Cognitive Behavioral Therapy

CBT mindfulness for depression may also reduce MD visits

wildmind meditation newsRick Nauert, PsychCentral: New Canadian research finds a reduction in primary care visits among individuals receiving mindfulness-based therapy for depression.

Investigators discovered frequent health service users who received mindfulness-based cognitive therapy showed a significant reduction in non-mental health care visits over a one-year period, compared with those who received other types of group therapy.

The mindfulness therapy group had one fewer non-mental health visit per year, for every two individuals treated with this therapy – which translates into a reduction of nearly 2,500 visits to primary care physicians, emergency departments or non-psychiatric specialists in Ontario over eight years.

“We speculate that mindfulness-based cognitive therapy …

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Conquering self-doubt with mindfulness-based therapies

The boss loves your work. Your spouse thinks you’re sexy. The kids—and even the cat—shower you with affection. But then there’s the Voice, the nagging presence in your head that tells you you’re a homely, heartless slacker.

Even people who appear supremely fit, highly successful and hyper-organized are sometimes riddled with debilitating doubts, fears and self-criticisms.

“Most people are struggling with difficult thoughts and feelings. But the show we put on for others says ‘I’ve got it handled,'” says Steven C. Hayes, a professor of psychology at University of Nevada-Reno. In reality, however, “there’s a big difference between what’s on the outside and what’s on the inside.”

Cognitive-behavioral therapy aims to help patients conquer their self doubts in two ways: Either by changing the behaviors that go along with it (I’m so fat—I need to get to the gym!) or by challenging the underlying thoughts, which are often distorted. (I’m 45-years old and I’m comparing myself to anorexic models. Get serious!)

Now, a third-wave of cognitive-behavioral therapy is catching on…

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in psychology and self-help circles. It holds that simply observing your critical thoughts without judging them is a more effective way to tame them than pressuring yourself to change or denying their validity.

” ‘Tame’ is an interesting word,” says Dr. Hayes, who pioneered one approach, called Acceptance and Commitment Therapy. “How would you go about taming a wild horse? You wouldn’t whip it back into a corner. You’d pat it on the nose and give it some carrots and eventually try to ride it.”

This new psychology movement centers on mindfulness—the increasing popular emphasis on paying attention to the present moment. One of its key tenets is that urging people to stop thinking negative thoughts only tightens their grip—”like struggling with quicksand,” Dr. Hayes says. But simply observing them like passing clouds can diffuse their emotional power, proponents say, and open up more options. (“Here’s that old fat feeling again. You know, this happens every time I look at fashion magazines. I am sure judging myself harshly. Do I want to go to the gym? Or I could go to a movie. Or I could stop reading magazines.”)

“Part of what mindfulness does is get to you to recognize that these critical thoughts are really stories you have created about yourself. They are not necessarily true, but they can have self-fulfilling consequences,” says Zindel V. Segal, a professor of psychiatry at the University of Toronto who devised Mindfulness-Based Cognitive Therapy to help depressed patients. “If you can get some distance from them, you can see that there are choices about how to respond.”

Mindfulness also involves paying attention to your breathing and other physical sensations while observing your thoughts so you have a tapestry of information to consider, says Dr. Segal. In fact, neuro-imaging studies have shown that when people consider problems mindfully, they use additional brain circuits beyond those that simply involve problem-solving.

Although some critics initially dismissed mindfulness-based therapies as vacuous and New Age-y, dozens of randomized-controlled trials in the past decade have shown that they can be effective in managing depression, panic disorders, social phobias, sleep problems and even borderline personality disorder.

A study of 160 patients with major depression, led by Dr. Segal and published in the Archives of General Psychiatry last month, found that mindfulness-based cognitive therapy was just as good at as antidepressants at warding off relapses of depression.

The National Institutes of Health is funding more than 50 research studies involving mindfulness treatments for psychological problems.

A growing number of therapists are also using mindfulness-based acceptance in their practices. Katherine Muller, associate director of the Center for Integrative Psychotherapy in Allentown, Pa., says she sometimes brings out a little plastic gnome to represent a patient’s negative feelings. “The idea is, ‘These feelings are going to come. What are you going to do about them?’ ” she says. “You don’t have to react to them at all. Just allowing them to exist takes away their power.”

She also finds that practicing mindfulness is more effective at easing her own fear of flying than being reminded about the safety statistics.

On one flight, she says, “all my cognitive skills were going right out the window.” Then another psychologist suggested focusing on the tray table rather than fighting her fears. “It helped me center my head and get a grip,” she says. “It gave me a chance to watch the movie and talk to the person next to me, rather than focus on how the plane might go down in a fiery ball.”

Psychologist Dennis Tirch, director of the New York Center for Mindfulness, Acceptance and Compassion-Focused Therapies, uses this formula to help even people with profound developmental disabilities take control of their emotions: “Feel your soles of your feet. Feel yourself breathe. Label your emotions and make space for your thoughts.”

Extending some compassion for yourself is also an important part of the new mindfulness therapies, Dr. Tirch says. “I can’t tell you how many clients I have who are just beating themselves up about things” says Dr. Tirch. “Give yourself a break—not so you can curl up in bed and stay home, but so you can interact better with the world.”

Kindness and accepting your thoughts nonjudgmentally doesn’t mean having to settle for the status quo, proponents say. Rather than be paralyzed by negative thoughts, you can opt to change your situation—get to the gym or work harder—but with a clearer set of options based on what really matters.

Some critics note that such advice doesn’t sound so different from standard cognitive-behavioral therapy or being kind to the “inner child” of earlier psychotherapy approaches. And some experts say that still more scientific data are needed to evaluate its effectiveness, particularly now that it’s being applied to such a wide array of disorders.

It’s also not clear yet who might benefit most from mindfully accepting their thoughts rather than reasoning with them. For example, Dr. Tirch thinks that it’s still important to convince someone with severe agoraphobia that a piano won’t fall on their head if they leave the house.

Yet Marsha Linehan, a professor of psychology at the University of Washington, found that the acceptance therapy she developed in the 1990s enabled suicidal patients and those with borderline personality disorder to accept their feelings and get help while trying to challenge them would only have created more bad feelings.

“It’s the nonjudgmental part that trips most people up,” says Dr. Linehan. “Most of us think that if we are judgmental enough, things will change. But judgment makes it harder to change.” She adds: “What happens in mindfulness over the long haul is that you finally accept that you’ve seen this soap opera before and you can turn off the TV.”

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Review – The Art and Science of Mindfulness

“Integrating Mindfulness into Psychology and the Helping Professions,”
by Susan Shapiro and Linda Carlson

Metapsychology Online Reviews: The integration and incorporation of mindfulness training into the mainstream of mental health may well turn out to be one of the most significant developments of the last ten or fifteen years. The literature has expanded exponentially and has moved in quite substantial ways from the use of Buddhist insights and techniques to a regular adjunct of CBT and especially DBT. This new text from Shapiro and Carlson takes us back to the origins of the concept, but also forward to the practical application of mindfulness in clinical settings. It is clearly and happily situated between the scientific paradigm of research evidence (and the authors show this) and the practical world of the individual experience.

The authors try to show the interweaving of Buddhist teachings that emphasize intentionality and focus on the knowable, and the scientific tradition that looks for evidence of efficacy and generalizability rather than particularity. It is clear from the outset that they want to consider what they call both the art and the science of mindfulness.

The authors detail three different ways in which mindfulness can be integrated into psychotherapy and how it can be applied to direct clinical work: the mindful therapist; mindfulness-informed therapy; and mindfulness-based psychotherapy. These different pathways, as the authors term them, show different ways to…

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integration of the basic precepts, and although there is a great deal of overlap, there are also distinct aspects. There may not, as the authors contend, be an awful lot of differences in the outcome, but the ways and directions of the approach bear some unpacking.

The mindful therapist emphasizes the skills of empathy and being present. The notion that these are skills is central for it assumes that techniques can be learnt and polished, that the doing is sometimes a separate question than the valuing. We may all agree that these qualities are good things, but how to show them in practice may be something else all together. The authors argue that mindfulness in the therapist can be taught and people can be trained, and they give a number of useful exercises that could be undertaken as n individual or as a group training program. Even if some of the reminders they scatter through the chapter, such as asking, “What is your intention? Why are you reading this book?”, could be used as handy prompts to even the most experienced therapist. What is your intention? Where is your attention? are questions that never go out of style and never lose their relevance.

Mindfulness-informed therapy is used to capture therapies that use insights from mindfulness and Buddhist teachings, but incorporate them into a more eclectic presentation rather than actually directly teaching meditation or other practices. This may well be the most influential aspect of the concept of mindfulness in current psychotherapy because although for many practitioners and many clients meditation may be difficult to access (both practically and conceptually), the informal practices refer to implementing and applying the ideas to everyday life and developing open, accepting and discerning attention, in a conscious and intentional manner can effect profound and lasting change.

Mindfulness-based psychotherapy is used to describe the explicit, perhaps pure application of principles to the therapeutic context. It is perhaps rarer and may even be, for some, pushing the argument a little too far. However, the explication of the techniques and programmes in the book are informative and thought-provoking.

There is a model of health that underpins the theorizing (as opposed to a model of ill-health). For the authors the intentional development of non-judgmental attention (focussing clearly on what is) leads, almost inevitably if applied clearly and rigorously, to self-awareness and self-regulation and equally inevitably to greater order and health — and all through internal loci of control rather than some external application of expertise. Mindfulness, in this way, is seen to promote self-efficacy alongside wellness.

It is a feature of the book that it reads as well from a therapist’s viewpoint as it does from a self-help position. Although it seems to have been written with practitioners in mind, it could easily be absorbed by anyone looking to understand themselves a little better. For some, it may appear to be too mystical or quasi-religious — there are certainly many references to Buddhist precepts and aphorisms, and there are meditation exercises which are not just thinking exercises — but for most the simple practices of reflection and action upon reflection may have a deep resonance.

It is a book that will appeal on many levels. It is approachable and not hard to digest. The authors should be congratulated for bringing out and explicating some of the most important and perhaps kindest trends in modern psychotherapy for the benefit of us all.

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