)

As with any study, there are limitations. Mediational analyses don't definitively tell us that particular variables lead to change. However, the results largely supported the hypotheses of the researchers, offering additional evidence in support of the theory.

To download a copy of the article, click on the full citation below:

Kuyken, W., Watkins, E., Holden, E., White, K., Taylor, R.S. et al. (2010). How Does Mindfulness-Based Cognitive Therapy Work? Behaviour Research and Therapy, 48, 1105-1113.

The U.S. Government Lists Acceptance and Commitment Therapy as an Evidence-Based Treatment

This is exciting news within the Acceptance and Commitment Therapy (ACT) community! The Substance Abuse and Mental Health Services Administration (SAMHSA), a major department within the U.S. government, now lists ACT as an empirically supported treatment. This is part of its National Registry of Evidence-based Programs and Practices (NREPP).

ACT received high scores across a number of different dimensions, including quality of research and efforts at dissemination (e.g., getting ACT out there to professional and the public). This is a great victory for mindfulness and acceptance-based treatments, and for ACT in particular!

Read about it yourself here.