Mindfulness-Based Therapies in The New York Times

TOPIC: mindfulness, popular press

Here's a great article by Benedict Carey in the New York Times on the increasing clinical interest in mindfulness-based practices and therapies:

Lotus Therapy, a New Old Path (NYT 5/27/2008)

Lotus therapy? Yes … well, in addition to the ridiculous title, someone decided to throw in two really silly pictures, one of a pseudo-Freudian-looking man, presumably a psychologist, floating in a lotus position with pen and notepad in hand, and the other an equally silly picture of Zindel Segal titled “a psychologist, demonstrating meditative therapy.” [see below, originally captioned as “ANXIETY AID Zindel Segal, a psychologist, demonstrating meditative therapy. Jim Ross for The New York Times.”].

I don't mean that Zindel Segal himself is silly, of course. I can just imagine some poor staff photographer sent over to get pics for this article and discovering that . . . there's nothing to photograph.

Photographer: well, maybe you could demonstrate the technique, you know, for a picture to go along with the article.

Segal: the technique?

Photographer: yeah, you know, like doing something mindfully?

Segal: you want to take a picture of me doing something mindfully?

Photographer: yeah, like just for a few seconds do something mindful and I'll take a few snaps and get out of here.

Segal: Hmmm. OK. [sitting down and crossing legs] How's this?

Photographer: Uh huh. Well, could you do something more active? I mean, something more obviously mindful?

Segal: So people will see it in the picture?

Photographer: yeah man, exactly.

Segal: no.

Photographer: well that sucks.

DESPITE that silliness, the article itself is a treat, mentioning all in one place a good handful of pioneering researchers in the field of mindfulness studies and applications (in order of appearance): Zindel Segal, Jon Kabat-Zinn, Marsha Linehan, J. Mark G. Williams, John D. Teasdale, & S. Helen Ma, and striking a reasonable balance between the pros and cons, the positive and negative results flowing from research into mindfulness-based applications to physical and mental health.

Among any number of nice bits of information, Carey quotes Segal as thinking “… a big part of [the rising interest in mindfulness] is that more and more therapists are practicing some form of contemplation themselves and want to bring that into therapy.” In fact (something Carey probably didn't have the space to point out), there are at least two other significant aspects to that particular influence — not just the therapists bringing contemplative practices from home into the office, but also taking mindfulness practices home to help with the stress of the job and using mindfulness practice to make themselves better therapists/practitioners. Just a few examples of recent research include:

Carson, S. H. & Langer, E. J. (2004). Mindful Practice for Clinicians and Patients. In Haas, L. J. (Ed) Handbook of primary care psychology, 173-183. New York:Oxford University Press.

Christopher, J. C., Christopher, S. E., Dunnagan, T., & Schure, M. (2006). Teaching Self-Care Through Mindfulness Practices: The Application of Yoga, Meditation, and Qigong to Counselor Training. Journal of Humanistic Psychology, 46(4), 494-509.

Grepmair, L., Mitterlehner, F., Nickel, M. (2006). Promotion of mindfulness in psychotherapists in training and treatment results of their patients. Journal of Psychosomatic Research, 60(6), 649-650.

Grepmair, L., Mitterlehner, F., Loew, T., Bachler, E., & Rother, W. (2007). Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: A randomized, double-blind, controlled study. Psychotherapy and Psychosomatics, 76(6), 332-338.

Shapiro, S. L., Brown, K. W., ; Biegel, G. M.(2007). Teaching self-care to caregivers: Effects of mindfulness-based stress reduction on the mental health of therapists in training. Training and Education in Professional Psychology, 1(2), 105-115.

Stratton, P. (2006) Therapist mindfulness as a predictor of client outcomes. Dissertation Abstracts International: Section B: The Sciences and Engineering, 66(11-B), 6296.

Wexler, J. (2006) The relationship between therapist mindfulness and the therapeutic alliance.Dissertation Abstracts International: Section B: The Sciences and Engineering, 67(5-B), 2848.

Carson & Langer (2004), e.g., note that “Increasing mindfulness rather than mindlessness can help patients recast their experiences in a different light as well as help clinicians approach patients' problems from a different perspective,” and argue that “a mindful perspective can have a useful impact on the decisions of a mental health professional regarding diagnostic issues and coordination with the primary care physician and staff.”

Carey points out that “Many researchers now worry that the enthusiasm for Buddhist practice will run so far ahead of the science that this promising psychological tool could turn into another fad.” The enthusiasm, of course, is building in both the professional health-care system and in the general public.

But this just reminds us that we need to carefully evaluate the science, continue to do the critical research, and remind ourselves that no single treatment will be effective or appropriate for complex human behaviors with multiple underlying causes.

Some Related References

Hahn, T. N. (1987). The miracle of mindfulness: an introduction to the practice of meditation. Boston: Beacon Press.

Kabat-Zinn, J. (1994/2005). Wherever you go, there you are: mindfulness meditation in everyday life (10th anniversary edition). New York: Hyperion.

Kabat-Zinn, J. (2005). Coming to our senses: Healing ourselves and the world through mindfulness. New York: Hyperion.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D (2002). Mindfulness-based cognitive therapy for depression. New Tork: The Guilford Press.

Prebish, C. S. & Baumann, M. (Eds) (2002). Westward Dharma: Buddhism beyond Asia. Berkeley: University of California Press.

Challenging GAD with Mindfulness

TOPIC: psychology, peer-reviewed research

RECENT results from a small pilot study by Susan Evans & colleagues (2008, see full citation and summary below) add to the growing literature on the efficacy of mindfulness-based approaches to various psychological disorders, in this case applied to generalized anxiety disorder (GAD), a disabling anxiety disorder characterized by chronic anxiety and associated physical symptoms in the face of little-or-no provocation (see, e.g. the NIMH site on GAD).

Mindfulness-based cognitive therapy (MBCT), perhaps best described in Segal, Williams, & Teasdale’s (2002) book Mindfulness-Based Cognitive Therapy For Depression, combines elements of cognitive therapy and mindfulness-based stress reduction (MBSR) originally pioneered by Jon Kabat-Zinn (see Full Catastrophe Living, 1990). Cognitive Therapy, or Cognitive-Behavioral Therapy (CBT), in general seeks to challenge a patient’s cognitive distortions (such as all-or-nothing thinking, labeling, etc). On the other hand, Kabat-Zinn describes mindfulness as "paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally" (see e.g. Kabat-Zinn’s Wherever You Go, There You Are, 1994). Combined in MBCT, participants learn to reflect nonjudgmentally on their own thought, a metacognitive process in which participants treat their thoughts as thoughts per se rather than reality and in which participants train themselves in attentional control.

Evans & colleagues point out that, although CBT is an effective treatment for GAD,

… GAD nonetheless remains the least successfully treated of the anxiety disorders (Brown, Barlow, & Liebowitz, 1994). Ninan (2001) points out that nearly twice as many patients in treatment for GAD achieve partial remission as those who achieve full remission and indicates the persistence of residual symptoms in many who respond to treatment. [pg 717]

But what’s the motivation to try MBCT for GAD? Why would we think that mindfulness training might complement and possibly enhance CBT treatment for GAD through mindfulness-based cognitive therapy? After all, attentional training is a big component of mindfulness training, and it’s superficially counterintuitive to suggest we should increase the attentional awareness of patients with GAD &mdash aren't they essentially too aware already?

Not necessarily. And mindfulness training isn't really about increasing awareness per se (although it can certainly have that effect). Instead, mindfulness is an exercise in attentional control. In this sense, there are several plausible mechanisms for the palliative effect of mindfulness training, including (1) the ability to redirect attention away from troubling thoughts; (2) the ability to relate to thoughts as thoughts instead of true reflections of reality; and (3) the redirection/redistribution of cognitive resources (i.e.thinking about one thing makes it difficult to think about some other thing). Evans’ team reminds us:

Roemer and Orsillo (2002) point out that since the nature of worry is future directed, training in present-moment mindful awareness may provide a useful alternative way of responding for individuals with GAD. Astin (1997) suggests that the techniques of mindfulness meditation help the person to develop a stance of detached observation towards the contents of consciousness and may be a useful cognitive behavioral coping strategy. [pg 217]

The results of the pilot study are consistent with MBCT being helpful in treating GAD, although firm conclusions aren’t possible from this non-experimental design. A summary of the paper appears below.

Article Summary

SOURCE:

EVANS, S., FERRANDO, S., FINDLER, M., STOWELL, C., SMART, C., HAGLIN, D. (2008). Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 22(4), 716-721. DOI: 10.1016/j.janxdis.2007.07.005

General Methodology	Small, pre-test post-test, non-experimental pilot study. No control group. Participants screened for inclusion/exclusion criteria, but otherwise self-selected.
Participants and Sample Size(s)	11 (6 female, 5 male), mean age = 49 yrs, mean educ = 17 yrs, resulting from first screening 36 applicants down to 12, then dropping 1 from data analysis due to unrelated medical problem.
Conditions/Manipulations	8-week mindfulness-based cognitive therapy (MBCT) program
Dependent Measures included	Beck Anxiety Inventory (BAI); Beck Depression Inventory (BDI); Penn State Worry Questionnaire (PSWQ); Profile of Mood States (POMS); Mindfulness Attention Awareness Scale (MAAS)
Other Measures	Anecdotal participant self-reports.
Results
Before MBCT:  moderate levels of anxiety (BAI); pathological degree of worry (PSWQ); significant levels of anxiety and tension (POMS); mild levels of depression (BDI); & mindful awareness significantly lower than normal (MAAS) After MBCT:  statistically significant improvement on all scales except the MAAS; MAAS scores improved to approximately normal, though the change didn't reach statistical significance (probably due to small sample size); all participants completed the 8-week MBCT course; very positive anecdotal stories from participants.
Discussion/Conclusions
MBCT appears to be "a feasible and acceptable treatment for individuals with GAD" [pg 720]; stronger conclusions not possible because of non-experimental design, and external validity (generalizability) difficult to assess.

Related references.

Astin, J. A. (1997). Stress reduction through mindfulness meditation: effects on psychological symptomatology, sense of control and spiritual experiences. Psychotherapy and Psychosomatics, 66(2), 97–106.

Brown, T., Barlow, D., & Liebowitz, M.(1994). The empirical basis of generalized anxiety disorder. American Journal of Psychiatry, 151, 1272–1280.

Kabat-Zinn, J. (1990) Full Catastophe Living. New York: Delta Publishing.

Ninan, P. T. (2001). General anxiety disorder: why are we failing our patients? Journal of Clinical Psychiatry, 62(Suppl. 19), 3–4.

Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment of generalized anxiety disorder: integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9(1), 54–68.