Mindfulness in Clinical Psychology

Mark WilliamsUniversity of Oxford

Department of Psychiatry

Collaborators: Zindel Segal, John Teasdale, Jon Kabat-ZinnOxford Team: Melanie Fennell, Thorsten Barnhofer, Catherine Crane,

Danielle Duggan, Adhip Rawal, Emily Hargus, Wendy Swift

www.mbct.co.uk

Buddhism and Science

March 2010

Outline

• Clinical psychology and cognitive science– Depression recurrence– Outcome evidence

• What is going on?– Modes of self-focus

• Conceptual vs experiential• Exploring modes of self-focus

• in eating pathology• through neuroimaging

• Mindfulness and relapse signatures

Age of onset of major depression (N = 4041; Zisook, 2007, Amer. J. Psychiat)

Depression recurrence

More than 50% who do recover will have at least one further episode

Those with history of 2 or more episodes have 70-80% chance of recurrence

Mindfulness-based Cognitive Therapy (MBCT)

Designed for patients in remission to prevent relapse/recurrence

Format Pre-class interview Eight weekly classes. Each 2 hours. Around 12 in each class Teaching meditation

sustained attention on breath and body thoughts as mental events

Home-based practice, up to one hour per day, 6 days a week - mostly CDs of mindfulness meditation practice

Teasdale, Segal & Williams, et al.,2000 Survival Curve (for patients with 3 or more previous episodes - 60 weeks)

MBCT: 37%

TAU: 66%

10 20 30 40 50 60

1.00

0.5

Procedural replication (Ma & Teasdale, 2004, J.Consult.Clin.Psychol.)

Kuyken et al (2008) MBCT vs m-ADMs

Outline

• Clinical psychology and cognitive science– Depression recurrence– outcome evidence

• What is going on?– Modes of self-focus

• Conceptual vs experiential• Exploring modes of self-focus

• in eating pathology• through neuroimaging

• Mindfulness and relapse signatures

Automatic vs strategic processes

• Darwin (1872)• What we seen in humans is a combination of

– evolutionary old, automatic reactions• Switch on AND OFF depending on

contingencies – evolutionary newer, strategic, representational

and symbolic reactions (working “off-line”)

Two Modes of Self-focus: Conceptual and Experiential

Conceptual / Simulation

Experiential / Direct

LabelingElaboratingAnalyzingJudgingGoal-settingPlanningComparingRememberingSelf-reflecting

Seeing Tasting TouchingHearing SmellingVisceral sensationsProprioceptive sensing

En

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• Conceptual mode useful – To complete meanings– To complete tasks

• But when it becomes over-used– Preoccupied by meaning– Planning (even when not wanted)

•I find it difficult to stay focused on what’s happening in the present. •I tend to walk quickly to get where I’m going without paying attention to what I experience along the way.•It seems I am “running on automatic” without much awareness of what I’m doing.•I rush through activities without being really attentive to them.•I get so focused on the goal I want to achieve that I lose touch with what I am doing right now to get there.•I find myself preoccupied with the future or the past.

•Cf Cornell Campus experiment

Consequences of conceptual mode (from the Mindful Attention and Awareness Scale; Brown & Ryan, 2003)

…in depression

• Key maintaining factorPERSISTENT OVER-USE OF CONCEPTUAL MODE– “adhesive pre-occupation”(rumination) & Attempts to stop it(avoidance)

»lack of interest in anything else

For example

• Focus on• Feelings of tiredness

Mindfulness training: Shifting mode of self-focus

- from conceptual to experientialE

nvi

ron

men

tal I

np

ut

Conceptual/ Simulation

Perceptual/Direct

A

B

Outline

• Clinical psychology and cognitive science– Depression recurrence– outcome evidence

• What is going on?– Modes of self-focus

• Conceptual vs experiential• Exploring modes of self-focus

• in eating pathology• through neuroimaging

• Mindfulness and relapse signatures

(Adhip Rawal’s DPhil thesis)

• Choose a condition where self-focus most problematic– Students with high eating concerns– Anorexic in-patients

Induction of processing modes (Watkins & Teasdale, 2004)

• Sample item:

• the physical sensations in your body• the way you feel inside• how awake or tired you are

• Mode induction – Conceptual:

• Think about the causes, meanings and consequences of……

– Experiential:• Focus your attention on the experience of ……

• 8 minutes

Stress test for Eating Concerns

• Imaginary meal procedure (Shafran et al.,1999)

•Participants asked to imagine eating a fattening food for a period of 2 minutes.

Outcome measures

• Estimate of actual weight “How much do you think you weigh right now?”

• Moral wrongdoing: – How morally unacceptable/wrong do you feel (0-100%) it

was to think about eating the food• Urge to reduce/cancel effects:

– “How strong do you feel is your urge (0-100%) to reduce or cancel the effects of thinking about the food?”

• Neutralization– imagining exercising– imagining eating celery– checking shape in a mirror

Analogue study: Pre and post stressor difference in weight estimate (in kg) for high ED group

-0.3

-0.2

-0.1

0

0.1

0.2

0.3

Conceptual Experiential

Mea

n W

eig

ht

chan

ge

Condition, p < .05

Mean ratings for moral wrongdoing/unacceptability post

stressor for high and low ED groups

0

5

10

15

20

25

30

35Analytical

Experiential

Mor

al W

rong

doin

g

High ED Low ED

Proportion of neutralisers and non-neutralisers post stressor for the high ED group

0

2

4

6

8

10

12

14

16

18

Neutralisers

Non-neutralisersFre

quency

Analytical Experiential

Anorexic patients?

• N = 13 in-patients• BMI=17.2• Matched controls

Patient study: Pre vs post stressor difference in weight estimate (in kg)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Conceptual Experiential Filler task

Anorexic

Controls

Patient study: Proportion neutralised after stressor in each condition

0

2

4

6

8

10

12

Conceptual Experiential Filler

Neutralisers

Non-neutralisers

Mindfulness training increases ‘viscero-somatic’ processing and uncouples ‘narrative-

based’ processing (Farb et al, 07)

Farb, N., Segal, Z.V., Mayberg, H., Bean, J., McKeon, D., Fatima, Z., & Anderson, A. (2007).Attending to the present: Mindfulness meditation reveals distinct neural modes of self-reference.Soc Cog Aff Neurosci., 2, 313-322.

Outline

• Clinical psychology and cognitive science– Depression recurrence– outcome evidence

• What is going on?– Modes of self-focus

• Conceptual vs experiential• Exploring modes of self-focus

• in eating pathology• through neuroimaging

• Mindfulness and relapse signatures

Relapse signatures (Emily Hargus’s data)

• Individual patterns of prodromal features that warn of onset of episode

• Very important for self-management (schizophrenia, bipolar disorder, suicidal behaviour)

• Not just whether noticed, but how we relate to them –– enmeshed

• “I’m not ever going to be able to sleep again”– with meta-awareness (“decentered”)

• “I felt life was getting difficult, but it was my own inability to cope at that time”

Meta-awareness of relapse signature

1

1.4

1.8

2.2

2.6

3

Pre Post

MBCTTAU

Summary

• Mindfulness training can reduce depression recurrence

• Training in experiential mode of self-focus- can prevent over-use of conceptual mode

• Impact of mode of self-focus – also seen in eating pathology– can be explored through neuroimaging

• Encouraging evidence for MBCT in decentring from suicidal thinking

Thank you

• www.mbct.co.uk