Episode 8: Mindfulness and Depression with Professor Zindel Segal

In cognitive therapy, we’re trying to teach patients how to have a little bit more psychological distance from moment-to-moment experience. That can happen. […] The thing about mindfulness is that there is a specific pattern of training in that particular skill that was at the heart of the approach.

There is a high level of empirical support that MBCT provides protection against depressive relapse and that protection is on par with what they would receive from an antidepressant.

In this episode of the Numinus podcast, Dr. Joe speaks with Dr. Zindel Segal. Zindel is a Distinguished Professor of Psychology in Mood Disorders at the University of Toronto. He is best known for co-founding Mindfulness-Based Cognitive Therapy (MBCT), along with his UK colleagues, Mark Williams and John Teasdale.

MBCT is an adaptation of Jon Kabat-Zinn’s eight week Mindfulness-Based Stress Reduction (MBSR) program for people suffering from depression. It combines the tools of cognitive therapy with the practice of mindfulness. The focus is on changing the relationship with one’s thoughts rather than the thoughts themselves. It has proven to be especially effective in preventing the relapse of depressive episodes.

Zindel has made an enormous contribution to the field of clinical psychology. His impact is reflected in an impressive publication record: he is an author of over 100 scientific publications, some in high profile medical journals and some featured in popular news media such as the Wall Street Journal, CNN Health and the New York Times. He is also an author of 10 books, including 2 very well-known ones on MBCT: 1) The Mindful Way Through Depression, which is a guide to using mindfulness to manage mood and 2) Mindfulness-Based Cognitive Therapy for Depression, which is the bible for teachers of MBCT.

In this episode, they discuss:

You can find lots of info about MBCT at mbct.com. You will also find a database of certified MBCT facilitators at accessMBCT.com.

If you’re interested in participating in an MBCT program or becoming an MBCT teacher, Numinus offers programming for both. Check out the mindfulness training and professional development sections at numinuswellbeing.com.

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Here are some highlights of the conversation with Zindel:

2:56 How did you get into mindfulness?

4:17 What was it about mindfulness that intrigued you and motivated you to change your focus from CBT to mindfulness?

6:11 Sounds like this psychological distance is really a target for MBCT and what you got interested in getting to the bottom of. Is that right?

 

7:22 What is decentering?

I think it’s been referred to in a number of different ways, but it’s developing a relationship to your present moment experience that allows you to be less fully identified with those experiences as self, as me, or as mine.

 

7:49 Decentering sounds a lot like the Buddhist insight of “no self.” Do people have to recognize the illusory nature of self in order to benefit from MBCT?

It doesn’t scare me off because that’s not how I talk about it or phrase it. These are not intended to dissolve self. These are intended to provide people with perspective on their experience that allows them to work more skillfully with the contents of mind as they show up.

But not from the perspective where the only thing they can do with those contents is to identify them as realities. So we don’t take in the extra step and say, ‘And therefore, ‘no self’ is a great place to get to. And therefore, self is an illusion.’ That’s something which is added maybe by other people. But that’s not really where we go.

 

9:01 What was it like to create the MBCT curriculum and then see it get adopted so widely across the world?

11:44 I’ve heard Jon Kabat-Zinn describe mindfulness as a way of being that is “totally orthogonal” to our usual way of being and that unless we understand that, we would be engaged in “just another form of CBT.” What do you make of that comment?

13:46 MBSR developed at the Centre for Mindfulness at UMASS and MBCT was developed by your group in Toronto and the UK. How have these two groups co-evolved over the years?

17:31 What was it like for you to see this program you develop grow into a global phenomenon?

21:51 MBCT is now covered by the public healthcare system in the UK. How do you rollout MBCT programming to meet demand at that scale?

24:07 You’re working with Kaiser Permanente (a large HMO in the US) on an online version of MBCT. What’s their interest in working on that project with you? How did that relationship come about?

26:49 How do you approach transforming the live, intimate group experience of MBCT into an online program?

29:47 Mindfulness-based programs are frequently adapted for other contexts or populations (schools, corporate settings, etc.) and the people teaching mindfulness in these contexts aren’t always fully trained. When do the active ingredients of evidence-based programs fall out of the intervention when it’s adapted?

 

35:06 What are the active ingredients in mindfulness programs?

These are things that the field itself is really grappling with. It’s a good discussion to have. I think that more and more one of the things from the research perspective that has been pointed out has–at least in MBCT–when people dwell on this approach, they are able to engage in decentering. They’re able to engage watching their experiences, and not reacting to them immediately, but having some measure of choice in how to respond.

This is especially true in situations where you’re speaking very much of regulation. I think a lot of mindfulness work helps you to see that anger is present in the mind for example. It’s here versus I am angry versus there is one thing which is true right now and that’s going to come from the anger that I’m feeling. So building that up is very important because it gives people choice and it allows them to respond more adaptively.

How you do that is I think part of the question you were referring to. ‘Does someone need a lot of training to do that?’ ‘Can people do that with just simple exercises?’ ‘Do you need to go through the full MBCT program?’ ‘Does it come from practicing sitting meditation?’ ‘Or does it come from a therapist who is welcoming and encouraging of you to share your experiences?’ ‘Does it come from the group members who are normalizing and deshaming whatever diagnosis you might have?’

We don’t exactly know for sure. But I think we do know generally that decentering is very important and how you arrive at that is something that a lot of teachers are concerned with.

There are some data that suggests that the practice of mindfulness helps you build decentering. There is now a paper now in press in JCCP that Norman Farb and I published showing that once MBCT or CBT are over, people who continue to practice the skills that they were taught in the course continue to build decentering, and increases in decentering help prevent them from relapsing over two years. Those are some of the first data that actually tie the practice of taught skills to important clinical outcomes.

 

38:16 And what are the active ingredients in MBCT?

Of the six practices that we looked at and they were collapsed were: sitting meditation, body scan, mindful movement, mindful walking, three minute breathing space, informal mindfulness or everyday mindfulness. If you look at that as a cluster and different people doing different things, practicing at a high frequency, compared to practicing at a lower frequency, was associated with an increase in decentering over two years. And increases in decentering uniquely predicted protection against relapse.

 

39:14 What do we know about the effectiveness of MBCT for preventing depressive relapse?

I think the best evidence comes from two sources. One of them is a large individual patient meta-analysis. So taking individual patient data from I think 5 or 7 studies that was published by Willem Kuyken and General Psychiatry–I think it was in 2015 or 2016–where they found that the effect size for MBCT was significantly greater than control conditions that were treatments as usual that people were receiving. And the effect sizes were on par for antidepressant medication.

The way that I interpret that is that the degree of protection by people taking MBCT is on par with what they would receive if they were continuing on an antidepressant over time. And that’s very powerful because we know antidepressants may not work for everyone or people may not be willing to stay on them for two or three years. So MBCT may offer an equivalent without sacrificing prophylaxis.

And I think the other study that is important is the one published in the Lancet, once again by Willem Kuyken and the group at Oxford that showed in a comparison between people who were treated to remission with an antidepressant–I think the overall sample was 424–so 212 patients stay on antidepressants over two years. 212 patients were able to come off antidepressants. They had support to taper their antidepressants and come off it. 70% in that group did.

And there was no difference in the rates of relapse between these people who were continuing to take their medicine versus people who had stopped taking their medicine, had MBCT, and presumably used those skills to stay well.

Those are two very high levels of empirical support for the idea that MBCT is both effective and has the capacity to provide people with a certain degree of care against relapses.

 

42:10 What’s the next frontier of mindfulness research?

46:16 I do agree with you.

In my experience as a teacher, so much of the air time of the inquiry and discussion in the group is about people’s disappointment about how much they practice. All of the same attitudes contributing of keeping the person down emotionally now become transferred to the practice.

I feel like so much of the time I’m helping people develop the right attitude towards the practice that it is important to do, but it shouldn’t become another source of self-criticism or pessimism. I really like the idea that a shift of attitude is required.

48:15 Let’s stay on the day-to-day reality of how these groups play out in clinics and hospitals. I wanted to ask you about my experience, and it’s probably very common.

In your studies, I think you fairly have clear inclusion and exclusion criteria, but when people show up at Numinus and other clinics, you get a real range of different types of problems.

So there’s definitely acute mood problems and there’s often anxiety in the mix as well because obviously anxiety and depression co-occur so much. I wonder what your take is on that the population that is being treated tends to be much more mixed.

51:13 What about this notion of adverse effects of meditation? Is that a concern of yours? Do you think people are adequately trained to manage those kinds of difficulties?

52:03 Meditation can certainly be challenging. There is an important insight that people have when going to an MBCT group that it’s not like going to a spa or getting a massage. A lot of the media coverage will talk about these programs like stress reduction or learn to calm your anxiety.

It’s done a disservice to people because of the expectations they bring to the program. So we try to cut that off at the orientation. I think the expectations go very deep because people are suffering and they want this to be a cure all.

 

55:43 Do you have any final thoughts on something that we haven’t covered? Or some suggestions for people who are curious about MBCT, but don’t know where to go next?   58:02 How do people find the Access MBCT resource?

Anxiety & Exposure: Facing Your Fear

What’s the take-home message? Cognitive Behaviour Therapy provides tools to modify thoughts and behaviours, which in turn diminishes anxiety and and lifts mood.

Cognitive Behavior Therapy (CBT) is an approach to psychotherapy that focuses on the thoughts (cognitions) you have and the actions (behavior) you engage in.

The underlying notion is that thoughts, feelings, and behaviors are all connected to one another. So, changes in one of these elements are likely to lead to changes in the other two. In CBT, we typically target thoughts and behaviour in order to help people feel less anxious or depressed, and to promote well-being.

Unfortunately, things happen in life which are beyond our control. The good news, though, is that we can develop some control over our reactions to life events.

These reactions occur in our thoughts, emotions, and actions. We now know that the way we interpret or think about what is happening has a big impact on how we feel about things. For example, if you couldn’t find your iPod, you might have two different thoughts:

  1. “It’s been stolen,” or
  2. “I must have left it at the gym”.

Thinking it’s been stolen would lead to different feelings (e.g., anger, fear) than thinking you had forgotten it somewhere (e.g., annoyance, worry).

These different thoughts/beliefs would also lead to different courses of action. Thinking your iPod has been stolen, you might look to see what else is missing, you might suspect people at the gym and treat them badly, and so on.

Alternatively, if you thought you’d left your iPod at the gym, you might call the gym to see if anyone has found it, you might go back there to look yourself, and so on. If we are able to manage the way we react to situations more effectively, then we will be more likely to diminish the impact of unnecessary worrying and discouraging thoughts.

Some reactions come to us so automatically that we take them for granted and believe them without question.

One of the ways CBT helps is by questioning (challenging) automatic thoughts that are not accurate or helpful. If you said hello to a neighbour but he did not answer back, you might think “He doesn’t like me”. That could be true, however, in CBT we encourage consideration of alternatives.

So, what other possibilities are there for why he did not respond? Perhaps he is hard of hearing or was distracted. If you believed those statements, you might feel better and be more inclined to say hello again in the future.

Changing how we think changes how we feel and what we do.

Another way CBT helps is by purposefully changing your behavior. If you are feeling down, you may not have the energy or desire to see friends. However, if you force yourself to go out with a friend, you may enjoy yourself and feel better. Changing what we do changes what we think and how we feel.

These CBT principles are often applied to anxiety disorders. Anxiety is a feeling of intense fear or nervousness. Let’s see how CBT might address excessive anxiety. Say you were afraid of dogs. You went over to your friend’s house and lo and behold there’s a dog barking at you. Anxious? Yes. Now, what might you be thinking that is leading you to feel this way? You might think “This dog is going to bite me” or “This dog is dangerous.”

Let’s say, you believed those thoughts; how would you act? Chances are you would leave the house or request that your friend lock up the dog for the duration of your visit. Once safely away from the dog, you would feel relieved. The conclusion you would likely come to is that avoiding the dog makes you feel better. While this is true, being afraid of dogs might have a negative impact on your life (e.g., your friend with the dog might not want to have you over again).

What would have happened had you stayed in the room with the dog (assuming your friend has reassured you it is a friendly dog who has never attacked or hurt anyone before)? Would your feeling of anxiety increase steadily until you fainted? Unlikely. Anxiety doesn’t work that way. The truth is, your anxiety would likely go away given enough time and exposure to the dog. Avoidance perpetuates anxiety.

That means that you will keep the anxiety going by never testing the theory that your anxiety would come down and you would feel better if you just stayed with whatever you were afraid of (in this case, the dog).

The same principles apply to other fears, such as giving a presentation, being in large crowds, and many more. So, what is the take-home message?

Thoughts and actions can be changed and in doing so, can reduce feelings of sadness and anxiety.