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The effects of mindfulness-based cognitive
therapy on risk and protective factors of
depressive relapse –a randomized wait-list
controlled trial
Elisabeth Schanche
1*
, Jon Vøllestad
1,2
, Endre Visted
1,3
, Julie Lillebostad Svendsen
3,4
, Berge Osnes
4,5
,
Per Einar Binder
1
, Petter Franer
3
and Lin Sørensen
4
Abstract
Background: The aim of this randomized wait-list controlled trial was to explore the effects of Mindfulness–Based
Cognitive Therapy (MBCT) on risk and protective factors for depressive relapse within the domains of cognition,
emotion and self-relatedness.
Methods: Sixty-eight individuals with recurrent depressive disorder were randomized to MBCT or a wait-list
control condition (WLC).
Results: Completers of MBCT (N= 26) improved significantly on measures assessing risk and protective factors of
recurrent depression compared to WLC (N= 30) on measures of rumination (d= 0.59, p= .015), emotion regulation
(d= 0.50, p= .028), emotional reactivity to stress (d= 0.32, p= .048), self-compassion (d= 1.02, p< .001), mindfulness
(d= 0.59, p= .010), and depression (d= 0.40, p= .018). In the Intention To Treat sample, findings were attenuated,
but there were still significant results on measures of rumination, self-compassion and depression.
Conclusions: Findings from the present trial contribute to evidence that MBCT can lead to reduction in risk factors
of depressive relapse, and strengthening of factors known to be protective of depressive relapse. The largest
changes were found in the domain of self-relatedness, in the form of large effects on the participants’ability to be
less self-judgmental and more self-compassionate.
Trial registration: ISRCTN, ISRCTN18001392. Registered 29 June 2018
Keywords: MBCT, Recurrent depression, Emotion regulation, Risk factors of depressive relapse, Protective factors of
depressive relapse
Background
Depression is a major public health challenge due to its
prevalence and recurring nature [1–4]. Although the on-
set of depression is often triggered by negative life
events, external circumstances seem to play a lesser role
for each new depressive episode [5,6]. Depression
affects cognitive processes [7], emotional processing [8],
and self-relatedness [9] in ways that heighten risk for de-
pressive relapse. That is, those with previous experiences
of depression become increasingly vulnerable to ordinary
occurrences of negative thinking or difficult emotions, in
that these happen more readily and are more difficult to
disengage from [10]. The aim of the present study was
to investigate the effects of a mindfulness-based inter-
vention tailored to prevent depressive relapse on risk
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* Correspondence: elisabeth.schanche@uib.no
1
Department of Clinical Psychology, University of Bergen, Bergen, Norway
Full list of author information is available at the end of the article
Schanche et al. BMC Psychology (2020) 8:57
https://doi.org/10.1186/s40359-020-00417-1
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factors and protective factors within the domains of cog-
nition, emotion and self-relatedness. In the cognitive do-
main, depression is associated with an increase in the
intensity of rumination, a style of recurrent negative
thinking in which the causes, consequences and implica-
tions of negative events and feelings are repetitively ana-
lyzed [11,12]. It includes persistently dwelling on
personal problems and inadequacies and reviewing what
has gone wrong and why, in the hope that this will be of
help [12]. This unproductive style of thinking is difficult
to control or stop [13,14]. The tendency to ruminate
persists after depressive symptoms remit, and likely con-
stitutes a vulnerability factor for depressive relapse [8].
Prospective studies have shown that the tendency to ru-
minate predicts future depressive symptoms in adults
[15] and adolescents [16,17], and may predict the onset
and recurrence of depressive episodes [18,19].
In the emotional domain, depression is character-
ized by an unwillingness to experience emotional re-
actions that may unfortunately serve to perpetuate
and intensify distress [20]. A comprehensive meta-
analysis found self-reported symptoms of depression
to be positively associated with emotion regulation
strategies trying to avoid or suppress emotions [11].
In a recent meta-analysis, individuals with recurrent
depression seem to use maladaptive emotion regula-
tion strategies and have more limited general emotion
regulation abilities compared to healthy controls [8].
Another marker of depression vulnerability is emo-
tional reactivity to stress [21]. There is a strong rela-
tionship between reactivity to stress and depression
[22], and heightened emotional reactivity to daily
stress has been shown to predict future depressive ep-
isodes [23,24].
In the domain of self-relatedness, depression is charac-
terized by self-critical attitudes and a lack of self-
compassion [9,25–27]. Remitted depressed individuals re-
port higher levels of self-criticism and lower self-
compassion than never-depressed controls [28], support-
ing the notion of low self-compassion as a risk factor for
depressive relapse. Furthermore, levels of self-compassion
has also been found to predict later levels of depressive
symptoms, while levels of depressive symptoms did not
predict later levels of self-compassion [29]. This indicates
that self-compassion prospectively protects against de-
pressive symptoms, rather than merely being influenced
by pre-existing depression levels.
Without treatment, people suffering from recurrent
depression experience relapse at rates as high as 80%
[30,31]. Based on the growing understanding of the
recurring nature of Major Depressive Disorder
(MDD), various treatment approaches have been de-
veloped that specifically target factors assumed to in-
fluence the risk of relapse in depression.
One such treatment approach is Mindfulness-based
cognitive therapy (MBCT [32,33]). MBCT is an eight-
week group-based therapy approach that integrates se-
lected elements of cognitive behavioral therapy for de-
pression with the clinical application of mindfulness
meditation [33]. An overarching goal of MBCT is to en-
able participants to relate to their own thoughts, emo-
tions and bodily sensations with mindful awareness, and
thereby break the habitual dysfunctional cycle of rumin-
ation, maladaptive emotion regulation and self-criticism
that make them vulnerable for depressive relapse. There
are different conceptualizations of mindfulness in the re-
search literature, but there is general agreement that
mindfulness encompasses self-regulation of attention to
monitor present-moment experience, and the concur-
rent attitudinal qualities of acceptance, openness and
non-judgment [34,35]. In mindfulness-based interven-
tions, participants learn an alternative to elaborating on
one’s current state by way of negative repetitive thinking,
or deficient coping by way of avoidance and passivity.
Mindfulness could thus be a skill that lets mental and
emotional states arise and pass without being prolonged
by inefficient attempts to “fix”them. This skill is thought
to facilitate a more “decentered”perspective, where the
person is less identified with the content of thoughts
and feelings and more able to view them as transient
phenomena that do not need to be acted upon. And this
in turn is assumed to lessen the cognitive and emotional
reactivity that is seen as central to depressive relapse
[36]. Mindfulness practice also emphasizes a consistent at-
titudinal stance of self-compassion and kindness, which
may serve to counterbalance the negative self-views and
judgmental thinking characteristic of depression.
There is increasing evidence that MBCT prevents de-
pressive relapse in patients who have had multiple prior
episodes of MDD [37,38]. A number of randomised
controlled trials have shown that MBCT significantly re-
duced the rate of relapse in recurrent major depression
compared to treatment as usual [39–42]. MBCT has also
proven to be as effective as long-term maintenance
treatment with antidepressants in preventing relapse [43,
44]. Still, we need a better understanding of the pro-
cesses by which MBCT may have its impact.
In the cognitive domain, several studies have found
MBCT to reduce rumination [45–47], with effects of the
intervention on depression or relapse risk either associ-
ated with or mediated by reductions in rumination [46,
48,49]. In the emotional domain, the direct effect of
MBCT on difficulties with emotion regulation and gen-
eral reactivity to stress for people having recurrent de-
pression has been less studied. One study demonstrated
that MBCT participants with recurrent depression
showed an overall decrease in emotional reactivity that
was not present in a waitlist control group [21]. In the
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domain of self-relatedness, several studies have found
that MBCT leads to an increase in self-compassion [31,
50]. Self-compassion is also shown to be a mediator of
treatment effect [31], possibly contributing to a decoup-
ling between depressive thinking and depressive relapse
and having a key role in modulating emotional
reactivity.
Aims of the present study
MBCT has been shown to be effective both in prevent-
ing depressive relapse as well as in ameliorating ongoing
depressive symptoms. Evidence also points to how
MBCT reduces risk of depressive relapse, namely by al-
tering processes of cognition (i.e. rumination) and self-
relatedness (i.e. self-compassion). The effect of MBCT
on risk factors within the emotional domain has how-
ever been less studied. The purpose of the present study
was to further investigate the effects of MBCT on risk
factors and protective factors of depressive relapse
within the domains of cognition and self-relatedness as
well as in the emotion domain. These processes are by
no means conceptually isolated mechanisms. Rather they
are interwoven and partially overlapping types of psy-
chological functioning. For instance, scales that measure
tendencies to ruminate will often seem to assess the op-
posite of the non-judgmental and non-reactive attitude
to mental events that is found in mindfulness question-
naires. Also, measures of difficulties with emotion
regulation will by necessity encompass qualities and cap-
acities of mind that cannot easily be distinguished from
mindfulness. As a final example, both mindfulness and
self-compassion can be seen as capturing similar do-
mains of experience. Nevertheless, there are separate lit-
eratures investigating the phenomena of rumination,
difficulties with emotion regulation, emotional reactivity
to stress, self-compassion, and mindfulness. It can be ar-
gued that these are related yet sufficiently unique con-
structs to warrant further investigation into how they
are impacted by the MBCT intervention.
Our first hypothesis was that MBCT would be associ-
ated with a reduction of rumination, difficulties with
emotion regulation, and emotional reactivity to stress.
These are factors known to be a risk for depressive re-
lapse. Although the tendency of negative repetitive
thinking and difficulties with regulating emotions wanes
as depressive symptoms remit, there is robust evidence
that individuals with recurrent depression show a per-
sistent tendency to ruminate and also have difficulties
with emotion regulation in largely asymptomatic phases
compared to people who have never been depressed [8].
Our second hypothesis was that MBCT would be associ-
ated with a strengthening of self-compassion, a factor
known to protect against depressive relapse. Our third
hypothesis was that MBCT would be associated with an
increase in self-reported mindfulness. We assumed that
the strongest findings with regard to mindfulness would
be in the domains of non-judgment and non-reactivity,
as these are the mindfulness facets that are most consist-
ently cultivated in the MBCT intervention [33]. Lastly,
our fourth hypothesis was that MBCT would be associ-
ated with decreased symptoms of depression and anx-
iety, although of a small magnitude as the included
participants would be in a state of remission for depres-
sion. Nevertheless, as residual symptoms of depression is
a risk factor for relapse [51], even a small reduction
could be of clinical relevance.
Method
Setting
The data in this randomized controlled trial were col-
lected to investigate change processes in MBCT. The
study utilized a randomized wait-list controlled trial de-
sign with assessment before and after treatment. The in-
dependent variables were time (pre- and post-treatment
assessments) and assigned treatment condition (MBCT or
a wait-list control condition; WLC). The main dependent
variables were risk and protective factors of depressive re-
lapse: rumination, difficulties with emotion regulation,
emotional reactivity to stress, and self-compassion. In
addition, we registered changes in mindfulness, and symp-
toms of depression and anxiety. These measures allowed
for detection of changes over time (pre-post) in the
MBCT group while statistically controlling for within-
subjects effects.
The minimum clinically meaningful difference be-
tween treatments that we wished to detect in BDI was 7.
Furthermore, we accepted a probability of Type 1 error
of 5% with 80% power. Kuyken et al. [43] reported an at-
trition rate of ca 15% in their MBCT group. We there-
fore expected an attrition rate to be below 20%. Given
this estimate, approximately 30 participants were
planned recruited to each treatment condition. A statis-
tical power analysis (performed using G*Power) indicates
that this sample size would give acceptable power.
Participant characteristics
The participants needed to fulfill the following inclusion
criteria: 18 years or older; at least three former episodes
of MDD; and full or partial remission from depression.
Individuals were allowed to continue use of antidepres-
sants while participating in project, if willing to not dis-
continue or change their dosage during the MBCT
intervention or during the wait-list period for those in
the WLC condition. Individuals were excluded from par-
ticipation if they fulfilled criteria of a comorbid severe
mental disorder (present or life time history of psychosis,
schizophrenia or bipolar disorder); fulfilled criteria for
another mental disorder needing treatment, including
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severe obsessive compulsive disorder, post-traumatic
stress disorder, severe eating disorder or borderline per-
sonality disorder; fulfilled criteria for current substance
use disorders; had any neurological or hormonal dis-
eases; had any prior or current serious cardiovascular
disease; attended psychotherapy two or more times per
month; had participated in a mindfulness-based inter-
vention in the past 2 years; were pregnant or lactating.
Sampling procedures
Participant flow is illustrated in Fig. 1. The project was
registered at the ISRCTN registry (Trial no
ISRCTN18001392). Participants did not receive any eco-
nomic compensation, but received the prevention pro-
gram free of charge. The main route for recruitment was
through advertisements posted at offices and waiting
rooms of general practitioners within the city of Bergen,
Norway. In addition, information about the project was
posted on mental health related forums on social media
(Facebook). The advertisement referred to a web-page
that contained additional information about the project,
including a list of exclusion criteria and contact
information.
After a preliminary telephone screening, 82 potential
eligible participants were interviewed and assessed for
eligibility. We assessed diagnostic criteria using the
structured interview MINI International Neuropsychi-
atric Interview (MINI [52]). MINI is a structured clinical
interview that assesses DSM-IV Axis I diagnoses. The
interview covers 17 modules including mood and anxiety
disorders, psychotic disorders, eating disorders, alcohol
and substance abuse disorders and antisocial personality
disorder. In addition, participants were screened for bor-
derline personality disorder using the borderline
Fig. 1 Participant flow
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subscale of the Structured Clinical Interview for DSM-
IV (SCID-II [53]). Clinical assessments were conducted
by two PhD students involved in the project (EV & JLS).
The PhD students were both clinical psychologists who
had undergone comprehensive training in the use of
MINI, and had extensive prior experience with using the
interview. The onset age of depression (assessed by
retrospective recall), demographic variables, number of
previous episodes of MDD and time in remission were
assessed during the clinical interview. Recruitment was
carried out in three separate cohorts throughout May
2016 and August 2017. The current project was an inter-
disciplinary collaboration featuring a wide array of out-
comes, including psychophysiological measures, brain
imaging data and performance-based tests of attention.
Between 4 and 8 weeks after the clinical interview, all eli-
gible participants in the study met in the laboratory at
the Department of Biological and Medical psychology at
the University of Bergen, Norway, where they filled out
the self-report questionnaires included in the present
study, as well as measures of personality traits, attach-
ment and childhood trauma. The participants also
underwent electrocardiography (ECG) measurement,
and performed cognitive tests that is not reported in the
present study. In addition, a sub- set of the participants
in both conditions underwent an fMRI procedure. The
assessors were blind to treatment condition. The total
time spent in the laboratory for each participant was ap-
proximately 3 h. After completion of the pre-treatment
tests, participants were randomly assigned to either the
experimental- or waiting list control groups. The
waiting-list period lasted for the duration of the treat-
ment period. Participants within the WLC group did not
receive any active treatment during the wait-list period,
but received the MBCT program 2 weeks after post-
assessment in the experimental group was completed.
To ensure that the two groups matched in gender distri-
bution, the randomization process was stratified for gen-
der. The randomization process was carried out by a
colleague not involved in the project, using the random
number generation function (RAND) of Microsoft Excel
(Microsoft Inc., Redmond, WA). The two PhD students
involved in the project contacted the participants and
assigned them to the interventions. The interventions
were carried out between August 2016 and December
2017.
Treatment
The MBCT relapse prevention intervention offered in
the present study followed the standard protocol de-
scribed by Segal et al. [33]. MBCT is a manualized,
group-based training program designed to enable pa-
tients to learn skills that prevent the recurrence of de-
pression. The program takes the form of eight two hour
weekly group sessions, an all-day silent retreat, and indi-
vidual daily homework in between sessions. The inter-
vention was delivered in a university setting with three
MBCT groups of 8–12 patients in each group. In each
session, participants were introduced to a theme relevant
for understanding how habitual modes of thinking, feel-
ing, and behaving contribute to depressive relapse and
to various formal and informal practices that aim to fa-
cilitate being mindful of bodily sensations, emotions and
thoughts. Throughout, participants were invited to share
their experiences with the practice with the instructors
and other members of the group. An aim of MBCT in-
structors is to convey the course themes through inter-
active inquiry and didactic teaching, and through
embodying the attitudinal components of curiosity,
openness and compassion that is at the heart of the pro-
gram. As the program proceeded, participants were in-
creasingly invited to be mindful of their own adverse
experiences, including thoughts, feelings and body sensa-
tions related to depression. In line with the MBCT man-
ual [33], the participants were encouraged to practice at
home between group-sessions. To aid their home prac-
tice, they were given access to recordings of formal
mindfulness practices made by the instructors of their
particular MBCT group. The recordings, also based on a
translation of recordings used in the standard manual of
Segal et al., [33] could be downloaded from a home page
created for the project (https://mindfulness.w.uib.no/).
Therapists
Three psychologists participated as instructors in the
MBCT condition. All of the therapists had undergone
MBCT training on a basic to intermediate level. How-
ever, none were formally certified as MBCT instructors
due to limited access to training pathways nationally in
Norway. All three therapists had experience of leading
previous MBCT groups within the public health system
in Norway, and had an ongoing personal mindfulness
practice. Each of the three groups in the MBCT condi-
tion was led by a pair of the instructors (two by ES & JV
and one by ES & PF).
Two complete MBCT programs were videotaped, one
from each therapist pair. Three two hour sessions from
each therapist pair were randomly selected. The video-
tapes from these sessions were translated into English
and checked for therapist competency and treatment ad-
herence by two experienced MBCT therapists independ-
ent of the trial team with the Mindfulness-Based
Interventions–Teaching Assessment Criteria (MBI: TAC
[54]). The MBI: TAC covers the domain of 1) coverage,
pacing and organization of session curriculum, 2) rela-
tional skills, 3) embodiment of mindfulness, 4) guiding
mindfulness practices, 5) conveying course themes
through interactive inquiry and didactic teaching, and 6)
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holding the group learning environment. Each therapist
is given a score per domain, a total competence/adher-
ence score per session, and an overall score across
sessions.
Self-report measures and covariates
The cognitive domain
Rumination-reflection questionnaire (RRQ-rum [55])
The RRQ-Rum was used to assess rumination. RRQ-
Rum is a 12 item questionnaire designed for measuring
an individual’s stable tendency to ruminate on negative
thoughts. The responses are given on a five-point Likert
scale ranging from 1 (“strongly disagree”)to5(“strongly
disagree”). Higher score on RRQ-Rum yield a greater
tendency to ruminate. In the present study, we used a
Norwegian translation of the RRQ-Rum which has been
reported to have a high internal reliability (Cronbach’s
α= .91) and to correlate negatively with self-esteem and
mindfulness, and positively with habitual negative think-
ing [56]. RRQ-Rum showed good reliability in the
current investigation [α= .87].
The emotional domain
Difficulties in emotion regulation scale (DERS [57])
The DERS was used to assess difficulties with emotion
regulation. DERS is a 36 item questionnaire designed for
measuring six facets of difficulties in emotion regulation.
The responses are given on a five-point Likert scale ran-
ging from 1 (almost never) to 5 (almost always). The
facets include (with Cronbach’s alpha from the present
study presented within brackets): (1) Lack of acceptance
of emotions [α= .90]; (2) Difficulties engaging in goal-
directed behavior [α= .84]; (3) Impulse control difficul-
ties [α= .86]; (4) Lack of emotional awareness [α= .72, 5)
Limited access to emotion regulation strategies [α= .83];
and (6) Lack of emotional clarity [α= .84]. Higher score
on DERS yield more difficulties in emotion regulation.
DERS was translated into Norwegian and validated in a
Norwegian sample by Dundas, Vøllestad, Binder, and
Sivertsen [58]. Recent studies have confirmed DERS’ac-
ceptable internal consistency, construct validity and fac-
tor structure [59,60]. The total DERS showed excellent
internal consistency in the current investigation
[α= .92].
State-trait anxiety inventory (STAI [61]) The trait-
anxiety scale STAI was used to assess emotional reactiv-
ity to stress. The trait-anxiety scale of STAI, is a 20 item
scale designed to measure anxiety as a personal charac-
teristic or a trait. The responses are given on a four-
point Likert scale ranging from 1 (“almost never”)to4
(“almost always”). The trait-anxiety scale has shown
excellent internal consistency (average α< .89) and test-
retest reliability (average r= .88 [62]). We employed a
Norwegian translation of the STAI [63]. The trait-
anxiety scale showed good internal consistency in the
current investigation (Cronbach’sα= .90).
The domain of self-relatedness
Self-compassion scale (SCS [64]) SCS was used to
measure the ability to meet oneself with support and
kindness when experiencing difficulties. SCS is a 26 item
questionnaire designed for measuring three positive and
three negative facets of how an individual treats him- or
herself when experiencing difficulties in life. The re-
sponses are given on a five-point Likert scale ranging
from 1 (almost never) to 5 (almost always). The positive
facets include (with Cronbach’s alpha from the present
study presented within brackets): (1) Self-kindness
[α= .83]; (2) Common humanity [α= .79]; and (3) Mind-
fulness [α= .62]. The negative facets include: (1) Self-
judgment [α= .82]; (2) Isolation [α= .84]; and (3) Over-
identification [α= .69]. High scores on the positive sub-
scales and low scores on the negative subscales yield a
higher level of self-compassion. The SCS scale has also
been used as a measure of two higher order factors [65,
66]: a strength building factor (i.e. building competency
in mindfulness, common humanity, and self-kindness),
and a vulnerabilities prevention factor (i.e. buffer against
self-criticism, isolation, and over-identification). The
positive higher order factor (composed of the positive
sub-scales), and the negative higher order factor (com-
posed of the negative sub-scales) showed identical and
good internal consistency in the current investigation
[α= .89]. SCS was translated into Norwegian and vali-
dated in a Norwegian sample by Dundas et al. [67]. Re-
cent studies have confirmed that the SCS has acceptable
reliability and cross-cultural validity [68]. The total SCS
showed excellent internal consistency in the current in-
vestigation [α= .91].
Additional self-report scales
Five facet mindfulness questionnaire (FFMQ [69])
FFMQ was used to measure the ability to have a present
centered awareness characterized by an attitude of open-
ness, curiosity and acceptance. FFMQ is a 39 item
questionnaire designed for measuring five facets of a
trait-like general tendency to be mindful in daily life.
The responses are given on a five-point Likert scale ran-
ging from 1 (almost never true) to 5 (almost always or
always true). The facets include (with Cronbach’s alpha
from the present study presented within brackets): (1)
Observing [α= .76]; (2) Describing [α= .94]; (3) Acting
with awareness [α= .80]; (4) Non-judging [α= .88]; and
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(5) Non-reactivity to inner experience [α= .77]. Higher
score on FFMQ yield a higher tendency to be mindful in
daily life. The FFMQ has shown high construct validity
[69,70]. The five subscales are internally consistent, with
alpha coefficients ranging from .76 to .91 [69]. The test-
retest reliability was demonstrated to be good to excel-
lent in a Dutch sample [71]. We employed a Norwegian
translation of the FFMQ [58]. The total FFMQ showed
good internal consistency in the current investigation
(Chronbach’sα= .85).
Beck depression inventory II (BDI-II [72]) BDI-II was
used to assess depressive symptoms over the past 2
weeks. BDI-II consists of 21 items that assess a range of
emotional, somatic and cognitive symptoms of depres-
sion. For each item, respondents are given four options
that describe the degree of a depressive symptom and
are then asked to circle the most fitting option. Higher
scores on BDI-II yield more severe depressive symptoms.
Recent studies have confirmed BDI-II’s acceptable dis-
criminant and convergent validity and good test–retest
reliability [72]. We employed a Norwegian translation of
the BDI-II [73]. BDI-II showed good internal consistency
in the current investigation (Chronbach’sα= .88).
The Beck anxiety inventory (BAI [74]) BAI was used
to assess symptoms of anxiety. BAI is a 21 item ques-
tionnaire designed for measuring the severity of anxiety
symptoms. The responses are given on a three-point
Likert scale ranging from 1 (never) to 3 (almost all the
time). Higher scores on BAI yield more severe anxiety
symptoms. Recent studies have confirmed BAI’s accept-
able internal consistency [74,75]. We employed a Nor-
wegian translation of the BAI [76]. BAI showed good
internal consistency in the current investigation (Chron-
bach’sα= .89).
Ethics
The Regional Committee for Medical Research Ethics of
South East Norway approved the protocols for the study
(Reference: 2016/388). Before participation, written con-
sent was obtained from all participants, and the study
was conducted in accordance with the guidelines of the
Declaration of Helsinki. The study adheres to the CON-
SORT guidelines.
Data analysis
Preliminary analyses
All analyses were conducted using SPSS version 25. In
preparation for the statistical analyses, self-report vari-
ables were inspected for outliers, skewness and kurtosis
were inspected to ensure normal distribution, and miss-
ing values were replaced. The dataset had the following
total number of missing pre and post items: Within the
scale RRQ (one missing response), DERS (twenty miss-
ing responses), STAI (thirteen missing responses), SCS
(twelve missing responses), FFMQ (twenty-seven missing
responses), BDI (eleven missing responses), BAI (four-
teen missing responses). For all variables containing
missing values, comparison of means and covariances
were conducted using Littles’missing completely at ran-
dom test [77]. The test indicated that all missing data
were randomly distributed (all ps > 0.127). Missing
values were therefore replaced using the expectation
maximization algorithm in SPSS.
For descriptive summaries of our samples, means and
standard deviations were calculated. Independent sam-
ples t-tests were conducted to test for differences be-
tween the treatment conditions in demographic
variables and covariates prior to intervention. In
addition, we calculated the following inference statistics:
t-tests were conducted with the various outcome mea-
sures to ensure that the factors these measured were
equally distributed in the treatment group and the wait-
ing list control group. Chi-square tests were conducted
with the demographic and clinical background variables.
Video recordings of the MBCT treatments were evalu-
ated and coded for adherence and competence for all
three therapists involved in the MBCT condition.
Main analyses
One-way between-groups analyses of covariance (ANCOVA)
were conducted to compare the effect of MBCT and WLC
on each of the factors assumed to contribute to vulnerability
for relapse in individuals with recurrent MDD following
intervention, while statistically controlling for pre-
intervention levels of the factor under investigation. The
between-group factor was treatment condition (MBCT or
WLC), and the between-group analyses were adjusted for
the corresponding pre-intervention levels of each risk factor
(rumination, difficulties with emotion regulation, and emo-
tional reactivity to stress), the protective factor of self-
compassion, or the additional factors of mindfulness, depres-
sion and anxiety. As the hypotheses in the present study
were mainly concerned with the relative effect of completing
a course of MBCT, the analyses were first performed accord-
ing to the principle of completion (i.e., comprised all clients
who completed both pre-and post-measurements, and
attended at least four of eight MBCT sessions), in line with
previous MBCT trials [41–43]. Next, identical analyses were
performed on the Intention To Treat sample (ITT: i.e., all cli-
ents included in random allocation). For the subset of cases
with missing post-treatment data, we used last variable car-
ried forward to impute missing data.
Results
None of the participants that withdrew from the study
during the MBCT intervention (see Fig. 1) reported
Schanche et al. BMC Psychology (2020) 8:57 Page 7 of 16
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
adverse effects of the MBCT intervention. Out of a total
of 3 participants that withdrew, one did so due to sched-
uling conflicts, one experienced somatic pain that was
an obstacle to partake in the mindfulness practices, and
one experienced deterioration of depressive symptoms
that also made it demanding to work with mindfulness
practices and follow the group-based sessions. This last
participant did not attribute the deterioration to the
MBCT intervention.
Preliminary analyses
Patient characteristics
Table 1shows patient characteristics of the ITT sample. In-
dependent sample t-tests were conducted on both the ITT
sample and the completer sample to investigate whether the
pre-levels of the various outcome measures were equally dis-
tributed in the treatment group and the waiting list control
group. The results indicated that the groups did not
significantly differ in total pre-scores in either of the two
samples. T-test results from the ITT sample were as follows:
RRQ (t (58.49) = −0.462, p= .646); DERS (t (60.50) = −0.427,
p= .671); STAI (t (57.63) = 0.622, p= .511); SCS (t (61.98) =
0.781, p= .438); FFMQ (t (61.97) = 0.736, p= .464); initial
levels of depression (t (60.69) = 0.408, p= .684); and initial
level of anxiety (t (60.107) = 0.939, p= .352). The results of
the non-significant chi-square analyses are reported in Table
1. These non-significant results imply that the randomization
was successful and the participants in the two groups did not
differ significantly in any of the pre-levels of demographic- or
psychiatric variables, or variables used as outcome measures
in the study. As no differences in baseline covariates between
groups were seen, analyses were performed without adjust-
ment for these variables.
Therapist adherence and competence
On the assessment with the MBI: TAC [54], two of the
therapists (ES & PF) had a proficient total competence
level across sessions (level 5 of 6) and one of the thera-
pists (JV) had an advanced total competence level across
sessions (level 6 of 6). Average total adherence scale
scores of 5.3 indicate acceptable adherence to protocol,
and that the MBCT was delivered competently across
therapists and groups.
Treatment effect - completer sample
An overview of changes in each of the main variables
from before to after the MBCT course when participants
who completed the MBCT intervention were included
(completer sample), is presented in Table 2. In the cog-
nitive domain, there was a significant medium effect of
MBCT on rumination, as measured by RRQ, after con-
trolling for the effect of pre-levels of RRQ, F (1,53) =
6.379, p= 0.015, d= 0.59.
In the emotional domain, there was a significant
medium effect of MBCT on difficulties in emotion regu-
lation, measured with DERS, after controlling for the ef-
fect of pre-levels of DERS, F (1,53) = 5.076, p= 0.028,
d= 0.50. An overview of changes in each subscale of the
DERS from before to after the MBCT course is pre-
sented in Table 3.
There was also a significant small effect of mindfulness
training on emotional reactivity to stress, as measured
by STAI-trait, after controlling for the effect of pre-
levels of STAI trait, F (1,53) = 4.097, p= 0.048, d= 0.32.
In the domain of self-relatedness, there was a large
and significant effect of mindfulness training on in-
creased levels of self-compassion, as measured by SCS,
after controlling for the effect of pre-levels of SCS, F (1,
53) = 26.704, p< 0.001, d= 1.02. There was a large and
significant effect of mindfulness training on a strength
building modality, measured by the positive sub-scales
of SCS, after controlling for the pre-levels of the positive
sub-scales, F (1,53) = 17.683, p< 0.001, d= 0.91. There
was also a large and significant effect of mindfulness
training on a vulnerabilities prevention modality, mea-
sured by the negative subscales of SCS, F (1,53) = 19.353,
p< 0.001, d= 0.90. An overview of changes in each sub-
scale of the SCS from before to after the MBCT course
is presented in Table 3.
Furthermore, there was a significant medium effect of
MBCT on total mindfulness, as measured by FFMQ,
after controlling for the effect of pre-levels of FFMQ, F
(1,53) = 7.155, p= 0.010, d= 0.59. An overview of
changes in each subscale of the FFMQ from before to
after the MBCT course is presented in Table 3.
Lastly, there was a significant small effect of MBCT on
symptoms of depression, as measured with BDI, after
controlling for the effect of pre-levels of BDI, F (1,53) =
5.92, p= 0.018, d= 0.40. There was not a significant ef-
fect of MBCT on symptoms of anxiety, as measured by
BAI, after controlling for the effect of pre-levels of BAI,
F (1,53) = 2.766, p= 0.102.
Treatment effect –intention to treat sample
An overview of changes in each of the main variables
from before to after the MBCT course when all partici-
pants randomized into the study were included
(Intention to treat sample), is presented in Table 4.
Treatment effects on measures of rumination (RRQ),
self-compassion (SCS), and depression (BDI-II) were still
significant in the ITT sample (see Table 4). Within the
SCS data, both the strength building modality (F (1,
61) = 12.63, p= 0.001, d= 0.85) and the vulnerabilities
prevention modality of the SCS (F (1,61) = 11.60, p=
0.001, d= 0.66) were also significant in the ITT sample.
Six participants from the ITT sample did not complete
treatment and post-measurements (3 in the MBCT
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condition and 3 in the WCL condition), and two partici-
pants in the MCBT condition did not attend a minimum
of 4 MBCT sessions. Seven of these eight participants
reported to have experienced more than 10 previous epi-
sodes of depression.
Discussion
Major Depressive Disorder (MDD) can develop into a
chronic disorder that constitutes a significant public
health challenge. Mindfulness-Based Cognitive Therapy
(MBCT) is one of several interventions aiming to reduce
Table 1 Characteristics of participants in MBCT and WLC Intention to treat sample
Variable Total sample (n= 64) MBCT (n= 31) WLC (n= 33)
Demographic characteristics p
Women: n (%) 47 (73.4) 22 (71) 25 (75.8) 0.665
Age (in years)
M (SD) 40.1 (12.80) 40.7 (13.19) 39.5 (12.61) 0.304
Range 20–71 20–63 23–71
Marital status n (%) 0.857
Single 21 (32.8) 11 (35.5) 10 (30.3)
Married or cohabiting 40 (62.5) 19 (61.3) 21 (63.6)
Separated, divorced, or widowed 3 (4.7) 1 (3.2) 2 (6.1)
Occupational status: n (%) 0.269
Work full time 35 (54.7) 18 (58.1) 17 (51.5)
Work part time 4 (6.3) 3 (9.7) 1 (3.0)
Sick leave 3 (4.7) 2 (6.5) 1 (3.0)
Unemployed/Social security 9 (14.1) 3 (9.7) 6 (18.2)
Student 11 (17.2) 5 (16.1) 6 (18.2)
Other 2 (3.1) 2 (6.1)
Level of education: n (%) 0.306
High school and/or vocational qualification 15 (23.4) 9 (29) 6 (18.2)
University degree/professional qualification 49 (76.6) 22 (71) 27 (81.8)
Psychiatric characteristics
Depression
HAM-D score: M (SD) 7.77 (5.38) 8.29 (5.47) 7.27 (5.34) 0.225
BDI-II score: M (SD) 12.80 (8.09) 13.23 (8.49) 12.40 (7.81) 0.579
Depression diagnosis at intake: n (%)
In full remission 26 (40.6) 11 (35.5) 15 (45.5)
In partial remission 19 (29.7) 11 (35.5) 8 (24.2)
Moderate depression 19 (29.7) 9 (29) 10 (30.3)
≥10 episodes: n (%) 25 (39.1) 12 (38.7) 13 (39.4) 0.955
Time (in months) since last depressive
episode: M (SD) 17.97 (44.8) 13.81 (26.0) 21.88 (57.2) 0.351
Suicide risk: n (%)
Low 27 (42.2) 14 (45.2) 13 (39.4) 0.641
Moderate 2 (3.1) 1 (3.2) 1 (3) 0.964
Antidepressive medication (n %) 18 (28.1) 9 (29) 9 (27.3) 0.876
Comorbidity: n (%)
Panic disorder current 3 (4.7) 3 (9.7) –0.067
Agoraphobia 9 (14.1) 6 (19.4) 3 (9.1) 0.238
Social Anxiety 3 (4.7) 1 (3.2) 2 (6.1) 0.592
GAD 12 (18.8) 6 (19.4) 6 (18.2) 0.904
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the risk of recurrent depressive episodes. The aim of the
current study was to investigate the effects of MBCT on
particular risk and protective factors of depressive re-
lapse within the cognitive domain, the emotional domain
and the domain of self-relatedness. These domains are
explicit targets of MBCT, and the processes of rumin-
ation, emotion regulation and self-compassion have been
found in recent reviews and meta-analyses to be likely
mechanisms of change in mindfulness-based interven-
tions [78–80]. Our findings show that completing an
MBCT course led to significant changes in the expected
direction in all three domains.
In line with our first hypothesis, we found that MBCT
was associated with a reduction of rumination, difficul-
ties with emotion regulation, and emotional reactivity to
stress. In the cognitive domain, MBCT participants
experienced a medium sized decrease in ruminative
thinking, measured with the Rumination-Reflection
Questionnaire (RRQ). This suggests that mindfulness
training did help the participants to control the tendency
to focus attention on repetitive thoughts concerning the
reasons and consequences for negative feelings. This
supports previous findings that MBCT is an intervention
that aids participants rehearsed in rumination to control
this unproductive style of thinking and vulnerability fac-
tor for depressive relapse [49]. The finding is also in line
with theoretical assumptions in MBCT that practicing
becoming aware of thoughts and relating to them non-
judgmentally, or learning to shift attention from
thoughts to the felt sense of experience in the present
moment, helps participants disengage from negative re-
petitive thinking [42].
In the emotional domain, MBCT participants experi-
enced a small to medium effect on emotion regulation,
measured with the Difficulties in Emotion-Regulation
Scale (DERS). The most prominent finding was on the
subscale of non-acceptance. This captures a tendency to
allow difficult emotions to come and go without trying
Table 2 Effect of MBCT intervention on outcome –Completer
sample
Variables MBCT (n= 26) WLC (n= 30)
M SD M SD F(1,53) ES
RRQ
Pre-intervention 3.9 0.6 3.9 0.5
Post-intervention 3.5 0.6 3.8 0.4 6.379* 0.59
DERS
Pre-intervention 105.5 17.9 106.6 23.8
Post-intervention 95.6 23.5 107.6 24.5 5.076* 0.50
STAI-trait
Pre-intervention 52.8 9.6 51.3 7.4
Post-intervention 46.3 10.5 49.6 9.9 4.097* 0.32
SCS
Pre-intervention 15.1 3.1 14.7 3.7
Post-intervention 18.5 4.9 14.1 3.6 26.704*** 1.02
FFMQ
Pre-intervention 14.6 1.8 14.3 2.0
Post-intervention 15.7 2.6 14.3 2.1 7.155** 0.59
BDI-II
Pre-intervention 14.6 8.3 12.8 8.0
Post-intervention 10.8 9.5 14.5 9.1 5.919* 0.40
BAI
Pre-intervention 14.8 6.8 12.7 9.0
Post-intervention 13.1 6.7 13.8 10.5 2.766 –
Abbreviations: MBCT Mindfulness Based Cognitive Therapy, WLC Waiting-list
Control, Mmean, SD standard deviation, ES effect size (Cohen’s d), RRQ
Rumination-Reflection Questionnaire, DERS Difficulties in Emotion Regulation
Scale (total score), STAI-trait trait–anxiety scale of the State-Trait Anxiety
Inventory, SCS Self-compassion Scale (total score), FFMQ Five Facet
Mindfulness Questionnaire (total score), BDI-II Beck Depression Inventory, BAI
Beck Anxiety Inventory. ∗p< 0.05; ∗∗p< 0.01; ∗∗∗p< 0.001
Table 3 ANCOVA analyses showing changes and effect sizes in
subscales of DERS, SCS, and FFMQ when comparing post values
of MBCT and WLC statistically controlled for pre-intervention
levels of the subscale under investigation
Variables MBCT (n= 26) WLC (n= 30)
M SD M SD F(1,53) ES
DERS
Non-acceptance 15.5 7.0 19.7 4.9 6.062* 0.69
Strategies 20.5 6.8 24.5 7.4 5.968* 0.56
Clarity 11.7 4.3 13.4 4.5 4.267* 0.39
Goals 16.3 3.4 17.0 4.7 2.157 –
Impulse 13.9 4.2 14.9 6.2 0.731 –
Awareness 16.5 4.0 17.0 4.7 0.190 –
SCS
Self-judgment 3.5 1.0 2.5 0.8 24.146*** 1.10
Over-identification 3.3 0.7 2.5 0.8 24.208*** 1.06
Self-kindness 2.8 1.0 2.1 0.6 14.532*** 0.85
Mindfulness 2.8 0.9 2.2 0.6 16.630*** 0.78
Common humanity 2.9 1.0 2.2 0.8 11.250*** 0.77
Isolation 3.2 1.1 2.8 1.0 3.419 –
FFMQ
Non-judgment 3.3 0.8 2.6 0.7 7.509** 0.93
Non-reactivity 3.0 0.7 2.6 0.5 6.33* 0.66
Observe 3.5 0.6 3.2 0.7 4.551* 0.46
Describe 3.1 1.0 3.1 0.8 2.308 –
Act with awareness 2.8 0.6 2.7 0.7 0.227 –
Abbreviations: MBCT Mindfulness Based Cognitive Therapy, WLC Waiting-list
Control, Mmean, SD standard deviation, ES effect size (Cohen’s d), DERS
Difficulties in Emotion Regulation Scale, SCS Self-compassion Scale, FFMQ Five
Facet Mindfulness Questionnaire; Scores on DERS, SCS and FFMQ ranges from
1 (Almost never) to 5 (Almost always). ∗p< 0.05; ∗∗p< 0.01; ∗∗∗p< 0.001
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to suppress or change them. Relatedly, the subscale of
strategies encompasses beliefs that difficult emotions will
pass and a sense of self-efficacy with regard to dealing
with them. Both of these effects were of a moderate
magnitude, indicating that MBCT participants experi-
enced changes in their ability to manage emotions in
line with what is taught in the intervention. Mindful
emotion regulation involves the non-judgmental aware-
ness of affective states as transient phenomena. Attend-
ing to aversive experiences with an attitude of
acceptance, instead of trying to decrease or remove these
experiences, is assumed to increase tolerance for difficult
emotions and lessen emotional reactivity. This stance of
noticing and letting be is in contrast to the maladaptive
emotion regulatory processes found to be associated
with depression, such as suppression and avoidance [11,
81–83]. The effect on the subscale clarity was small but
significant–indicating that there was somewhat of a
tendency in participants to become more aware of and
able to discern and understand emotional reactions.
Also, in the emotional domain, MBCT participants ex-
perienced a small positive impact on their tendency to
attend to, experience and report negative emotions, such
as fear, worry and anxiety across situations, measured
with the State-Trait Anxiety Inventory (STAI). This
could be indicative of MBCT contributing to emotional
stability. The results are in line with findings from Brit-
ton et al. [21], with MBCT participants showing an over-
all decrease in emotional reactivity that was not present
in the waitlist control group. Furthermore, the changes
in emotional reactivity partially mediated improvements
in symptoms of depression. The results are also in line
with findings from Sharplin, Jones, Hancock, Knott,
Bowden, & Whitford [84], investigating the effect of
MBCT for patients with cancer who also experienced
symptoms of depression and anxiety.
In line with our second hypothesis, MBCT was associ-
ated with a strengthening of self-compassion, as mea-
sured by the Self-Compassion Scale (SCS). It is notable
that the strongest findings in the current study were
within the domain of self-relatedness, in the form of the
participants’increased ability to be accepting and sup-
portive towards themselves in times of suffering. The
large effect of MBCT on self-compassion indicates that
what is being cultivated during MBCT is not mere equa-
nimity or a form of adaptive disengagement from mental
and emotional content. Rather, our findings show that
participants are able to relate to experience with a
greater sense of warmth, kindness and benevolence. The
strong effect of MBCT on participants’self-compassion
is in line with Kuyken et al. [43], who found that self-
compassion seemed to reduce cognitive reactivity and
mediate the effect of MBCT treatment on depressive re-
lapse, and concluded that self-compassion is a key skill
learned in MBCT.
The active countering of self-criticism with a compas-
sionate perspective may be particularly important, as de-
pression is characterized by severe and categorical
negative judgments about oneself, others and the world.
In the present study, we also found a consistent pattern
with five of six subscales showing significant effects,
three of which are of large magnitude and two medium
to large. Participants clearly indicate that they have be-
come less judgmental and kinder toward themselves.
Furthermore, the scores on the subscale of over-identifi-
cation points to changes in the relationship to one’s own
emotional state –from a proneness to being overly
absorbed and overwhelmed, to gaining a healthy sense
of perspective. The subscale of common humanity cap-
tures a dimension unique to the self-compassion con-
struct, namely the tendency to view ongoing difficulties
as a universal feature of life instead of being due to
Table 4 Effect of MBCT intervention on outcome –Intention to
Treat sample
Variables MBCT (n= 31) WLC (n= 33)
M SD M SD F(1,53) ES
RRQ
Pre-intervention 3.8 0.7 3.9 0.5
Post-intervention 3.5 0.7 3.7 0.4 4.595* 0.40
DERS
Pre-intervention 102.1 19.1 104.4 23.8
Post-intervention 96.2 24.3 105.3 24.6 2.259 –
STAI-trait
Pre-intervention 51.7 10 50.2 8.0
Post-intervention 47.2 10.1 48.7 10 1.135 –
SCS
Pre-intervention 15.8 3.5 15.1 3.8
Post-intervention 18.3 4.7 14.5 3.8 15.823*** 0.89
FFMQ
Pre-intervention 14.9 1.9 14.5 2.0
Post-intervention 15.5 2.5 14.5 2.1 2.526 –
BDI-II
Pre-intervention 13.2 8.5 12.4 7.8
Post-intervention 10.4 9.1 13.9 8.9 5.120* 0.39
BAI
Pre-intervention 14.2 6.8 12.4 8.7
Post-intervention 13.1 8.2 13.4 10.2 1.455 –
Abbreviations: MBCT Mindfulness Based Cognitive Therapy, WLC Waiting-list
Control, Mmean, SD standard deviation, ES effect size (Cohen’s d), RRQ
Rumination-Reflection Questionnaire, DERS Difficulties in Emotion Regulation
Scale (total score), STAI-trait trait–anxiety scale of the State-Trait Anxiety
Inventory, SCS Self-compassion Scale (total score), FFMQ Five Facet
Mindfulness Questionnaire (total score), BDI-II Beck Depression Inventory, BAI
Beck Anxiety Inventory. ∗p< 0.05; ∗∗p< 0.01; ∗∗∗p< 0.001
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personal weakness and insufficiencies. The robust
changes on this subscale in the current study could thus
indicate that participants have become more accepting
and less judgmental about their own vulnerabilities –a
stance very much in keeping with the curriculum of
MBCT concerning depression.
The only null finding with regard to self-compassion
was for the isolation subscale. This subscale assesses a
tendency to lose a sense of belonging when experiencing
difficulties, with concomitant self-criticism. We find this
somewhat puzzling, as the positive effects on common
humanity were so large. It is possible that the items of
this subscale taps a type of negatively charged self-
relatedness that is more deep-seated and thus would re-
quire longer time to change. Another possibility is that
feeling less isolated does not necessarily mean one feels
more connected to the rest of humanity. Lopez and col-
leagues [65] have argued that the best use of the SCS
scale is to measure two separate factors. A strength
building factor consisting of the positive subscales (i.e.
building competency in mindfulness, common humanity,
and self-kindness), and a vulnerability prevention factor,
consisting of the positive subscales (i.e. buffer against
self-criticism, isolation, and over-identification). In line
with this argument, the isolation subscale is best under-
stood as part of a vulnerability factor, and not as the
converse of common humanity [65]. In the present
study, MBCT was found as a method to strengthen both
these factors.
In line with our third hypothesis, we also found a
medium sized increase in self-reported mindfulness in
the form of significant effects on the total score of the
Five Facet Mindfulness Questionnaire (FFMQ). This ef-
fect was largely driven by large size increases in the
facets of non-judgment and a medium sized increase in
non-reactivity, validating that MBCT had a positive im-
pact on the participants’ability to accept their own
thoughts and emotions and be less prone to react to
them in habitual and maladaptive ways. This is import-
ant, as mindfulness is the central capacity that is being
cultivated in MBCT. It is also the case that an open and
accepting attitude toward one’s own experiences is as-
sumed to be of particular relevance in alleviating depres-
sion and other internalizing disorders. Previous trials of
MBCT have found changes in mindfulness during treat-
ment to be associated with reduced risk for relapse [31,
85]. Non-judgement has also been found to predict de-
pressive symptoms 2 years later [86]. The theoretical as-
sumption is that a stance of equanimity enables distress
to fluctuate naturally, without the individual contribut-
ing to further distress by maladaptive emotion regulation
strategies. In this regard, findings from both the DERS
and FFMQ indicate that MBCT participants have be-
come more skilled at managing difficult experiences
without becoming absorbed in them or trying to sup-
press or escape them. The reported reduction in the ten-
dency to ruminate further supports the emergence of a
more allowing stance with regard to negative and repeti-
tive thinking.
Conversely, the null findings for the other facets of
mindfulness could point to these being less crucial to
the clinical application of mindfulness. The subscale of
observe did show change, albeit with a small effect size.
This facet of mindfulness has been debated, as there are
contradictory findings both with regard to its relation-
ship to the overall factor of mindfulness [69] and its re-
lationship to mental health and well-being [86]. There is
an emerging consensus that the ability to observe one’s
own experience can be both adaptive and maladaptive,
depending on the presence of concurrent capacities for
non-judgment and non-reactivity [87]. In the absence of
these attitudinal aspects of mindfulness, an elevated
observe scale could indicate aversive forms of self-
awareness. However, in the present sample, the notable
increase in non-judgment and non-reactivity lends sup-
port to participants having learned a more beneficial
mode of self-observation during MBCT.
Finally, in line with our forth hypothesis, there was
also a reduction of depressive symptoms as measured by
the Beck Depression Inventory (BDI-II). There are clear
limitations as to how large an impact we could expect to
find, as it was a prerequisite for inclusion that partici-
pants were not acutely depressed. Nevertheless, the
small to medium sized reduction in BDI scores is rele-
vant as research indicates that residual depressive symp-
toms increase the risk of relapse [88]. However, we did
not find as hypothesized that MBCT was associated with
a significant reduction in anxiety as measured with the
Beck Anxiety Inventory (BAI).
When performing the more conservative analyses in-
cluding the patients who did not attend MBCT, or
attended less than a minimum of 4 sessions, we found
that only significant changes in rumination, self-
compassion and depression remained. Nevertheless,
these can be regarded as key outcomes in the preventing
of depressive relapse [31]. The results from the ITT ana-
lyzes confirmed the main conclusion of this manuscript,
that is that the largest effect of MBCT seems to be in
the domain of self-relatedness, in the form of large ef-
fects on the participants’ability to be less self-
judgmental and more self-compassionate.
One purpose of an ITT analysis is to investigate
whether there are systematic differences between treat-
ment completers and non-completers. In the present
study, seven out of eight patients who dropped out of ei-
ther the MBCT or the WCL condition reported having
experienced more than ten previous episodes of depres-
sion. This could indicate that a more chronic course of
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recurrent depression can make it more challenging to
complete MBCT. However, this needs to be confirmed
in other studies to investigate that this is a systematic
tendency in MBCT, and not a random finding in the
present study. One possible implication of this finding
might be to take extra care preparing participants with a
high number of previous depressive episodes that they
might lose hope or motivation, and offer them the possi-
bility to get in touch and discuss their decision before
giving up on treatment.
Strengths and limitations
A strength of the present study was that independent re-
searchers completed the recruitment, diagnostics and as-
sessments of the participants. Still, participants may have
been influenced by factors such as social desirability,
wanting to be perceived as socially acceptable rather
than according to how he or she truly behaved or felt. It
is nevertheless of interest that in the current study, there
is a differential pattern of effects in that not all subscales
on questionnaires show significant changes.
Another strength of the study is that treatment integ-
rity was assessed by independent raters, and all thera-
pists involved in the study showed satisfying levels of
competence and adherence.
One main limitation of this study was the absence of
an active control group, which means we cannot exclude
the possible impact of non-specific factors, such as being
part of a group, receiving care and attention or other
group related factors. This means that the improvement
experienced by the MBCT participants may in part be
due to their expectations to improve, that is, placebo ef-
fect. However, previous studies, which did include an ac-
tive control, have demonstrated the effect of MBCT for
individuals with recurrent depression [89–91].
Another limitation is that the study is solely based on
self-report measures. Answering questions related to
one’s own mental habits and behaviors is a difficult cog-
nitive task [92], and it is likely that participants do not
have a detailed memory or insight into all relevant be-
havior. Participants’self-ratings might represent their
own perceptions of levels of self-compassion and mind-
fulness rather than “objective”or true levels, and the val-
idity thus relies on participants’memory, honesty and
introspective abilities (e.g. [93]).
Using the BDI-II as an outcome variable to calculate
sample size may not have been the most optimal choice.
As most of the participants were between depressive epi-
sodes and had a relatively low level of depressive symp-
toms at pre-treatment, it would have been more suitable
to estimate power based on a measure that one would
expect to be more impacted by the intervention, such as
level of rumination/self-criticism. However, post-hoc
power analyses using G*Power3, [94] revealed an
observed sufficient power (above .80) on the main mea-
sures of rumination and self-compassion in the com-
pleter sample.
The assessors in the present study were blind to treat-
ment condition. However, at post-treatment, some of
the participants did comment on the effect of the MBCT
course. It was therefore difficult to uphold a totally unin-
formed perspective.
The participants in the present study were relatively
homogenous, especially when it comes to education. As
a group, the participants had a quite high level of educa-
tion, which may limit the generalizability of the findings.
Future research
As a direct continuation of the present study, it would of
relevance to investigate to what degree the various vul-
nerability and protective factors are associated with re-
duced occurrence of depressive relapse after 6, 12 and
24 months. Also, it would be of interest to investigate
whether changes in vulnerability and protective factors
of depressive relapse are associated with performance on
cognitive tests, measures of heart rate variability and
functional MRI.
Conclusion
MBCT is tailored to prevent depressive relapse. The
present study validates MBCT as an intervention that has
an effect on risk factors and protective factors of depres-
sive relapse within the cognitive domain, emotional do-
main and the domain of self-relatedness. The main
change was within the domain of self-relatedness, in the
form of positive changes in participants’level of self-
judgement and self-compassion.
Abbreviations
MBCT: Mindfulness based cognitive therapy; WLC: Wait-list control;
MDD: Major depressive disorder; RRQ: Rumination-reflection questionnaire;
DERS: Difficulties with emotion regulation scale; STAI: State-trait anxiety
inventory; SCS: Self-compassion scale; FFMQ: Five facet mindfulness
questionnaire; BDI: Beck’s depression inventory; BAI: Beck’s anxiety inventory
Acknowledgements
We thank the participants of this study for their courage and their valuable
effort of working towards increased psychological flexibility. We will also
thank all members of the MBCT colleague group at the Department of
psychology at the University of Bergen,) who have had regularly meetings
offering a safe environment for instructor training and personal mindfulness
practice. Especially thanks to Linn Achre Tveit who served as an MBCT
instructor for the WLC participants. We will also thank Rebecca Crane and
Vici Williams, who in addition to rating our material for adherence and
competence, gave highly valuable feedback for our continued development
as MBCT instructors.
Authors’contributions
ES, LS, BO, PEB and JV conceived and designed the study. ES, LS, EV, JLS, JV,
BO, PEB and PF acquired the data. ES analyzed and interpreted the data, and
ES and JV wrote the manuscript. ES, JV, LS, EV, JLS, BO, PEB, and PF critically
reviewed the manuscript and agreed to be accountable for all aspects of the
work.
Schanche et al. BMC Psychology (2020) 8:57 Page 13 of 16
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Funding
The project was financed by several of the researchers’positions at the
University of Bergen, Norway and by two PhD grants from the same
institution.
Availability of data and materials
This dataset are available by contacting the corresponding author ES.
The trial protocol can be made available by contacting the corresponding
author ES.
Ethics approval and consent to participate
The study was carried out in accordance with the recommendations and
approval of the Regional Committee for Medical Research Ethics of South
East Norway, University of Oslo, Norway, study number 2016/388. All subjects
were informed about the study and gave a written informed consent in
accordance with the Declaration of Helsinki.
Consent for publication
All authors have read through the final version of the manuscript and given
consent for publication in BMC Psychology.
Competing interests
There are no conflicting interests with industrial companies or
commercialization of products in the study. The researchers receive no
economic benefits from the project.
Author details
1
Department of Clinical Psychology, University of Bergen, Bergen, Norway.
2
Solli District Psychiatric Centre (DPS), Nesttun, Norway.
3
Kronstad District
Psychiatric Centre (DPS), Division of Psychiatry, Haukeland University Hospital,
Bergen, Norway.
4
Department of Biological and Medical Psychology,
University of Bergen, Bergen, Norway.
5
Bjørgvin District Psychiatric Centre
(DPS), Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.
Received: 17 November 2019 Accepted: 4 May 2020
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