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Mechanisms of Change in Mindfulness-Based Cognitive Therapy for Depression: Preliminary Evidence from a Randomized Controlled Trial

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Abstract

Mindfulness-based cognitive therapy (MBCT) is an effective treatment for reducing depressive relapse as well as residual depressive symptoms among adults with recurrent depression but the specific mechanisms through which this treatment works have yet to be examined. This study investigated MBCT's immediate (pre to post) effects on depressive symptoms and its potential theory-driven change mechanisms in a wait-list randomized control trial. Recurrently depressed patients, the majority of them in partial remission, were randomized to either an 8-week MBCT group (N = 26) or a wait-list control group (N = 19). Participants completed measures of depressive symptoms as well as measures of rumination and trait mindfulness before and after the intervention. Consistent with the MBCT change theory, bootstrapping-based mediation analyses demonstrated that reductions in brooding (an aspect of rumination) and increases in mindfulness independently and uniquely (accounting for other mediators) mediated the effects of the intervention on depressive symptoms. Given the pre-post design and the lack of temporal precedence, these findings provide initial evidence supporting the notion that mindfulness and brooding may be important change processes through which MBCT affects depressive outcomes.
... Few studies have focused on the underlying mechanism of preventive CT after remission from MDD, and those that did focused on MBCT. Two studies had inconsistent results in examining rumination as a mediator of the effect of MBCT on depressive symptoms (Bieling et al., 2012;Shahar, Britton, Sbarra, Figueredo, & Bootzin, 2010). To date, only one study directly tested mediation by cognitive reactivity on the preventive effect of CT on relapse (Kuyken et al., 2010), which was unable to demonstrate that MBCT exerted its effects on relapse through posttreatment cognitive reactivity. ...
... Yet, the preventive CT used in this study was found to be effective in increasing survival time and reducing cumulative relapse risk up to 5.5 years (Bockting et al., 2005. Studies on potential mediators of CT after remission have so far provided mixed results (Bieling et al., 2012;Britton et al., 2012;Kuyken et al., 2010;Shahar et al., 2010). Unfortunately, like the before mentioned studies, we were also unable to pinpoint a mediator of the effect of CT after remission. ...
... Third, from the perspective of improving mindfulness, its improvement has shown significant buffering role in the relation between psychological needs satisfaction and depressive symptom. Therefore, school counselors should try to promote mindfulness skills among students by setting up mindfulness classes such as mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR), which have been shown to be effective in relieving depressive symptom (Shahar et al., 2010;Williams, 2008). ...
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Prior studies have revealed that positive parent–child relationships are negatively associated with college students’ depressive symptom. However, the underlying mechanisms of this relation whether specific mediators or moderators are at play are little known. Therefore, the current study examined the potential mediating role of psychological needs satisfaction and the moderating role of mindfulness in the link between parent–child relationships and depressive symptom among college students. A total of 900 college students from Shenzhen, China (53.40% male; Mage = 19.82, SD = 1.01, range from 17 to 27 years) completed questionnaires regarding parent–child relationships, psychological needs satisfaction, mindfulness, and depressive symptom. This study found that (1) parent–child relationships are negatively related to college students’ depressive symptom; (2) psychological needs satisfaction could be a potential mediator in the link between parent–child relationships and depressive symptom; and (3) mindfulness could moderate both the relation between parent–child relationships and depressive symptom as well as that between psychological needs satisfaction and depressive symptom, and those relations were weaker among college students with high levels of mindfulness than those with low levels of mindfulness. The current study highlights the mediating and moderating mechanisms that may underlie the correlation between parent–child relationships and depressive symptom, which may contribute to the development of more effective intervention and prevention programs for alleviating college students’ depressive symptom.
... Indeed, most rumination scales contain a negatively valenced self-evaluation dimension (brooding) and a neutral or non-valenced self-focus dimension (reflection). It is the negatively valenced dimension (brooding) and not reflection (non-valenced SRP) that is both reduced by MBPs and mediates reductions in depression symptoms (Armstrong & Rimes, 2016;Shahar et al., 2010). In contrast, MBP studies that combined the two scales often found no effect (Eisendrath et al., 2016;Robins et al., 2012). ...
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The current study investigated purported mechanisms by which mindfulness-based programs (MBP) improve depression symptoms, specifically, whether mindfulness-related changes in the processing of self-referential and/or emotionally valenced information are associated with improvements in depression symptoms. Four domains of the Self-Reference Task (SRT)—valence bias, self-bias, negative self-bias and positive self-bias in memory recall—were assessed before and after an 8-week MBP in 95 individuals with mild-severe depression symptoms. Associations between pre-post intervention changes in SRT biases and improvements in mindfulness skill acquisition and depression symptoms were examined. Intervention-related changes in SRT biases were also examined as a function of treatment response. Mindfulness skill acquisition from baseline to week eight was significantly associated with decreased self-bias and decreased negative self-bias. Improvement in depression symptom severity from baseline to week 20 was significantly associated with pre-to-post intervention decreases in negative valence bias and increases in positive self bias, but not changes in self-bias or negative self bias. Changes in valence bias significantly interacted with treatment response, while self biases did not. These findings suggest that MBPs decrease depression symptoms through changes in valence and valenced self rather than a global reduction in self-referential processing. Trial registration clinicaltrials.gov NCT01831362
... Consistent with our hypothesis, we found that the interval practice group was effective at improving trait mindfulness, while the mass group did not exhibit any significant changes. Given that most research has documented significant changes in trait mindfulness using an interval (i.e., weekly) practice format for about 8 weeks (Carmody et al., 2008;Shahar et al., 2010;Shapiro et al., 2008Shapiro et al., , 2011, we consider this finding as especially meaningful and interpret it to suggest that trait mindfulness effects can occur within a shorter time using brief MBIs. ...
... However, it should be noted that most rumination scales contain a negatively valenced self-evaluation dimension (brooding) and a neutral or non-valenced self-focus dimension (reflection). It is the negatively valenced dimension (brooding) and not reflection that is both reduced by MBIs and mediates reductions in depression (Shahar et al., 2010;Armstrong and Rimes, 2016). In contrast, MBI studies that combined the two scales often found no effect (Robins et al., 2012;Eisendrath et al., 2016). ...
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Self-related processes (SRPs) have been theorized as key mechanisms of mindfulness-based interventions (MBIs), but the evidence supporting these theories is currently unclear. This evidence map introduces a comprehensive framework for different types of SRPs, and how they are theorized to function as mechanisms of MBIs (target identification). The evidence map then assesses SRP target engagement by mindfulness training and the relationship between target engagement and outcomes (target validation). Discussion of the measurement of SRPs is also included. The most common SRPs measured and engaged by standard MBIs represented valenced evaluations of self-concept, including rumination, self-compassion, self-efficacy, and self-esteem. Rumination showed the strongest evidence as a mechanism for depression, with other physical and mental health outcomes also supported. Self-compassion showed consistent target engagement but was inconsistently related to improved outcomes. Decentering and interoception are emerging potential mechanisms, but their construct validity and different subcomponents are still in development. While some embodied self-specifying processes are being measured in cross-sectional and meditation induction studies, very few have been assessed in MBIs. The SRPs with the strongest mechanistic support represent positive and negative evaluations of self-concept. In sum, few SRPs have been measured in MBIs, and additional research using well-validated measures is needed to clarify their role as mechanisms.
... Overtime, invoking the state of mindfulness through mindfulness practice leads to the development of the trait of mindfulness (Kiken et al., 2016), or the propensity to act mindfully in everyday life (e.g., Baer et al., 2006). Increases in trait mindfulness as a result of participating in MBIs have been found to be associated with psychological health benefits (Carmody and Baer, 2008;Shapiro et al., 2008;Shahar et al., 2010). MBIs are demonstrating promise in treating SUDs broadly and OUD specifically. ...
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A growing body of neurobiological and psychological research sheds light on the mechanisms underlying the development and maintenance of opioid use disorder and its relation to parenting behavior. Perinatal opioid use is associated with risks for women and children, including increased risk of child maltreatment. Drawing from extant data, here we provide an integrated mechanistic model of perinatal opioid use, parenting behavior, infant attachment, and child well-being to inform the development and adaptation of behavioral interventions for opioid-exposed mother–infant dyads. The model posits that recurrent perinatal opioid use may lead to increased stress sensitivity and reward dysregulation for some mothers, resulting in decreased perceived salience of infant cues, disengaged parenting behavior, disrupted infant attachment, and decreased child well-being. We conclude with a discussion of Mindfulness-Oriented Recovery Enhancement as a means of addressing mechanisms undergirding perinatal opioid use, parenting, and attachment, presenting evidence on the efficacy and therapeutic mechanisms of mindfulness. As perinatal opioid use increases in the United States, empirically informed models can be used to guide treatment development research and address this growing concern.
... The concept of trait mindfulness has not yet a under validation according to the authors and distinct concept in the scientific literature (Rau & Williams, 2016), and it is difficult to use a single self-report measure to explore different degrees of mindfulness. To address these limitations, we relied on recent research showing that trait mindfulness is conceptually different from state mindfulness and can be increased through meditation-based interventions (Carmody et al., 2008;Csillik & Tafticht, 2012;Shahar et al., 2010;Shapiro et al., 2008). We chose to use this scale, because all the existing questionnaires were self-report measures of trait mindfulness (Grossman & Van Dam, 2011). ...
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The current study explored the mediating roles of affects and coping strategies in the relationship between mindfulness and burnout among a sample of French healthcare professionals. A total of 180 professionals (mean age = 30.10 years) from various health and social care centers in different parts of France completed a questionnaire that contained measures of mindfulness, emotional experience (positive vs. negative affects), coping strategies, and the three dimensions of burnout. Results indicated that trait mindfulness protects healthcare professionals from burnout (especially the emotional exhaustion and depersonalization dimensions). In addition, coping strategies and affects mediate the link between trait mindfulness and emotional exhaustion. More specifically, participants with a low degree of mindfulness reported more negative affects and greater use of emotion-focused coping strategies. These findings suggest that trait mindfulness and positive affects help these professionals maintain a high level of personal accomplishment through the use of problem-focused coping strategies. Based on our results, recommendations could be drawn up to protect healthcare professionals from burnout and enhance their personal accomplishment. Keywords: Trait mindfulness; burnout; positive affects; negative affects; coping strategies
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Acceptance and mindfulness-based therapies have shown efficacy in the treatment of anxiety and depression. Arguably, acceptance and mindfulness-based therapies target core processes in anxiety and depression by increasing mindful attention, decentering, and acceptance. The present study identified randomized controlled trials of acceptance and mindfulness-based therapies for anxiety and depression. Specifically, we aimed to synthesize the indirect effect of the three putative mediators (i.e., mindful attention, decentering, acceptance) on anxiety and depression. Electronic searches yielded 4989 unique records, which were screened for eligibility by two independent raters, resulting in the identification of 33 eligible studies (30 independent trials). The overall pooled mediating effect of mindful attention, decentering, and acceptance was small to medium (r = 0.145, p < .001). Type of mediation analysis emerged as the only statistically significant moderator. Specifically, studies using correlation-based mediation approaches showed statistically significant mediating effects, while studies using causal time-lag analyses did not yield statistically significant mediating effects. Mediator specificity could not be established. In conclusion, putative mediators of acceptance and mindfulness-based therapies mediated treatment effects on anxiety and depression. Limitations in study number, designs, and statistical approaches employed restrict conclusions regarding specificity and causality.
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Au cours des vingt dernières années, le concept de mindfulness a été largement investigué dans les recherches scientifiques. De multiples définitions de la mindfulness émanent des études publiées. L’une d’entre elles a particulièrement retenue notre attention, il s’agit de celle de Brown & Ryan (2003). Ces auteurs définissent la mindfulness comme une disposition à être attentif et conscient de ce qui se déroule dans le moment présent. Pour ces auteurs, la mindfulness est une capacité innée ou une ressource psychologique qu’il est possible de développer (Brown & Ryan, 2003; Brown, & Ryan, 2004; Weinstein & al., 2009). Même si quelques études ont établi un lien entre mindfulness et différentes variables liées au travail comme la performance, l’équilibre de vie professionnelle et personnelle ou encore le burnout, trop peu d’études sont menées pour étudier ces effets dans le milieu professionnel (Hülsheger & al., 2013). Cette thèse a pour ambition de répondre à ce constat en étudiant la mindfulness en lien avec la santé au travail. Nous avons souhaité mettre en évidence le rôle de la mindfulness comme une ressource psychologique potentielle pour les individus au travail pouvant leur permettre d’accroître leur bien-être professionnel et les protéger du burnout. Pour cela, nous avons mis en oeuvre quatre études (par questionnaire) permettant de répondre à cet objectif. En conclusion de ces études, les résultats permettent d’enrichir les connaissances, la compréhension du concept et de proposer des pistes d’actions pour élargir son utilisation.
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The most commonly used method to test an indirect effect is to divide the estimate of the indirect effect by its standard error and compare the resulting z statistic with a critical value from the standard normal distribution. Confidence limits for the indirect effect are also typically based on critical values from the standard normal distribution. This article uses a simulation study to demonstrate that confidence limits are imbalanced because the distribution of the indirect effect is normal only in special cases. Two alternatives for improving the performance of confidence limits for the indirect effect are evaluated: (a) a method based on the distribution of the product of two normal random variables, and (b) resampling methods. In Study 1, confidence limits based on the distribution of the product are more accurate than methods based on an assumed normal distribution but confidence limits are still imbalanced. Study 2 demonstrates that more accurate confidence limits are obtained using resampling methods, with the bias-corrected bootstrap the best method overall.
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We explored the notion—derived from conceptualisations of mindfulness—that what makes attention to distress harmful is negative judgement about it. In Study 1 we examined factors of Nolen-Hoeksema's Ruminative Response Scale (RRS). A “Brooding” scale included items describing negative judgements of experience, and a “Reflection” scale, comprised items describing analysis of thoughts and feelings without obvious judgement. Correlations of Reflection with depression and thought suppression were lower than those for Brooding, but still significant, perhaps because all items implied some judgement. In Study 2, items were reworded to de-emphasise evaluative judgements (RRS-nonjudging) and compared to the original RRS. Although the factor structures of the original and RRS-nonjudging versions were essentially identical, the RRS-nonjudging Reflection scale was uncorrelated with depression and thought suppression, and was more highly correlated with emotional processing than was the original Reflection scale.
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Findings consistent with the hypothesis have also been obtained in other prospective studies which have shown that cognitive measures, administered in the depressed state, predict the future course of depression independently of initial levels of depression.The hypothesis is elaborated to incorporate the demonstrated relationship of elevated neuroticism to risk and persistence of depression. Recent views on the nature of sex differences in rates of depression, and on the relationship of attributional style to depression are also compatible with the hypothesis. It is concluded that the hypothesis has encouraging preliminary support.SUMMARYTwo broad aspects of cognitive vulnerability to depression can be distinguished. The first is the tendency to evaluate certain types of life event in ways which will produce intense rather than mild depression. This is the aspect of vulnerability on which Beck's cognitive model appears to concentrate. There are considerable difficulties in assessing this aspect of Beck's model and it is not consistently supported by comparison of recovered depressed patients with control groups.The second aspect of cognitive vulnerability relates to the cognitive processes and constructs that become active and accessible once a person is in a state of depression. Within this approach, vulnerability to onset and vulnerability to persistence of depression can be roughly distinguished, depending on whether the focus is on the period when the depression has been present for only a brief period, or is mild, or whether depression has already existed for some time and reached at least moderate severity. The account presented here proposes that a crucial factor determining whether an initially mild or transient depressed state remains mild or soon disappears, or becomes more severe and persistent, is whether a vicious cycle based on a reciprocally reinforcing relationship between depressed mood and negative cognitive processing can become established. The probability that this cycle will become established is, in turn, a function of a complex interaction between the environmental difficulties facing a person, the support available to them, their biological state, and the nature of the cognitive processes and constructs that are active and accessible in the depressed state. The kind of cognitive process and constructs that are most active and accessible in the depressed state will be a function both of the patterns of cognitive processing that are characteristic of the person in their normal mood state (such as those related to neuroticism), and of the patterns of cognitive processing that become active in the depressed state. It is on these latter that the differential activation hypothesis concentrates. It suggests that individual differences in the cognitive processes and constructs that become active and accessible in the depressed' state can make an important contribution to whether an initial state of depression becomes more intense, or fades away, and whether, once established, depression of moderate severity persists a long time or a short time. In particular, it is proposed that processes and constructs related to global negative characterological evaluations of the self or that, in other ways, lead to interpretations of experience as highly aversive and uncontrollable are likely to act to intensify and maintain depression.Two investigations specifically designed to test predictions from the differential activation hypothesis yielded positive results. Further supportive evidence is available from a number of other studies which have examined the relationship between cognitive measures, administered in the depressed state, and the future course of depression. Such studies haverecurringly found that persistence or return of depression is associated with initially high scores on measures of negative cognition, and this association remains when the effects of initial depression level are partialled out.In addition to this encouraging preliminary empirical support, the differential activation hypothesis has the further attraction that it can incorporate into this account the well established finding that neuroticism is associated with risk of becoming depressed, and of depression persisting. Further, it is quite consistent with recent proposals related to sex differences in rates of depression, and to the relationship of attributional style to depression.
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In this study, the authors examine the measurement invariance of the Mindful Attention Awareness Scale (MAAS) across adult attachment style. A 1-factor model and measurement invariance was supported across groups. As predicted, latent mean differences showed that securely attached individuals reported significantly more mindfulness than did insecurely attached individuals, providing construct validity evidence for the MAAS. (Contains 1 figure and 4 tables.)
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Rumination has been recognised as an important maintaining factor in depression. Most assessment up until now been concerned with what people ruminate about and the frequency of the rumination, rather than exploring the reasons for rumination. A sample ( N = 61) self-identified as suffering from rumination reported the reasons they ruminated in response to open-ended questions. Approximately 80% of participants (mean age 47.7 yrs) reported at least one perceived benefit of rumination. The most frequently reported benefits of rumination were increasing self-awareness and understanding of the depression, and solving problems/preventing future mistakes. A scale was also developed to provide a quantitative measure of the reasons for ruminating. Participants with higher levels of self-reported rumination endorsed significantly more strongly the reasons for ruminating than participants with lower levels of self-reported rumination. The scale showed sufficient validity and reliability in this preliminary study to indicate that further use is appropriate. The implications for understanding and treating rumination are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Interventions based on training in mindfulness skills are becoming increasingly popular. Mindfulness involves intentionally bringing one's attention to the internal and external experiences occurring in the present moment, and is often taught through a variety of meditation exercises. This review summarizes conceptual approaches to mind-fulness and empirical research on the utility of mindfulness-based interventions. Meta-analytic techniques were incorporated to facilitate quantification of findings and comparison across studies. Although the current empirical literature includes many methodological flaws, findings suggest that mindfulness-based interventions may be helpful in the treatment of several disorders. Methodologically sound investigations are recommended in order to clarify the utility of these interventions.