An introduction to mindfulness

Mindfulness cognitive behavioural therapy can be a useful psychological intervention for patients with recurrent depression. By Dr Tamara Russell

The mindfulness-based stress reduction programme includes various Hatha yoga postures
The mindfulness-based stress reduction programme includes various Hatha yoga postures

Mindfulness is a term used to refer to the mental ability to remain in the present moment, noticing and observing internal and external experiences and phenomena as they occur, in a non-judgmental manner.

It is one of many practices of mental training arising from eastern contemplative traditions, specifically Buddhism.

The practice, and the term, have been appropriated by the west and secularised to facilitate its adoption in physical and mental health settings.

Mindfulness-based stress reduction
Jon Kabat-Zinn introduced mindfulness to the American medical system via his mindfulness-based stress reduction (MBSR) programme.

MBSR helps patients who are suffering from chronic medical conditions where mental stress is known to exacerbate physical symptoms, such as psoriasis, IBS and eczema.

An eight-week training programme requires 26 hours of formal, facilitated group-based practice and daily informal homework between sessions. Participants learn how to bring a non-judgmental present awareness to activities, such as walking, breathing and various Hatha yoga postures, as well as thoughts, perceptions, emotions and bodily sensations.

Research shows that MBSR improves quality of life, reduces the distress related to symptoms and decreases anxiety and depression.1

It also changes the response of the immune system and brain activation in regions related to positive mood.2

Mindfulness cognitive behavioural therapy
A modification of the MBSR programme has been developed by UK clinicians and academics for use in the mental health setting.

Mindfulness cognitive behavioural therapy (MCBT) is a similar eight-week programme. It is specifically designed to include mindfulness and cognitive techniques for patients with recurrent, chronic depression.

Empirical data from RCTs indicates that for these patients, MCBT is more effective than usual treatment in reducing relapse, as assessed over a 60-week period,3 and that MCBT is more effective than maintenance antidepressant therapy at reducing residual depressive symptoms and improving quality of life.4

In one study, 75 per cent of patients in the MCBT group stopped taking medication altogether. The work from this group has led to an update in NICE guidance for the treatment of depression.

As such, MCBT is now a recommended treatment option for patients with more than three presentations of depression who are currently in a period of remission. Referrals would typically be made via the improving access to psychological therapies pathway, or by direct referral to a psychology service where staff have been trained in MCBT. Referral to a private practitioner might also be considered.

The Mental Health Foundation has spearheaded a campaign promoting mindfulness approaches.

Its report concluded that mindfulness-based approaches should be offered at the primary care level and their website provides materials to support GPs. There is also a growing evidence base for the efficacy of mindfulness-based approaches for other mental health conditions, including anxiety.5

While it may seem unusual that one approach can be effective across so many different domains, the key to the mindfulness technique is that it prompts an exploration of the relationship that the individual has with their pain or difficult experiences.

It works with the perennial avoidance that accompanies painful or distressing experiences, encouraging the individual to approach rather than avoid the distress. This helps the patient achieve a sense of control.

Additionally, the knock-on damaging effects of avoidance (for example excessive alcohol or drug use) are mitigated.

Mindfulness practice does not promise that the distress will disappear, rather it facilitates an acceptance of all experiences and the chance to discover that pain can be alleviated when it is explored in a deliberate, curious and non-judgmental way.

Mindfulness training encourages the patient to stop and examine their behaviour for long enough to see where unhelpful patterns of avoidance may be aiding and abetting the problem, and provides tools to explore patterns of behaviour in a more skilful way.

Mechanism
A growing field of 'contemplative neuroscience' is using brain imaging techniques, such as functional MRI, to better understand the functional and structural changes in the brain following sustained mindfulness and meditative practice.

These studies have used a variety of participants, ranging from those who have many years of continuous, daily meditative practice, to individuals who have completed an MBSR course (or similar shorter-duration training).

The emerging story from these studies is that mindfulness training alters the functionality of attention networks in the pre-frontal cortex, particularly the anterior cingulate, medial pre-frontal cortex and insula.

These regions are engaged in a more efficient way during emotionally challenging tasks, likely to be a reflection of the ability of mindful individuals to stop, pause and evaluate what is happening during times of emotional challenge.

These are the same regions implicated in depression. Structural changes in grey matter density of these regions have also been reported.6 There is some suggestion that the reactivity of the amygdala, a critical limbic structure involved in emotional regulation and the flight/fight response is moderated by mindfulness practice.7

Taken together, these findings suggest that sustained and regular mindfulness practice enhances the ability to take control of the mind and direct one's attention in a skilful way when in distress.

The challenge for the implementation of these techniques in mainstream health settings centres on the delivery of mindfulness interventions and the training required by those who deliver it.

  • Dr Russell is an honorary lecturer at the Institute of Psychiatry, King's College London, and an assistant professor at the Western Psychiatric Institute and Clinic, Pittsburgh University, USA

Resources

References
1. Grossman P, Niemann L, Schmidt S et al. J Psychosom Res 2004; 57 (1) (07): 35-43.

2. Davidson R J, Kabat-Zinn J, Schumacher J et al. Psychosom Med 2003; 65(4): 564-70.

3. Teasdale JD, Zindel V, Segal J et al. J Consult Clin Psychol 2000; 68(4): 615-23.

4. Kuyken W, Byford S, Taylor R et al. J Consult Clin Psychol 2008; 76(6): 966-78.

5. Chadwick P, Newman Taylor K, Abba N. Behav Cogn Psychother 2005; 33 (3) (07): 351-59.

6. Britta K, Ott U, Gard T et al. Soc Cogn Affect Neurosci 2008; 3 (1) (03): 55-61.

7. Brefczynski-Lewis J, Lutz A, Schaefer H et al. Proceedings of the National Academy of Sciences of the United States of America 2007; 104(27): 11483-88.

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