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.

Mindfulness Practice Leads to Increases in Regional Brain Gray Density Matter

Last week, I posted a New York Times article about a study looking at brain changes following an 8-week mindfulness program. As promised, I've since read the study on which the article was based and am posting my own summary.

Lead by Dr. Britta Hölzel, a group of researchers, mainly located at Massachusetts General Hospital, examined changes in the brain following an 8-week Mindfulness-Based Stress Reduction (MBSR) program. As I've posted about before, previous research has indicated differences in cortical thickness in areas of the brains of experience meditators compared to age-matched control groups. The weakness of the previous studies is that it doesn't rule out that people with pre-existing differences in brain structure may be more likely to gravitate towards meditation.

In the current study, the researchers conducted MRI scans of 16 people 2 weeks before and 2 weeks after an 8-week MBSR course. This scans were compared against a control sample of 17 people on wait list for the course. Researchers scanned the wait list group twice about 2 months apart. In addition the scans, participants also completed the Five-Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006), a self-report measure of mindfulness.

As the researchers predicted, MBSR participants showed significant increases in gray matter density in the left hippocampus, an area of the brain associated with arousal, responsiveness, and emotion regulation, according to the researchers. They suggest these changes may reflect improvements in regulating emotional responding. These changes were unrelated to self-reported mindfulness scores on the FFMQ and to the amount of time people practiced mindfulness outside the course. Contrary to the researchers' predictions, there was no changes in the insula, a region of the brain associated with awareness.

I'll note here that the researchers predicted changes in the hippocampus and insula prior to conducting the study. After looking at these regions, they also conducted exploratory analyses to examine whether there were changes in other parts of the brain that they did not make specific hypotheses about. What this means is that the researchers had no prior expectations about whether these other areas would change. Since they had the data, they thought, "Hey, let's take a look!" There's nothing wrong with this, but it does mean these results should be interpreted more cautiously, since there were no prior reasons to believe they would change.

These exploratory analyses found increases in density in the posterior cingulate cortex (PCC), the left temporo-parietal junction (TPJ), and in two regions of the cerebellum. In addition, there were changes in density within the brain stem. In the interests of space, I'll give a more general summary of the functions associated with these regions. According to the researchers, these regions of the brain appear to be associated with consciousness of one's self (TPJ), assessment of the self-relevance of stimuli (PCC), regulation of emotion and cognition (cerebellum).

This is a general summary of what the study found. As I'm not an expert in neuroscience, any errors in what I reported are likely mine. I encourage anyone interested to consult the original study if you want more detail.

Although this study shows greater methodological rigor in controlling for other possible influences other than meditation, as the authors note, their methodology is not completely airtight. Perhaps the biggest weakness is comparing a wait list control group against an active treatment. It's perfectly reasonable comparison, but the downside is that it doesn't control for the possibility of non-specific factors other than meditation influencing outcome. Said less technically, simply being in a group for 8 week may have caused changes independent of the actual mindfulness practices. In addition, the sample size is pretty small--which is understandable as neuroimaging research is expensive!

These caveats aside, this is a really important study in gathering further evidence that people may show actual physical changes in relevant areas brain through mindfulness practice. That significant differences were shown with only 8 weeks of mindfulness practice is pretty remarkable.

To download the article, click on the citation below:

Hölzel, B.K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S.M., et al. (2011). Mindfulness Practice Leads to Increases in Regional Brain Gray Density Matter. Psychiatry Research: Neuroimagining, 191, 36-43.

Mindfulness-Based Stress Reduction For Solid Organ Transplant Recipients: A Randomized Controlled Trial

In the United States, approximately 28,000 solid organ transplants are performed annually.  Transplant recipients frequently continue to have health problems, which can contribute to mental health difficulties. Given the complexity of transplant medication regimens, a drug-free strategy may be preferred in managing subsequent anxiety, depression, and anxiety. 

A group of researchers led by Dr. Gross conducted a randomized controlled trial to test the effectiveness of a Mindfulness-Based Stress Reduction (MBSR) program. MBSR has been associated with improved health outcomes for patients with medical and psychological concerns across a number of studies.

Transplant recipients who were at least 6 months post-transplant were randomly assigned to one of three conditions: an 8-week MBSR program, an 8-week health education program, and “usual care” waitlist. The health education program was created to account for non-specific effects of MBSR, such as group support. Of the initial 150 patients, 122 completed one or more of the follow-ups, which were administered at 8 weeks, 6 months, and 1 year.

MBSR showed the strongest outcomes. Greater home practice was related to reduced anxiety, increased vitality, and increased mindfulness. Compared to the waitlist condition, patients who completed MBSR showed fewer depressive symptoms, improved sleep, and increased vitality. Compared to the health education program, MBSR participants showed less anxiety, improved sleep, and more vitality at the 1-year follow-up; stated another way, improvements in the MBSR condition were more enduring at the 1-year follow-up than improvements in the health education condition. Contrary to expectations, there were no improvements in physical health and pain symptom perception.

As the authors note, the gains from MBSR were obtained without additional psychotropic meds (e.g., antidepressants). A non-psychopharmacological approach such as MBSR may be a useful alternative to additional medications, as it is likely transplant recipients already have complex med regimes managing other health problems. Moreover, the researchers were able to show that improvements from this 8-week program were maintained a year after treatment ended. Results are very supportive of MBSR as a viable treatment for organ transplant recipients.

For the full citation:

Gross, C.R., Krietzer, M.J., Thomas, W., Reilly-Spong, M., Cramer-Bornemann, M., et al. (2010). Mindfulness-Based Stress Reduction For Solid Organ Transplant Recipients: A Randomized Controlled Trial. Alternative Therapies, 16(5), 30-38.

Many thanks to Jennifer Connolly for her assistance in creating this post!