Mindfulness-Based Cognitive Therapy
DAVID M. FRESCO, JESSICA J. FLYNN, DOUGLAS S. MENNIN,
AND EMILY A. P. HAIGH
According to the fourth revision of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV-TR, American Psychiatric Association [APA], 2000),
Major Depressive Disorder (MDD) is a mood disorder characterized by one or more
major depressive episodes (i.e., at least two weeks of depressed mood or loss of interest
or pleasure in nearly all activities), accompanied by at least four additional symptoms
such as changes in sleep, appetite or weight, and psychomotor activity; decreased en-
ergy; feelings of worthlessness or guilt; diffi culty thinking, concentrating, or making
decisions; or recurrent thoughts of death or suicidal ideation, plans, or attempts. MDD
represents an enormous mental health challenge, with lifetime prevalence estimated at
17% (Kessler, Bergland, et al., 2005). Similarly, individuals who suff er from one depres-
sive episode will, on average, experience four major depressive episodes of 20 weeks’
duration over their lifetime.
According to a recently released World Health Organization study of 245,000 in
sixty nations, MDD is more damaging to everyday health than chronic diseases such
as angina, arthritis, asthma, and diabetes (Moussavi et al., 2007). MDD is estimated to
cause the fourth greatest burden of ill health of all diseases worldwide and will move
into second place by 2020 (Murray & Lopez, 1998). Despite successful medication and
psychotherapies, fewer than half of patients achieve remission (Casacalenda, Perry, &
Looper, 2002), and relapse is more likely in individuals who do not fully recover (Jarrett
et al., 2001; Th ase, Entsuah, & Rudolph, 2001). For these reasons, both basic and treat-
ment research eff orts are homing in on the identifi cation of vulnerability factors associ-
ated with the onset and maintenance of depression as well mechanisms that promote
risk of relapse.
Meditation and other mental training exercises deriving from the 2,500-year
Buddhist and Hindu traditions represent one potentially fruitful area of study that
has the potential to expand contemporary models of depression as well as complement
existing medication and psychotherapy treatments. Th e past 30 years have witnessed an
increasing interest in meditation, yoga, and other mental training exercises that emanate
from Hindu and Buddhist traditions. Th e use of these practices has dovetailed in recent
years with the emergence of aff ective neuroscience, a subdiscipline within the fi elds
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58 NEW DEVELOPMENTS IN THE BEHAVIOR THERAPY TRADITION
of psychology, psychiatry, and neurology that examines the neural bases of mood and
emotion. Th e union of these Eastern practices within the scrutiny of a Western scientifi c
approach to investigation has lead to the development of novel and eff ective clinical
interventions that aim to restore psychological functioning and reduce human suff ering
across a wide variety of illnesses (Ospina et al., 2008), while also off ering a tantalizing
glimpse into neural correlates of emotional processing (e.g., Cahn & Polich, 2006) and
how factors (e.g., the presence of major depressive disorder, or a lifetime of monastic
practice) result in signature patterns of activation within the brain (Davidson & Lutz,
2008). One practice that has been shown to have saliency to the study and treatment
of MDD is mindfulness meditation. Kabat-Zinn (1995, p. 4), a contemporary theorist,
practitioner, and teacher, describes mindfulness as a process of bringing a certain qual-
ity of attention to moment-by-moment experience by “paying attention in a particular
way . . . on purpose . . . in the present-moment . . . non-judgmentally.” Th e ability to culti-
vate a state of mindfulness is believed to arise with practice of Buddhist mental training
exercises, such as meditation.
Th e objectives of this chapter are to provide a contemporary theoretical account
of MDD as a bio-psychosocial condition that has been enriched by mindfulness
and acceptance principles. In doing so, we create linkage to the traditional cognitive
behavioral model, which, even early on, viewed MDD as arising from a failure to
access metacognitive skills that promote healthy emotional processing. After review-
ing evidence associating metacognitive awareness with depression, we posit that this
emphasis on metacognition instead of cognitive content per se has created fertile
ground to incorporate mindfulness principles into the etiology and treatment model.
We conclude the chapter by reviewing fi ndings from studies that include mindfulness-
enriched treatments for MDD and other emotional disorders, and then frame issues
facing our fi eld given the promising start in incorporating mindfulness principles into
THE TRADITIONAL COGNITIVE BEHAVIORAL MODEL OF
THE PSYCHOPATHOLOGY AND TREATMENT OF MAJOR
Cognitive diathesis-stress theories of depression (Abramson, Seligman, & Teasdale, 1978;
Beck, 1967; 1976) have advanced our understanding of the etiology, maintenance, and
treatment of the disorder in a number of ways. Th ese theories posit that vulnerability
to depression arises through early life experiences that lead one to develop a depressogenic
view of the world. Specifi cally, the Reformulated Learned Helplessness Th eory (Abramson
et al., 1978) and Hopelessness Th eory (Abramson et al., 1989) both conceptualize vulner-
ability to depression in terms of a depressogenic or pessimistic explanatory style (specifi -
cally, the tendency to view negative events as arising from stable, global, and internal
causes). Similarly, Beck’s (1967; 1976) theory of depression posits that vulnerability to
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Mindfulness-Based Cognitive Th erapy 59
depression is associated with dysfunctional attitudes and negative schema regarding the
self, world, and future.
Traditional Targets of Cognitive Th erapy of Depression
Cognitive behavioral theories of depression have informed and infl uenced eff orts to
develop psychotherapies that include techniques to teach individuals how to identify
and challenge pessimistic causal attributions for actual events (Seligman, 1980) or
dysfunctional thoughts (Beck et al., 1979). Empirical fi ndings consistently support the
effi cacy of cognitive therapy of depression (e.g., Hollon, Stewart, & Strunk, 2006).
Th e specifi c mechanisms of change in cognitive therapy remain a topic of great interest
in the fi eld, and a detailed review is beyond the scope of the current chapter. Early in
the canon of cognitive therapy, discussion focused on which facets of cognition were
the most appropriate targets for change in cognitive therapy. Hollon and colleagues
diff erentiate between two main kinds of cognitions: cognitive structures and cognitive
products (Ingram & Hollon, 1986; Hollon & Garber, 1988; Hollon & Kriss, 1984;
Kendall & Ingram, 1989). Cognitive structures represent “the way or manner in which
information is represented in memory” (Ingram & Hollon, 1986, p. 263). Cognitive
structures play an active role in the processing of information. Cognitive schemas (or
schemata) represent a form of cognitive structure important to the cognitive theories
and therapies for depression. In contrast, cognitive products represent directly ac-
cessible, conscious thoughts, such as self-statements, automatic thoughts, and causal
attributions. Such products result from the processing of sensory input information
through cognitive structures.
Th e distinction between cognitive structures and cognitive products is important
with respect to cognitive therapy of depression. For example, theorists caution that
targeting cognitive products will likely yield limited clinical utility, as such interven-
tions amount to symptomatic treatments (Hollon & Kriss, 1984; Safran, Vallis, Segal,
& Shaw, 1986). Th is issue has propelled treatment approaches that address cognitive
structure. For example, Beck and colleagues (1979) state explicitly that changes in
cognitive structures or core schemas represent critical change mechanisms in cognitive
therapy. Similarly, Safran et al. (1986) assert that eff orts at cognitive change should focus
on core processes. Furthermore, Beck (1984) warned that depressed individuals would
remain vulnerable for relapse when underlying cognitive structures were not targeted
and changed. More recently, Hollon et al. (2005) found that patients treated with cogni-
tive therapy who became unrealistically positive or optimistic in their thinking actually
evidenced less durable treatment responses compared to patients who developed think-
ing that was seen as more realistic. Th us, throughout the history of cognitive therapy of
depression, the discussion has, at times, centered on whether cognitive content change
was suffi cient to produce the therapeutic benefi ts or rather whether a more structural
change in the relationship with cognitive material was the true mechanism of action.
Clearly, the issue of cognitive change mechanisms has remained a topic of great interest
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60 NEW DEVELOPMENTS IN THE BEHAVIOR THERAPY TRADITION
(e.g., Jacobson et al., 1996; Tang & DeRubeis, 1999) and, more specifi cally, has provided
opportunities to better elucidate the metacognitive nature of cognitive therapy.
METACOGNITIVE APPROACHES TO EMOTIONAL
“Metacognition refers to one’s knowledge concerning one’s own cognitive processes or
anything related to them” (Flavell, 1976, p. 232). In essence, metacognition represents a
cognitive process that facilitates the making and transformation of meaning in our lives.
Transforming meaning remains an important focus in many systems of psychotherapy par-
ticularly outside of traditional cognitive therapy (e.g., Brewin & Power, 1999; Greenberg,
2002). However, cognitive behavioral approaches, particularly in relation to fear and
anxiety, have long discussed and studied emotional processing (e.g., Foa & Kozak, 1986;
Rachman, 1980). A common thread tying together these approaches is an appreciation
that the making and transformation of meaning is the result of the processing and
integration of information, particularly emotionally laden information from multiple
pathways. Specifi cally, investigators typically distinguish explicit higher-order concep-
tual processing involving primarily rule-based learning from more rapid, associational
processing involving classically conditioned learning (e.g., Power & Dalgleish, 1997;
Teasdale, 1999). Th ese processing channels correspond closely to the higher and lower
routes proposed by LeDoux (1996) in his neurobiological model of emotions. Similarly,
Greenberg and Safran (1987) also stressed the importance of addressing multiple path-
ways to emotion within therapy. Th us, drawing from cognitive science approaches, these
multilevel models of emotion processing stress the qualitative aspects of the information
that are typically generated from higher and lower order emotional pathways and the
manner in which they are retrieved (e.g., Leventhal & Scherer, 1987; Power & Dalgleish,
1997; Teasdale, 1999).
Metacognitive Model of Depression
Although recent years have seen a growing emphasis on metacognitive factors in the
etiology and treatment of depression (e.g., Teasdale, 1999), Beck’s (1984) etiological
and treatment model was inherently metacognitive in nature. For instance, Ingram
and Hollon (1986, p. 272) stated that “cognitive therapy relies on helping individuals
switch to a controlled, eff ortful mode of processing that is metacognitive in nature and
focuses on depression-related cognition” and that “the long-term eff ectiveness of cog-
nitive therapy may lie in teaching patients to initiate this process in the face of future
stress.” Barnard and Teasdale’s multi-level theory of mind (1991; Teasdale, 1999) provides
an explicit metacognitive framework for understanding the relationship between psy-
chopathology and how individuals process their environment. According to Teasdale’s
theory, vulnerability to depression is associated with the degree to which an individual
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Mindfulness-Based Cognitive Th erapy 61
relies on a particular mode of mind to the exclusion of the other modes. Teasdale (1999)
postulated that risk of recurrence and relapse to depression is related to the ease in which
depressogenic, ruminative processing becomes reinstated, rather than the presence or
absence of particular negative beliefs or assumptions.
METACOGNITIVE PROCESSING AND DEPRESSION
Interacting Cognitive Subsystems and Vulnerability to Depression
Barnard and Teasdale’s (1991) multilevel theory of mind, the Interacting Cognitive Sub-
systems (ICS), identifi es three modes of mind available to individuals for processing in-
formation. Th e mindless emoting mode is characterized by purely reactive, sensory-driven
reactions without attention to “the bigger picture.” Th e conceptualizing-doing mode is
associated with processing that involves a focus on conceptual content and analysesófor
example, going grocery shopping. Finally, the mindful-experiencing mode of mind refers
to the recognition of thoughts, feelings, and internal and external sensations, which
culminate in a synthesis of awareness. Th e ICS theory strives to account for the ways in
which humans process information both cognitively and emotionally.
According to ICS theory, mental health is associated with the ability to disengage
from a particular mode of mind or to fl exibly switch among the modes of mind. Th us,
an optimal state is one in which individuals can deftly switch between the three iden-
tifi ed modes of mind based upon conditions in the environment. Still, each of these
modes of mind has particular relevance to one’s vulnerability to depression.
Within the ICS framework, the mindful experiencing/being mode is characterized
by cognitive-aff ective inner exploration, use of present feelings as a guide for problem-
solving and a nonevaluative awareness of present subjective-self-experience. In this
mode, feelings, sensations, and thoughts are directly sensed as aspects of subjective
experience, rather than being objects of conceptual thought. Of the three diff erent
processing confi gurations, the mindful experiencing/being mode is the only confi gura-
tion conducive to emotional processing. Emotional processing involves integrating new
elements within the existing schema to create new alternative patterns of schematic
meanings. Th e mindful/experiencing mode of mind is thought to relate to emotional
well-being (Teasdale. 1999).
In contrast, according to ICS theory, the mindless emoting and conceptualizing/
doing modes of mind are theorized to confer vulnerability to depression (Teasdale,
1999). Individuals in a mindless emoting mode have a conscious experience charac-
terized as being immersed in, and identifi ed with, their aff ective reactions, with little
self-awareness, internal exploration, or refl ection. Th is mode can be contrasted with the
awareness of subjective experiences characteristic of the mindful experiencing/being
mode. One form of mindless emoting mode is cognitive reactivity, which is defi ned as a
change in one or more cognitive indices in response to an emotion evocation challenge
(Fresco, Segal, Buis, and Kennedy, 2007). Cognitive reactivity has been associated with
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62 NEW DEVELOPMENTS IN THE BEHAVIOR THERAPY TRADITION
psychological vulnerability and increased risk to depression (Segal, Gemar, & Williams,
1999; Segal, et al., 2006).
Th us, Teasdale (1999) postulates that the risk of recurrence and relapse to depression
is related to an individual’s capacity to alternate between processing modes in a fl exible
manner depending on input from the environment. In this way, individuals who remain
rigidly in a mindless emoting or conceptualized/doing mode are subject to increased risk
for negative aff ect states. However, it is particularly problematic when individuals vacil-
late between conceptualizing/doing and mindless emoting processing modes. Although
not rigidly bound to one mode of processing, a rapid switching between these modes
leaves individuals vulnerable to what Teasdale (1999) refers to as a “depressive interlock,”
which involves a feedback loop of ruminative thinking about the self, about depres-
sion, and about its causes and consequences. Depressive interlock occurs when the
mind becomes dominated by processing information with negative, depressive content.
Th is type of thinking creates a negative feedback loop that is hypothesized to maintain
depression and reinstate it at time of relapse and recurrence. Teasdale suggests that this
pattern of thinking is similar to Nolen-Hoeksema’s (1991) conceptualization of depres-
sive rumination. Th erefore, when considering Teasdale’s ICS model, any treatment for
depression should result both in more time spent in mindful-experiencing mode and
the ability to more fl exibly switch among modes of mind depending on the context of
Metacognition and Vulnerability to Depression
A central component of the metacognitive model of depression is the construct of
metacognitive awareness, which is broadly defi ned as the ability to experience negative
thoughts/feelings as mental events instead of being synonymous with one’s self (Teasdale
& Barnard, 1993; Teasdale, Segal, & Williams, 1995). Th is broadened perspective on
negative events is encoded in memory and consequently represents a more adaptive way
to relate to negative thoughts when they arise. Individuals high in metacognitive aware-
ness, compared to individuals low in metacognitive awareness, are better able to evade
depression and its sequelae when disidentifying with negative thoughts and feelings that
arise in the face of a stressful situation. In recent years, several correlates of metacogni-
tive awareness have received attention in correlational, prospective, experimental, and
Teasdale and colleagues (2002) examined the relationship of reduced metacognitive
awareness to depression vulnerability and the eff ects of cognitive therapy on metacogni-
tive awareness in relation to depression relapse. Th e fi rst study revealed that euthymic
patients with a history of depression demonstrated signifi cantly lower levels of meta-
cognitive awareness compared with age- and gender-matched nondepressed controls. In
the second study, Teasdale et al. (2002) demonstrated that lower levels of metacognitive
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Mindfulness-Based Cognitive Th erapy 63
awareness accessed fi ve months before baseline assessment predicted earlier relapse in
patients with major depression. Th is fi nding is consistent with the hypothesis that the
ability to relate to depressive thoughts and feelings within a wider perspective reduces
the likelihood of future relapse. Th ese researchers also found that cognitive therapy
increased accessibility to metacognitive sets with respect to negative thoughts and feel-
ings compared with the comparison treatment. Diff erences between cognitive therapy
and the comparison treatment were evidenced only on memories encoded during the
treatment phase and not on prior memories, suggesting that changes in metacognitive
awareness, as a result of cognitive therapy, refl ected cognitive therapy’s eff ects on the
encoding of depressing experiences rather than artifactual eff ects of cognitive therapy
on the way depressing experiences were described in recall. Th us, cognitive therapy is
successful at increasing metacognitive awareness and these metacognitive gains are as-
sociated with positive outcomes.
Another construct closely related to metacognitive awareness is decentering, which
represents one’s ability to observe thoughts and feelings as temporary, objective events
in the mind, as opposed to refl ections of the self that are necessarily true. From a
decentered perspective, “. . . the reality of the moment is not absolute, immutable,
or unalterable” (Safran & Segal, 1990, p. 117). For example, an individual engaged in
decentering would say, “I am thinking that I feel depressed right now” instead of “I
am depressed.” Decentering is present- focused and involves taking a nonjudgmental
and accepting stance regarding thoughts and feelings. Although the concept of decen-
tering can be found in traditional cognitive therapy (e.g., Beck et al., 1979), Teasdale
and colleagues (2002, p. 276) suggest that it was primarily seen as “a means to the
end of changing thought content rather than, as . . . the primary mechanism of thera-
peutic change.” In other words, both Beck and Teasdale agree that cognitive therapy
has always included decentering as a concept and a capacity that successfully treated
depressed patients cultivate. However, a primary diff erence between cognitive therapy
of depression as delivered by Beck and colleagues (1979) and Teasdale and colleagues
(2002) is that for Beck, decentering is a capacity that allows an individual to make the
important change in one’s core beliefs, whereas for Teasdale, decentering is, in and of
itself, the capacity that produces durable relief from depression.
In a recent study, Fresco, Moore, and colleagues (2007) introduced the Experiences
Questionnaire (EQ), an 11-item self-report measure of decentering. In a series of three
studies, the factor structure was demonstrated in both student patient samples. Further,
decentering, as assessed by the EQ, demonstrated theoretically meaningful correlates with
concurrent self-report depression symptoms in college students (r = −.40), concurrent
self-report (r = −.46) and clinician assessed (r = −.31) depression symptoms in depressed
patients, experiential avoidance (r = −.49; Hayes et al., 2004), expressive suppression
(r = −.31; Gross & John, 2003) and cognitive reappraisal (r = .25; Gross & John, 2003).
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64 NEW DEVELOPMENTS IN THE BEHAVIOR THERAPY TRADITION
Fresco, Segal, and colleagues (2007) examined the relationship between decentering
and treatment response in a secondary analysis of Segal et al. (2006). Segal and col-
leagues (2006) demonstrated that cognitive reactivity in conjunction with an emotion
evocation challenge predicted relapse in patients treated to remission through either
antidepressant medication (ADM) or cognitive behavioral therapy (CBT) in an 18-
month prospective study. Fresco, Segal et al. (2007) demonstrated that patients who
achieved a positive treatment response following random assignment to CBT evidenced
signifi cantly greater gains in self-reported decentering compared to patients with a
positive treatment response to ADM. Further, post-treatment levels of decentering in
conjunction with low levels of cognitive reactivity were associated with the most durable
treatment response. Th us, the ability to decenter is an important mechanism of change
that can result from cognitive therapy for depression. However, Teasdale and colleagues
(2002) posit that eff ective and durable treatment of MDD results from an increase
in metacognitive capacities rather than the more traditional approach that cognitive-
behavioral therapy has treatment eff ects by changing cognitive content.
Explanatory Style and Flexibility
Explanatory fl exibility in the assigning of causal explanations for negative events is a
metacognitive extension of explanatory style, the cognitive diathesis at the heart of the
reformulated learned helplessness theory of depression. Broadly construed, explanatory
fl exibility is the ability to view events with a balance of historical and contextual infor-
mation (Fresco, Rytwinski, & Craighead, 2007). Like explanatory style, explanatory
fl exibility is assessed with the Attributional Style Questionnaire (ASQ; Peterson et al.,
1982), a self-report measure in which respondents are presented with hypothetical nega-
tive events and asked to record the main cause of the event, as well as numeric ratings
on the causal dimensions of internality, stability, and globality. Whereas explanatory
style is scored as the sum or average of the attributional dimensions, with higher scores
indicating a more depressogenic style, explanatory fl exibility is computed as the intra-
individual standard deviation on the ASQ dimensions of stability and globality for
negative events. A small standard deviation is considered rigid responding, and a large
standard deviation is interpreted as fl exible responding.
To date, studies in several contexts have demonstrated a relationship between ex-
planatory fl exibility and depression. Fresco and colleagues have shown that explanatory
style and explanatory fl exibility were relatively uncorrelated with one another, and that
lower explanatory fl exibility scores were not simply proxies for extreme responding in
terms of explanatory style (Moore & Fresco, 2007), that explanatory fl exibility is associ-
ated with concurrent depression and anxiety symptoms (Fresco, Williams, & Nugent,
2006), and that levels of explanatory fl exibility at baseline were associated with higher
levels of subsequent depression symptoms in the face of negative life events (Fresco,
Rytwinski, & Craighead, 2007). In addition, a series of studies has demonstrated that
an emotion provocation can engender reactivity in explanatory fl exibility for individuals
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Mindfulness-Based Cognitive Th erapy 65
deemed at risk for reactivity (Fresco, Heimberg, Abramowitz, & Bertram, 2006), and
that this reactivity interacts with intervening negative life events to predict depression
symptoms eight weeks and six months later (Moore & Fresco, 2009). Further, reactiv-
ity of explanatory fl exibility in the direction of reduced fl exibility was associated with
reductions in parasympathetic tone during the mood priming challenge and inferior
recovery of parasympathetic tone following the mood priming challenge (Fresco, Flynn,
Clen, & Linardatos, 2009).
Two studies have examined the relationship of explanatory fl exibility to depression
in the context of acute treatment for major depressive disorder. Specifi cally, in a second-
ary analysis of the dismantling study of cognitive therapy of depression conducted by
Jacobson and colleagues (1996), fi ndings revealed that depressed individuals responding
to behavioral activation evidenced greater gains in explanatory fl exibility, whereas de-
pressed patients who received a combination of behavioral activation plus disputation of
negative automatic thoughts evidenced reductions in pessimistic explanatory style (i.e.,
less stable and global attributions for negative events) (Fresco, Schumm, & Dobson,
2009b). Furthermore, the combination of increased explanatory fl exibility and reduced
pessimistic explanatory style predicted better protection from relapse during the two-
year follow-up period (Fresco et al., 2009b). Th us, the behavioral activation part of the
treatment may have resulted in changes in cognitive structure (i.e., fl exibility), whereas
the disputation of negative thoughts may have infl uenced cognitive content change,
both of which predicted better protection from relapse.
Fresco, Ciesla, Marcotte, and Jarrett (2009a) conducted secondary analysis of an-
other recent randomized clinical trial examining the benefi ts of cognitive therapy of
depression. In the initial study, Jarrett and colleagues (2001) treated patients with MDD
in an open-label fashion with cognitive therapy (CT) for 20 sessions. Responders were
then randomly assigned to ten additional CT sessions delivered over an eight-month
period (Continuation Phase CT) or to an assessment-only condition. Patients were then
followed with no further study treatment for 16 additional months. Findings revealed
that patients who received continuation CT evidenced reduced rates of recurrence and
relapse compared to patients who received no additional CT. In the secondary analysis
conducted by Fresco and colleagues (2009a), fi ndings indicated that gains in explanatory
fl exibility during the acute, open-label phase of CT preceded and predicted drops in self-
report and clinician-assessed depression symptoms. However, continuation phase CT
was not associated with additional gains in explanatory fl exibility. Similarly, explanatory
fl exibility was not associated with rates of recurrence and relapse in the follow-up phase
of the study. Th us, gains in explanatory fl exibility provided by behavioral approaches may
result in reduced relapse and recurrence and hence more durable treatment eff ects.
Another metacognitive factor associated with depression symptoms is rigidity in assigning
causal explanations to hypothetical negative or positive events on the ASQ. Specifi cally,
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66 NEW DEVELOPMENTS IN THE BEHAVIOR THERAPY TRADITION
several studies have found that extreme responses on the ASQ are related to poor clinical
outcomes for patients with depression (Beevers, Keitner, Ryan, & Miller, 2003; Peterson
et al., 2007; Teasdale, Scott, Moore, Hayhurst, Pope, & Paykel, 2001). In one study by
Teasdale and colleagues (2001), 158 patients with residual depression currently being treated
with antidepressant medication were randomly assigned to receive drug continuation with
clinical management either alone or with cognitive therapy (CT). Participants were asked to
report attributions on the ASQ before and following the treatment. Extreme responding (i.e.,
either “totally disagree” or “totally agree”), but not the content of responding (i.e, response
to specifi c items) predicted relapse. Beevers and colleagues (2003) found similar results, in
that poor change in extreme responding predicted a shorter amount of time until depressive
symptoms returned in individuals treated for asymptomatic or partially remitted depression.
Support was also garnered for the relationship between extreme responding and depression
by Petersen and colleagues (2007) who found that medication-only treatment for chronically
depressed patients was associated with an increased frequency in extreme responding on the
ASQ compared to no signifi cant change in responding when treated with CBT. Moreover,
extreme responding on the ASQ predicted a signifi cantly higher likelihood of depressive re-
mission in these patients. Th us, cognitive therapy seems to have an eff ect on by reducing the
likelihood of extreme responding which in turn leads to less depressive symptoms.
Numerous studies conducted by several independent investigators are converging on
the role that metacognitive factors play in the treatment of major depressive disorder.
Two fi ndings are especially relevant at this point. First, to prevent relapse, it seems
important to heighten the capacity to approach emotionally evocative situations with
metacognitive awareness. Second, this metacognitive awareness is refl ected in several
constructs that have demonstrated a relationship to depression: decentering, explanatory
fl exiblity, and extreme responding. Specifi cally, existing psychosocial treatments can be
augmented by targeting these capacities to achieve acute and durable treatment gains.
Many questions remain unanswered regarding metacognition and well-being. However,
one important question that is being hotly pursued is whether metacognitive awareness
can be cultivated more readily than with standard psychosocial treatments. Part of the
answer to this question stems from the observation that these metacognitive skills bear a
close resemblance to the capacities believed to arise from the practice of mental training
exercises that derive from Buddhist and Hindu traditions. Th e conceptual similarities
have led clinical scientists (e.g., Segal, Williams, & Teasdale, 2002) and aff ective neuro-
scientists (e.g., Lutz, Slagter, Dunne, & Davidson, 2008) to take notice of these mental
training exercises. Concentrative practices, such as mindfulness meditation, involve fo-
cusing attention on a specifi c mental or sensory activity, such as repeated imagery, sensa-
tions, sounds, or mantras. Cultivating such a practice is believed to foster metacognitive
awareness (Teasdale et al., 2002). We now turn to a review of eff orts to infuse Buddhist
mental training exercises into Western treatments for MDD.
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Mindfulness-Based Cognitive Th erapy 67
USING MINDFULNESS MEDITATION TO PROMOTE
Barnard and Teasdale’s (1991) multilevel theory of mind posits that the mindful ex-
periencing/being mode is the most likely mode of mind to lead to lasting emotional
changes, which in turn has implications for prevention of relapse in depression. Fur-
thermore, cognitive therapy can promote the mindful experiencing/being mode of
mind. Specifi cally, one facet of cognitive therapy involves helping individuals create and
encode in memory alternative schematic models that will be triggered by the same pat-
terns of information that normally trigger depressogenic schematic models. A second
facet helps individuals learn skills to disengage from fl uctuations between the conceptu-
alizing/doing mode and the mindless emoting mode (i.e., depressive interlock) in order
to function in the mindful experiencing/being/mode.
Although cognitive therapy can lead to the cultivation of these capacities, Teasdale
(1999) suggests that individuals would likely benefi t from learning “mind management”
skills to prevent depressive interlock at times of potential relapse. In recent years, inter-
ventions composed of mindfulness exercises (e.g., transcendental meditation, Maharishi
; mindfulness-based stress reduction, Kabat-Zinn ; and mindfulness-based
cognitive therapy, Segal, Williams & Teasdale ) have emerged as viable supplements
to standard Western medical and psychological practices. Mindfulness has been described
as a nonjudgmental awareness of moment-by-moment experiences (Kabat-Zinn, 1990).
Mindfulness is an active process whereby attention to the present moment is cultivated
in a way that allows a full and meaningful experience of all aspects of that moment with-
out avoiding, judging, or ruminating about certain features. In mindfulness-based stress
reduction (MBSR; Kabat-Zinn, 1990), participants are encouraged to use mindfulness
techniques to introduce simplicity to their lives by focusing on basic experiences such as
breathing, bodily sensations, and the fl ow of thoughts through one’s mind. Kabat-Zinn
describes the following as the foundations of mindfulness: nonjudging of the moment
and of oneself, patience, beginner’s mind (i.e., an openness to seeing everything as a new
experience), trust in oneself and one’s feelings, nonstriving (not needing a purpose to
do something), acceptance of the moment and oneself, and letting go (or nonattach-
ment). When considering Teasdale’s (1999) metacognitive model, these practices serve to
diminish a detached, goal-oriented focus (conceptualizing/doing mode of mind) and a
frame of mind in which emotions are all-encompassing and experienced without aware-
ness (mindless emoting). In MBSR, techniques such as deep breathing, body scans, and
mindful walking are used to cultivate a mindful-experiencing attitude, integrating all
aspects of experience into a meaningful whole. Th ese techniques were originally designed
to lessen some mental and physical suff ering associated with chronic pain.
Mindfulness-based cognitive therapy (MBCT) borrows techniques derived from
MBSR while in conjunction teaching cognitive-behavioral interventions to specifi cally
target vulnerability to depressive relapse. MBCT is an eight-week group program run
with up to twelve recovered recurrently depressed patients. Th e goal of the program is
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68 NEW DEVELOPMENTS IN THE BEHAVIOR THERAPY TRADITION
for patients to develop an awareness of, and to respond more eff ectively to, negative
thinking patterns such as avoiding unwanted thoughts, feelings, and bodily sensations
(Ma & Teasdale, 2004). Th e mindfulness skills aim to help participants to accept these
negative thought patterns and to respond in intentional and skillful ways to these pat-
terns. In this way, MBCT cultivates a decentered relationship to negative thoughts and
feelings in the service of moving from an “automatic pilot” mode to a “being” mode of
emotional processing. Th e therapy begins by identifying the negative automatic think-
ing that is characteristic of those experiencing recurrent episodes of depression, and by
introducing some basic mindfulness practices. In the second session, participants are en-
couraged to understand the reactions they have to experiences in life more generally, and
to mindfulness experiences more specifi cally. Mindful awareness is fostered in the third
session by teaching breathing techniques to focus attention on the present moment. In
the fourth session, experiencing the moment without becoming attached, aversive, or
bored is presented as a way to prevent relapse. Session fi ve is used to promote acceptance
of one’s experience without holding on, and session six is used to describe thoughts
as “merely thoughts.” In the fi nal sessions, participants are taught how to take care of
themselves, to prepare for relapse, and to expand their mindfulness practice to everyday
life. In a recent study examining the relationships among mindfulness training, meta-
cognitive awareness, and depressive symptoms, Carmody, Baer, and colleagues (2009)
found that mindfulness training led to enhanced mindfulness and decentering. More to
the point, both factors signifi cantly predicted a reduction in psychological symptoms,
suggesting to the authors that mindfulness and decentering are highly related.
“Kendra” is a 40-year old woman who presented for treatment after many unsuccessful
attempts to rid herself of depression using many diff erent treatments. Although not
currently depressed, an evaluation of Kendra’s life indicated that she had experienced
four previous episodes of major depression dating back to when she was 17 years old,
which corresponded to the stresses of her senior year in high school, the divorce of her
parents, and the breakup of her fi rst serious romantic relationship. Prior to this episode,
Kendra viewed herself as a generally happy person with a supportive family. Following
this episode, Kendra described herself as scarred by the experience, and said that subse-
quent major depressive episodes seemed to occur in the face of less severe stressors. Th us,
although Kendra has managed to remain free of depression for the past six months, she
remains quite concerned that she is a “depressive episode waiting to happen.” In fact,
the initial evaluation revealed that Kendra was presently highly reactive to any feelings of
sadness or depression and that just about any stress in her life could set off a full-blown
depression. Given Kendra’s risk of relapse, the therapist suggested that she participate in
a study of MBCT that was being off ered in a local clinic.
In the fi rst week, Kendra was encouraged to identify her feelings and to stop auto-
matically reacting to situations by undertaking some simple exercises designed to promote
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Mindfulness-Based Cognitive Th erapy 69
mindful awareness. One such exercise is slowly savoring and attending to a raisin. Another
awareness exercise is a therapist-led body scan. Kendra was also given several mindfulness
exercises to complete as homework. In the second session, the therapist identifi ed common
reactions to negative thoughts and described methods of disengaging from these reac-
tions. Th ese instructions included techniques such as a thought and feelings exercise and a
pleasant events calendar. Mindfulness exercises, including the body scan and a 10-minute
meditation, were used to demonstrate positive ways to disengage from negative thoughts.
Kendra responded favorably to these exercises and seemed to more clearly understand why
her negative thoughts contribute to her depression. Th e goal of the third week was to intro-
duce some more time-intensive mindfulness techniques that teach the ability to maintain
awareness in the moment. Kendra reported that she felt she had more skills to deal with
her negative thoughts and that if she was able to continue the mindfulness exercises on her
own they might have lasting eff ects on her life. In the fourth week, Kendra learned about
cognitive reactivity and how certain negative automatic thoughts can allow life experiences
to spiral into episodes of depression. She also learned additional practices in mindfulness
techniques, such as a 40-minute sitting meditation. After this session, Kendra reported that
she better understood the process of depression and how her ability to disengage her mind
from her automatic thoughts would provide her with protection against depressive relapse.
In the fi fth and sixth weeks of the program, Kendra again learned new mindfulness exer-
cises aimed at gaining acceptance of all experiences and learning that thoughts are merely
thoughts and not facts (i.e., decentering). In the seventh week, Kendra designed a plan for
what to do if she senses a future relapse. Th e last week was focused on tying together all of
the lessons provided and linking the practices learned to everyday life. Kendra fi nished the
program feeling as if she “had learned about why her depressions happen” and that she now
had “ways to stop the depression from coming back.” She also felt a strong sense of control
over possible future relapse because of the action plan created in session seven.
Kendra returned to her therapist a year after the MBCT treatment ended, describing
feelings of slight depression. She reluctantly reported that she was no longer using the
mindfulness strategies on a regular basis. However, she resumed practicing these strate-
gies, and after a few weeks of practicing some of the techniques she learned in MBCT,
she began to feel better and stopped therapy. Th e Kendra vignette typifi es the experience
of a patient who has suff ered numerous bouts of depression and lives in fear of that next
episode, and who has participated in the growing number of randomized controlled tri-
als and open trials of MBCT. Th ese studies are reviewed in the following sections.
MBCT FOR DEPRESSION TRIALS
Prevention of MDD
Several recent randomized clinical trials attest to the benefi ts of MBCT in preventing
relapse of MDD. Teasdale and colleagues (2000) compared the eff ect of MBCT and
treatment as usual (TAU) on relapse rates in 145 recovered recurrently depressed patients
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70 NEW DEVELOPMENTS IN THE BEHAVIOR THERAPY TRADITION
with two or more previous episodes of major depressive disorder (MDD). Th e patients
enrolled had not taken any depression medication for at least 12 weeks prior to the study
and agreed to random assignment to MBCT or TAU. For patients with three or more
previous episodes of MDD, MBCT led to signifi cantly lower relapse rates over a one-
year follow-up period than TAU, with rates being 40% for MBCT and 66% for TAU.
No signifi cant diff erences in relapse rates were found between MBCT and TAU for pa-
tients with a history of less than three episodes of MDD. Using the same study design,
several additional studies have replicated the fi nding that MBCT protects patients with
three or more MDD episodes against depression relapse. Teasdale, Segal, & Williams
(2003) found that relapse rates were 66% and 37% for TAU and MBCT respectively,
and Ma and Teasdale (2004) found relapse rates of 78% for TAU and 36% for MBCT.
Bondolfi and colleagues (in press) set out to replicate these results in two samples of
Swiss individuals who were currently in remission but had previously experienced more
than three previous episodes of depression. Two randomized controlled trials compared
MBCT+TAU to TAU-only during the 14-month follow-up period. Although there were
similar relapse rates for both the MBCT+TAU and TAU-only, there were signifi cantly
more days to fi rst relapse in the MBCT+TAU group (median = 204 days) compared to
median of 69 days for the TAU-only group. Th us, even when examined cross-culturally,
MBCT has eff ects on depressive relapse when compared to the typical treatment of
MBCT may also have benefi ts above and beyond other traditional treatments for
depression. For example, Kuyken and colleagues (2008) conducted a two-group ran-
domized controlled trial to compare maintenance antidepressant medication (m-ADM)
and MBCT with support for tapering or discontinuing ADM for recurrent depressive
individuals. As predicted, relapse rates were signifi cantly higher in the m-ADM con-
dition (60%) than the MBCT condition (47%). Interestingly, MBCT was also more
eff ective at reducing ADM use, as evidenced by a signifi cantly higher average number
of days of ADM use for the m-ADM group (411.4) than the MBCT group (266.46).
Furthermore, an unpublished study by Dobson and Mohammadkhani (personal com-
munication, November 1, 2009) revealed preliminary results that the eff ects of MBCT
may be comparable to CBT, even in another culture. Th ese researchers conducted a
randomized controlled trial to compare MBCT to group CBT and TAU in an Iranian
sample in Tehran, Iran. After 52 weeks of observation, including 8 weeks of treatment,
both CBT and MBCT had similar rates of protection against relapse (13.4% and 11.7%)
compared to TAU (41.1%).
Acute Treatment of MDD Trials
Mindfulness-based cognitive therapy was designed to reduce relapse in depression, but it
is has also been shown to have positive eff ects on current depressive symptom relief above
and beyond the eff ects of TAU. In a controlled clinical trial, Kingston and colleagues
(2007) randomly assigned 19 recurrently depressed patients with three or more previous
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Mindfulness-Based Cognitive Th erapy 71
episodes of MDD and current residual symptoms to receive either MBCT or TAU. As
predicted, there was a larger reduction in self-reported symptoms of depression for the
group receiving MBCT than the group receiving TAU. Th ese researchers also expected
that MBCT would have larger eff ects on reducing rumination, but there were no signifi -
cant diff erences in self-reported rumination between the conditions.
In a controlled pilot study, Barnhofer and colleagues (2009) found that MBCT plus
TAU (n = 14) was more eff ective at reducing symptoms of depression than TAU alone
(n = 14) for individuals with chronic-recurrent depression who had experienced at least
three previous episodes. Symptoms were reduced from severe to mild in the MBCT
group, whereas there was no signifi cant change in the symptom levels of individuals in
the TAU-only group.
Findings from several open trials indicate that MBCT is eff ective at reducing symp-
toms of depression in treatment-resistant populations. A study designed to examine the
acceptability and eff ectiveness of MBCT revealed that in addition to being acceptable
to patients, treatment with MBCT was successful at reducing symptoms of depression
and anxiety (Finucane & Mercer, 2006). Eisendrath and colleagues (2008) found that
MBCT reduced symptoms of depression for medication-refractory depressed patients.
Similarly, Kenny and Williams (2007) found that MBCT led to lower levels of depres-
sive symptoms in depressed individuals who had been resistant to both antidepressant
medication and cognitive therapy previously. Finally, Williams and colleagues (2008)
found that treatment with MBCT led to reduced symptoms of anxiety and depression
for individuals with remitted bipolar depression with suicidal ideation or behavior. In
summary, there is strong evidence that MBCT reduces rates of relapse for recovered, re-
currently depressed individuals with three or more episodes of depression. Also, it seems
that MBCT might have benefi ts for relieving depression symptoms as well as relapse
when compared to other traditional treatments for depression.
Process and Mechanism Trials
Various studies have examined possible mechanisms of the eff ects of MBCT on depres-
sive relapse. Teasdale and colleagues (2002) found that low metacognitive awareness
on the Measure of Awareness and Coping in Autobiographical Memory (MACAM),
indicating inaccessibility of metacognitive sets, predicted relapse to depression in pa-
tients with residual depression. In this study, both cognitive therapy (CT) and MBCT
led to increased metacognitive awareness. However, CT reduced relapse in residually
depressed patients, and MBCT reduced relapse in recovered depressed patients. Th us,
both CT and MBCT may have their eff ects on preventing depressive relapse by chang-
ing the cognitive structure, such as relationships to negative thoughts, rather than the
cognitive content, such as negative beliefs. Raes, Dweulf, Van Heeringen, and Williams
(2009) examined the relationship between MBCT and cognitive reactivity and found
that levels of trait mindfulness, measured by self-report, were signifi cantly negatively
correlated with cognitive reactivity, even when controlling for symptoms of depression
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72 NEW DEVELOPMENTS IN THE BEHAVIOR THERAPY TRADITION
and prior history of depression. Furthermore, when comparing the eff ect of MBCT and
wait-list control on cognitive reactivity in individuals signing up to take MBCT (with
no exclusion criteria), MBCT signifi cantly reduced cognitive reactivity, and this eff ect
was mediated by an increase in mindfulness skills.
Other research has revealed that when comparing MBCT to TAU, MBCT leads to
a smaller discrepancy between ratings of the ideal and actual self (Crane et al., 2008),
and more adaptive memory encoding (Williams et al., 2008). Also, when comparing
MBCT to a wait-list control, recovered depressed individuals with suicidal ideation and
behavior treated with MBCT showed signifi cantly less thought suppression after treat-
ment (Hepburn et al., 2009).
Despite the evidence showing that gains in metacognitive awareness are associated
with recovery and durability of treatment gains, the more traditional view is that the
benefi ts of cognitive therapy are in helping individuals change the content of their
negative thoughts and core beliefs. Th us, Teasdale and colleagues (2002) sought to
distinguish these two possibilities by training patients in increased metacognitive aware-
ness without any explicit attempt to change belief in negative thoughts or underlying
dysfunctional attitudes. One hundred participants, currently in remission or recovery
from major depression, were randomized to receive either treatment-as-usual (TAU)
or MBCT. Results showed that MBCT patients, compared to those who received
TAU, evidenced increases in metacognitive awareness as well as lower rates of relapse
and recurrence of major depression. Although, traditional cognitive therapy was not
included in this study, the fi ndings do show that at least in the context of MBCT, gains
in metacognitive awarenessóand not change in cognitive contentówere associated with
reductions in relapse and recurrence of major depression.
APPLICATIONS OF MINDFULNESS TO ANXIETY DISORDERS
Mindfulness techniques have recently been examined as treatments for anxiety disorders
(e.g., Ree & Craigie, 2007; Evans, Ferrando, Findler, Stowell, Smart, & Haglin, 2008).
We review these approaches herein. In our review of this literature, we focus on therapies
more closely derived from MBSR and MBCT. Other treatments, such as acceptance and
commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) and dialectical behav-
ioral therapy (DBT; Linehan, 1993) contain mindfulness principles and involve various
mindfulness techniques. However, other chapters in this volume more comprehensively
address these treatments.
Implementations of MBCT
Several studies have also recently reported the results of studies that have adapted MBCT
to treat individuals with a particular anxiety disorder (e.g., generalized anxiety disorder
[GAD] or social phobia) with mixed results. Evans and colleagues (2008) reported that
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Mindfulness-Based Cognitive Th erapy 73
MBCT led to reductions in anxiety and depression symptoms in individuals with GAD.
Craigie, Ree, Marsh, and Nathan (2008) also found that a nine-session adaptation
of MBCT produced reductions in self-report measures of worry, and depression and
anxiety symptoms. However, the magnitude of changes was inferior to the eff ect sizes
reported in other CBT treatments for GAD (e.g. Borkovec et al., 2002; Dugas et al.,
2003). A larger study by Kim and colleagues (2009) revealed that individuals with GAD
and panic disorder (PD) receiving MBCT showed signifi cantly more improvement on
self-reported anxiety and depression symptoms compared to those receiving an anxiety
disorder educational program. Bögels, Sijbers, and Voncken (2006) treated nine severely
socially phobic patients by adding mindfulness training to task concentration training,
which involves teaching patients to redirect attention toward the task they are complet-
ing and away from bodily symptoms (Bögels, Mulkens, & de Jong, 1997) and found that
this combination of techniques was eff ective at reducing social anxiety in this group.
Th us, overall, MBCT shows some promise as an acute treatment for anxiety disorders,
but the state of the fi eld is rather preliminary. To date, few studies have been conducted
that incorporate random assignment to condition, with active comparisons, and with
long-term follow-up to assess the durability of treatment gains. In the better controlled
studies, the fi ndings have not yet been as encouraging as the studies with MDD samples.
However, newer eff orts that infuse aspects of mindfulness, as opposed to directly porting
these protocols from one disorder to the other, are showing promise.
Novel Treatments for GAD Informed by Mindfulness Techniques
Two recent treatments for GAD (emotion regulation therapy, Mennin & Fresco,
2009; and acceptance-based behavioral therapy [ABBT], Roemer & Orsillo, 2008), are
presently being developed and evaluated. To date, only ABBT has yet demonstrated
effi cacy in an open trial (Roemer & Orsillo, 2007) and an RCT (Roemer, Orsillo, &
Salters-Pedneault, 2008). In their randomized controlled trial, Roemer, Orsillo, and col-
leagues demonstrated that ABBT evidenced signifi cant reduction in GAD symptoms,
signifi cant increase in end-state functioning, and decreases in depressive symptoms in
15 individuals with GAD compared to 16 randomly assigned to a wait-list for delayed
treatment (Roemer et al., 2008). Preliminary fi ndings from these two GAD protocols
are encouraging, but time will tell whether they produce eff ect sizes superior to existing
protocols not infused with mindfulness and acceptance strategies.
SUMMARY, LINGERING QUESTIONS, AND
As evidenced by the work reviewed in this chapter, our understanding of the etiology and
treatment of major depressive disorder in particular, and emotional disorders in general, has
greatly benefi ted from an infusion from Buddhist and Hindu principles and mental train-
ing exercises. Traditional cognitive behavioral models of psychopathology and treatment
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74 NEW DEVELOPMENTS IN THE BEHAVIOR THERAPY TRADITION
propelled our understanding of emotional disorders in the latter decades of the 20th cen-
tury. However, the incorporation of theoretical and practical elements such as mindfulness
meditation, when studied in a principled and empirical manner, is likely to play a large and
increasing role in taking us even further in our understanding of adaptive and maladaptive
aspects of the human condition. Despite the promise that mindfulness-enriched treatments
have in reducing suff ering and providing durable treatment gains, several important ques-
tions remain. We conclude this chapter by framing some of these questions and, where
available, providing suggested ways to pursue answers to them.
How has Mindfulness Infl uenced our Perspective
About the Nature of Psychopathology?
Unquestionably, cognitive behavioral models of the etiology and treatment of emotional
disorders represent a principled, evidence-based approach to the study and treatment
of these disorders (Hollon et al., 2006). Nonetheless, debates about the centrality of
cognitive change have persisted. Th is has largely been fueled by fi ndings that putative
cognitive mechanism measures demonstrate change following noncognitive treatments,
including antidepressant medication (e.g., Fresco, Segal, et al., 2007, Imber et al. 1990,
Simons et al., 1984) or simply with remission (Hollon, Kendall, & Lumry, 1986). But,
as this debate has continued, the fi eld has seen important growth and expansion. Th is
entire volume is a testament to that work. One important development has been the
emergence of models of psychopathology and treatment that emphasize emotion and
emotion regulation (e.g., Kring & Sloan, 2009). In much the way that the cognitive
behavioral movement arose from animal and basic research on classical and instru-
mental conditioning, emotion regulation models also translate principles from basic
research into theories and approaches to treating emotional disorders. In fact, during
the ascendancy of cognitive-behavioral models, emotions were largely misunderstood or
viewed as epiphenomena secondary to cognition (Mennin & Farach, 2007). However,
perhaps fueled in part by growing interest in neuroscience, emotion is no longer the
“terra incognita” of clinical science (Samoilov & Goldfried, 2000). Systems within the
cognitive behavioral tradition, such as DBT (Linehan, 1993), ACT (Hayes et al., 1999),
and MBCT (Segal et al., 2002) began to take notice of emotion, which in turn has fu-
eled many additional approaches represented in this volume. Interestingly, these systems
were the fi rst to fi nd common ground with mindfulness and other mental training
exercises derived from Buddhism and Hinduism.
How Has Mindfulness Changed the Way
We Deliver Psychosocial Treatments?
One trend that is quite apparent within the cognitive behavioral tradition has been a
de-emphasis on direct cognitive change strategies, particularly those targeting cognitive
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Mindfulness-Based Cognitive Th erapy 75
content. Rather, as noted above, promoting decentering or metacognitive awareness was
always part of cognitive therapy (Beck et al., 1979), but, in recent years, it has gained in
prominence as the putative mechanism that promotes both acute and durable treatment
eff ects rather than simply as one means to promote cognitive change (Teasdale et al.,
2002). To bring this point into perspective, one of us (DMF) recently asked Zindel Segal
to describe how MBCT has changed his implementation of CT, to which he answered
that when working on a thought record with patients, he is now much more interested
in the left side of the thought record, which emphasizes the identifi cation of negative
automatic thoughts, rather than the right side of the record, which focuses on disputa-
tion and generation of rational responses. By focusing on the left side of the thought
record, patients are better able to cultivate a decentered perspective on negative cogni-
tive content (personal communication, October 26, 2007).
Does One Need to Practice Mindfulness to Produce
Lasting Protection Against Depression?
Th e clinical benefi ts of mindfulness meditation are compelling. Recent reviews of more
than 400 meditation trials (Ospina et al., 2008) and a recent meta-analysis of mindful-
ness meditation trials (Hofmann et al., in press) attest to the benefi ts for a variety of
psychiatric and medical conditions. Despite these positive fi ndings, the degree to which
sustained practice of mindfulness is necessary for the therapeutic benefi ts has yet to be
determined. As noted above, acute treatments for depression such as cognitive therapy
produce gains in metacognitive awareness, which is associated with acute treatment
response as well as the durability of treatment gains (Fresco, Segal et al., 2007). Th is
implementation of cognitive therapy lacks any explicit mindfulness practice. Th us, a
simple answer to the question is no. Mindfulness practice is neither necessary nor suf-
fi cient to produce treatment benefi ts. However, a related question is whether initiating
and maintaining a mindfulness practice is associated with more rapid acquisition of
therapeutic benefi ts. Th is question has yet to be studied systematically or quantifi ed in
treatment studies. Although not a direct answer to this question, the most thorough
statement on a related topic was recently off ered by Carmody and Baer (2009) who re-
viewed available studies of MBSR and MBCT in terms of length of treatment, number
of sessions, and duration of each session. Carmody and Baer found that the eff ect sizes
of the studies they reviewed were not statistically related to the length of protocol, nor
the amount of assigned out-of-session practice. Th e available studies did not provide
actual practice time. Th ey go on to call for empirical investigations that systematically
vary the amount of session time and assigned practice time. However, there is a growing
body of research in aff ective neuroscience showing diff erences in patterns of neural cor-
relates among adept meditators (i.e., monks) with tens of thousands of hours of practice
compared to novice meditators (e.g., Davidson & Lutz, 2008), as well as diff erences in
previously naïve meditators following completion of a course in mindfulness (e.g., Farb
et al., 2007).
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76 NEW DEVELOPMENTS IN THE BEHAVIOR THERAPY TRADITION
How Can We Create Synergy Between Clinical Science and
Neuroscience to Advance the Study of Mindfulness While Also
Reducing Human Suff ering?
Interest in integrating mindfulness and other mental training exercises into our Western
models of psychopathology and treatments has never been greater. Th e fi ndings are
promising, and we are providing relief from suff ering for many people. However, mind-
fulness-enriched treatments are equally vulnerable to the challenges faced by traditional
cognitive behavioral treatments to convincingly isolate the mechanisms that produce
treatment gains (Corcoran, Farb, Anderson, & Segal, 2009). We may in fact be reaching
the limit that self-report measures and clinician assessments can tell us about mindful-
ness (Davidson, 2010). Our colleagues in the aff ective sciences have been touching the
elephant that is mindfulness in diff erent and complementary ways; in doing so, they are
providing provocative clues to the biological and neural bases that arise with practice of
these mental training exercises.
An important next step is to begin evaluating mindfulness-related treatment effi cacy
within the context of biomarker change. First, we must begin to examine whether and
how patients with emotional disorders diff er from healthy controls on the biological
indices in the context of cognitive and emotional provocation tasks used in the basic
aff ective sciences. Second, and importantly, we must also investigate the ways that all of
our effi cacious treatments, whether or not they possess mindfulness elements, impact
biological and neural systems that are, in turn, associated with relief from disorders such
as major depression while producing durable treatment gains.
In this chapter we reviewed the evidence supporting both cognitive-behavioral therapy
and mindfulness-enriched treatments as eff ective therapies for depression, which leads
us to several conclusions. First, increasing metacognitive ability (e.g., decentering)
has always been part of traditional cognitive therapy of depression—although recent
fi ndings emphasize metacognitive capacities as the active ingredient in cognitive therapy.
Second, the benefi ts of increasing metacognitive abilities can be realized without explic-
itly practicing mindfulness exercises. Th ird, given that cognitive content change is less
important as compared to cultivating metacognitive ability for the prevention of relapse,
developing treatments that explicitly foster this ability may be more eff ective and endur-
ing than treatments that produce metacognitive awareness as a by-product.
On balance, the fi ndings are promising and are stretching our theoretical conceptu-
alizations, and in turn helping us to reduce human suff ering. Despite these encouraging
developments, many challenges lie ahead. Th e fi elds of clinical science and neurosci-
ence are shedding light on many aspects of normative and disordered aspects of our
emotional lives. In some respects, this work is occurring on parallel and nonintersecting
tracks. However, the time is ripe to embark on programs of translational research that
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Mindfulness-Based Cognitive Th erapy 77
creatively integrate and synthesize basic and applied research fi ndings. As theory and ex-
perimental research become more complex, however, it has become increasingly impor-
tant for researchers to clarify and agree on terminology and units of analysis. Questions
such as: What is mindfulness? How should we measure it? Can we reliably measure it in
fi rst person accounts? Th ird person accounts? Biological and neural correlates? And, im-
portantly, how can our clinical approaches benefi t from the research? Th e work reviewed
in this chapter, and indeed in this volume, suggests some preliminary answers to these
questions. However, the road ahead is likely to be challenging, exciting, and rewarding
as we strive to answer these remaining questions.
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