Table of contents
3.1 Mindfulness and decentering in MBCT
3.2 Cognitive models of depression
3.3 Defining rumination
3.4 Research questions
4.1 Mindfulness and rumination
4.2 Mindfulness and decentering
4.3 Mindfulness vs. other treatments
4.4 Mindfulness in schizophrenia and ADHD patients
5.1 Research summary and conclusion
5.3 Future outlooks
7.1 Literature research
Mindfulness-based interventions are applied in clinical therapy to treat a variety of symptoms, e.g. chronic pain, anxiety, stress, depressive symptoms (Baer, 2003). Can mindfulness-based interventions be considered an alternative treatment to cognitive therapy for depression? Two mechanisms are identified which may play an important role in the positive impact of mindfulness meditation (MM) on depressive symptoms. It is hypothesized that mindfulness meditation 1) is associated with a reduction of ruminative thinking which is associated with depression and 2) is associated with increases of decentering, a metacognitive perspective which changes a person’s relationship towards negative thoughts and feelings. Traditional cognitive theories focus on changing the negative content of thoughts and feelings (Beck, 1967) or behavioral theories emphasize an extinction of intrusive thoughts through habituation (Huppert & Roth, 2003). MM which partially originates in Buddhist tradition (Kabat-Zinn, 2003) proposes a unique feature in training attention to, awareness of and a non- judgmental attitude towards mental phenomena, e.g. negative thoughts and feelings. A decentered view may facilitate non-reactivity to aversive stimuli and thus reduce depressive symptoms (Segal, Williams & Teasdale, 2002). In addition, mindfulness-based intervention are compared to alternative treatments, e.g. relaxation or pharmaceutic therapy. Results from current research articles suggest that mindfulness is associated with decreases of ruminative thinking and increases of decentering. Further results show that mindfulness meditation a) is associated with higher amounts of experienced thoughts due to increases in awareness (Feldman, Gresson & Senville, 2010) and b) is more effective in reducing ruminative thinking than a relaxation treatment (Jain et al., 2007). Mindfulness was successfully applied in a sample of patients diagnosed with anxiety in schizophrenia who were in a stable, post-acute phase after illness. The rationale of mindfulness should be further refined in order to develope existing intervention programs. Further research is needed to examine differential effects of mindfulness meditation in contrast to cognitive therapy.
Mindfulness is a term introduced to Western society only a few decades ago by popular Buddhist representatives such as the Dalai Lama, the Vietnamese Buddhist monch Thich Nhat Hanh or Lama Ole Nydahl, together with his wife Hannah they were the first Western students of the late 16th Karmapa, spiritual leader of the Karma Kagyu School in Tibetan Buddhism. 2500 years ago in India, the historical Buddha Shakyamuni taught meditative techniques which lead the practitioner to liberation, a state free from the illusion of a permanent ego or self. After years of intensive meditation practice, the state of enlightenment may be attained. In a practitioner, three qualities appear effortlessly if dualistic concepts are removed through meditation; these qualities are fearless intuition, self-arising joy, and powerful active love (Nydahl, 2008). Enlightenment is a state of mind where the nature of outer phenomena has been recognized as empty. Emptiness in Buddhism is the experience that any perceived object (e.g. physical objects) is impermanent and depends on certain conditions. From this experience, the libidinal attachment to this world seizes (Scherer, 2005). Buddhist meditations work on two levels. Calm abiding (Tibetan: Shine; Sanskrit: Shamata) refers to the activity of holding mind’s attention to one object (e.g. candle or statue) in order to calm it. Insight meditation (Tibetan: Lhaktong; Sanskrit: Vipassana) emerges from such a calm state of mind. It is the awareness of thoughts and feelings constantly and spontaneously arising in the stream of conciousness, that they can be experienced and that they dissolve again (Diamantweg Stiftung, 2011). The concept of mindfulness draws attention from many scientists. In 2010, five times more articles were published compared to the year 2000. Provided in a group-treatment, mindfulness can be taught to a wide range of people with different backgrounds in a relatively short amount of time - such courses usually last up to 8 weeks. Popular treatment interventions are mindfulness-based stress reduction (MBSR; Kabat-Zinn, 2009) and mindfulness-based cognitive therapy (MBCT; Segalet al., 2002). Meditation is a non-envasive treatment as opposed to medication treatment (Kuyken et al., 2008). Mindfulness-based interventions are accessible in many Western countries. In 1982, Kabat-Zinn performed a first study with chronic pain patients assessing the effects of mindfulness. Twenty years later, mindfulness is applied in treatment of a variety of disorders, for example borderline personality disorder, stress management and depression (Baer, 2003). Depression is an affective disorder which evolves from a dynamic interaction of biological, social and psychological risk-factors (Segal & Dobson, 1992). Depression is projected to be the number two cause for loss of life years due to disability by 2020. Already 121 million people worldwide are affected by depression (World Health Organization, 2011). Patients who experience a first acute depressive episode relapse at a 22% rate, however those who experienced three or more episodes relapse at a 67% rate (Segal et al., 2002). Lifetime prevalence (17-19%; Kessler et al., 1994) is high due to high realpse rates in formerly depressed patients (Berti, Ceroni, Neri & Pezzoli, 1984). It is important to elaborate prevention of depression relapse in the context of the (economic) burden of chronic depression. MM is effective in reducing depressive symptoms, but the mechanisms at work are not fully understood (Baer, 2003; Shapiro, Carlson, Astin & Freedman, 2006). Within the context of cognitive theories of depression, two mechanisms that may frame the effect of MM on depressive symptoms are rumination and decentering. Ruminative thinking in depressive patients circles around the negative emotional state (Nolen-Hoeksema, 1991) and is associated with higher levels of depression over time (Nolen-Hoeksema & Davis, 1999). Decentering is described as the ability to see interal experiences with increased objectivity (Feldman et al., 2010) and is associated with a less habitual pattern of reacting to and ruminating on arising thoughts and feelings (Ramel, Goldin, Carmona & McQuaid, 2004). In MBCT, the core element is a change of underlying views that shape the relationship in a practitioner towards negative thoughts and feelings. Such a shift in mental models may be the result of repeated learning experiences (Segal et al., 2002). Another approach in the treatment of depression is cognitive therapy. Cognitive therapy mainly focuses on identifying and changing dysfuctional attitudes (Beck, 1967). In exposure therapy, a behavioral approach to obessive-compulsive disorders, habituation to intrusive thoughts is the mechanism that shows the most promising results (Whittal, Thordarson & McLean, 2005). Intrusive thoughts are a universal human phenoma and patients feel the need to take actions to prevent harmful actions against themselves (Salkovskis, 1989). In this paper, I argue that the mindfulness approach (shift in perception) is unique compared to cognitive therapy (change in cognition) and behavioral exposure therapy (extinction) in the treatment of depressogenic thinking. Mindfulness may enable a person to topple automatic negative thoughts and behaviors and instead engage in self-responsible, deliberate thinking and reasonable behavior on the basis of attention and awareness (Ma & Teasdale, 2004). Greater mindfulness and increased decentering may help a patient to recognize destructive thinking patterns early in time (Ramel et al., 2004) and dislink from automatic negative reactions to negative cognitions (Feldman et al., 2010). Subsequently, relapse of depression may be prevented.
3.1 Mindfulness and decentering in MBCT
Linehan (1993) provides a set of exercises that allow patients with a diagnosis of borderline personality disorder to pay attention to their experiences, then to attend to mental events (such as thoughts and feelings), and step back from those events. This distance should give patients a chance to choose from more options how to react to such events rather than getting carried away by them. This training procedure Linehan called „mindfulness“ (Segal et al., 2002). Kabat-Zinn, the most prominent representative of mindfulness in the West, describes mindfulness as the main component of Buddhist meditation (Kabat-Zinn, 2003). In Buddhist teachings, it is discussed as the seventh link of the eightfold path which leads the practioner to lasting happiness (Scherer, 2005). Buddha’s teachings are highly refined and aim at „systematically training and cultivating various aspects of mind (...) via the faculty of mindful attention“ (Kabat-Zinn, 2003). Mindfulness is described as the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment (Kabat-Zinn, 2009). It is an inherent human capacity, but individuals differ in the extent to which they are mindful (Lakeya, Campbella, Brown & Goodie, 2007). Dispositional mindfulness is the tendency to rest in mindful states over time (Brown, Ryan & Creswell, 2007). It is associated with better self-control, higher emotional intelligence, and lower depressive symptoms, anxiety, neuroticism, and rumination (Brown et al., 2007). Mindfulness may be divided into three components: attention to, awareness of and a nonjudgmental attitude towards mental events (such as thoughts and feelings) and body sensations (Baer, 2003; Bishop, 2002). Mindfulness training teaches participants to reduce arousal through breathing and relaxation exercises and to bring an openness and acceptance to their emotional experiences (Zylowska et al., 2007). Mindfulness- based stress reduction (MBSR; Kabat-Zinn, 2009) and mindfulness-based cognitive therapy (MBCT; Segal et al., 2002) are two intervention programs that apply mindflulness. The programs usually consist of 8 weekly 1 - 1.5 h group sessions and 45 min daily home practice. Processes that may result from MM practice are described as greater awareness (Grossman, Niemann, Schmidt & Walach, 2003) sustained attention, attention switching and inhibition of elaborate processing (Chambers, Chuen Yee Lo & Allen, 2008); short-circuiting negative thought cylces (Teasdale, Segal, Williams, Ridgeway, Soulsby & Lau, 2000), emotion regulation, e.g., rumination and worry (Labelle, Campbell & Carlson, 2010); and increased accessibility to metacognitive sets (Teasdale, Pope, Moore, Hayhurst, Williams & Sindel, 2002). Potential results that may be related to MM practice are more approach coping and less avoidance coping (Sears & Kraus, 2009); cultivation of positive qualities, e.g. wisdom, equanimity, insight (Shapiro, Schwartz & Santerre, 2002; Fredrickson, 2004); non- goal-based processing, “non-striving” (Chambers et al., 2008); and facilitation of choice between alternative options (Ramel et al., 2004). Mindfulness may be assessed using the Five Facet Mindfulness Questionnaire (Baer, Smith, Hopkins, Krietemeyer & Toney, 2006). The FFMQ measures five factors of the mindfulness construct which are observing, nonreactivity to inner experience, describing, nonjudging of inner experience and acting with awareness. Nonreactivity to inner experience is described as „allowing thoughts and feelings to come and go, without getting caught up in them“; an item of this factor may be „I perceive my feelings and emotions without having to react to them“ (Carmody & Baer, 2003). This sense of discrimination of thoughts and behavior is similar to the construct of decentering.
Segal et al. (2002) describe decentering as a shift in perception, where negative mental events are seen as passing events, rather than valid reflections of reality or central aspects of the self. Decentering implies continous observation of thoughts as they arise, then stepping back and evaluating their accuracy (Teasdale et al., 2002). Decentering may be a process through which mental thoughts are unlinked from the corresponding reaction (Feldman et al., 2010). Developments in literature on decentering provide preliminary evidence that, in a student sample, mindfulness predicts higher perceived ability to disengage from negative thoughts (Frewen, Evans, Maraj, Dozois & Partridge, 2008). In two non-controlled studies, participation in a MBSR course was associated with increases of decentering (Lau et al., 2006, Study 2; Carmody, Baer, Lykins & Olendzki, 2009). Decentering is also referred to as metacognitive awareness, an alert state of observating elaborative thinking patterns (Ramel et al., 2004). Metacognitive sets are seen as a store of memorized moments where negative depressive symptoms have been experienced in a decentered view. In times of potential relapse, increased accessbility of metacognitive sets may enable patients to respond in a more decentered way to negative thoughts and feelings. This shift in relationship mediates the effect of MBCT in preventing relapse (Teasdale et al., 2002). Higher scores in metacognitive awareness indicate that participants show more discrimination of thoughts and feelings. This discrimination includes seeing thoughts and feelings independent of the external situation as well as not necessary for the identification with a self. Participants who report high scores are able to stand back from their internal mental events and judge the appropriateness of their thoughts and feelings (Teasdale et al., 2002). Metacognitive awareness is distinguished from metacognitive beliefs. This construct reflects the extent to which individuals believe particular thoughts are true (Teasdale et al., 2002). This paper does not adress meditation forms such as transcendental meditation. Transcendental meditation is a concentration-based meditation where attention is constantly hold on and brought back to an object (e.g. mantra or statue). In contrast, mindfulness meditation involves observation of constantly changing internal and external stimuli as they arise (Baer, 2003).
3.2 Cognitive models of depression
In clinical psychological research, diathesis-stress models state that an interaction of experienced high stress levels and a predisposition in the individual may lead to psychopathology (Monroe & Simmons, 1991). Theories of depression have adopted such diathesis-stress models (Abramson, Metalsky & Alloy, 1989). Within theories of depression, critical life events were supposed to trigger episodes of depression (Kessler, 1997). However, there was little empirical support for this hypothesis since after a first or second episode, further episodes correlate less with negative life events (Segal et al., 2002). Later episodes seem to be triggered more easily and without corresponding negative life events. Cognition is an important factor in unipolar depression (Ingram, Miranda, Segal, 1998). Within cognitive theories of depression, Kovacs & Beck (1978) describe depressive patients’ cognitions as predominantly negative in tone and self-referential. As a consequence, cognitive therapy focuses on identifiying and changing dysfunctional attitudes (e.g., „I have to be perfect“) and negative automatic thinking in depressive patients (Beck, 1967; Teasdale et al., 2000). However, research shows that the amount of dysfunctional attitudes does not predict relapse in formerly depressed patients (Ingram, Miranda, Segal, 1998; Teasdale et al., 2000). Automatic negative thoughts should be distinguished from intrusive thoughts which are a core symptom of obsessive-compulsive disorder (Whittal, Thordarson & McLean, 2005). Wenzlaff (2005) describes such differences: first, intrusive thoughts seem incongruent with prior thoughts, regardless of their valency (negative, neutral, or positive). In contrary, negative automatic thoughts are expected. Second, intrusive thoughts may redirect thinking. In contrast, negative automatic thoughts may appear in a chain of negative thinking and are thus predictable, even if they are experienced as uncontrollable (Wenzlaff, 2005). The treatment of choice for intrusive thoughts in obsessive-compulsive disorder is exposure and response prevention of behavioral therapy (Whittal et al., 2005). The main effect of exposure and response prevention is seen in habituation to aversive stimuli (Solem, Haland, Vogel, Hansen & Wells, 2009; Huppert & Roth, 2003). The aim of this behavioral approach was to diminish clinical symptoms to a non-clinical level (Paunovic & Öst, 2001). Another approach in cognitive theories of depression is the differential activation hypothesis (Teasdale, 1983).
In this model, cognitive reactivity reflects the tendency of an individual to react to small changes in mood with large changes in negative thinking (Segal et al., 2002; Lau, Segal & Williams, 2004). People differ from each other in the extent to which small downward shifts in mood produce negative thinking patterns (Raes, Dwulf, Van Heeringen & Williams, 2009). According to the differential activation hypothesis, negative thinking may have been associated with depressed mood in the past and consequently a link was formed. As a result, low mood may trigger memory sets of negative thinking patterns. Such automatic thinking patterns may result in changes in affect. This reciprocal process may result in an escalation of low mood into depression if not stopped early in time (Segal et al., 2002; Ma & Teasdale, 2004).
3.3 Defining rumination
A ruminative response style to depressed mood involves thoughts and behaviors which focus on the depressive symptoms, their causes, their meaning and their consequences; people primarly focus on their negative emotional state (Nolen-Hoeksema, 1991). Research has shown that this „self-referent“ (Lau et al., 2004) way of relating to one’s illness impairs instrumental problem-solving (Lyubomirsky & Nolen-Hoeksema, 1995), predicts higher levels of depression over time (Nolen-Hoeksema & Davis, 1999), and is associated with a hopeless and pessimistic evaluation of the future (Lyubomirsky & Nolen-Hoeksema, 1995) and the self (Lyubomirsky, Caldwell & Nolen-Hoeksema, 1998) both of which are associated with depression (Abramson et al., 1989). Future research is needed to test whether rumination predicts the chronicity of depressive episodes (Nolen-Hoeksema, 2000). A possible alternative to a ruminative response style is distraction. It is the deliberate act of directing one’s attention away from the illness to neutral or pleasant activities, e.g. engaging with friends, spending time on a hobby, spend time at work (Nolen-Hoeksema, 1991). Distraction is associated with reduced depressive symptoms in adolescents and adults (Nolen-Hoeksema, Morrow & Fredrickson, 1993). Distraction must be distinguished from reckless activities which may still prolong depression in the long run due their consequences, e.g. alcohol abuse or fast driving (Nolen-Hoeksema, 1991). Participation in a distraction group as opposed to a rumination group is associated with less peristent and less intensive sadness after sad mood induction (Nolen-Hoeksema, Morrow & Gemar, 1996).
3.4 Research questions
The main research question of this paper builds on previous empirical research which investigated the relationship between mindfulness and rumination as well as the correlation between mindfulness and decentering. Analysis of current research literature may provide preliminary support for the following hypothesis: 1) MM practice in MBSR and MBCT is associated with decreases of rumination and a reduction in depressive symptoms and 2) MM practice in MBSR and MBCT is associated with increases of decentering and decreases in depressive symptoms. It is hypothesized that 3) mindfulness is unique in its approach to encourage participants to change their perspective on thoughts and feelings. Therefore, MM interventions are compared to alternative treatments, e.g. relaxation or pharmaceutic therapy. MM training does not intend to change the content of such mental events as in cognitive therapy and it does not intend to diminish and extinguish negative thoughts and feelings as in behavioral therapy. Therefore it is assumed that the amount of experienced thoughts does not decrease, but it may even increase due to increased awareness. Finally, a sub-hypothese is that 4) mindfulness may lead to an amelioration of clinical symptoms in psychotic patients and patients with attention disorders.
- Quote paper
- Benjamin Ulrich (Author), 2011, Mindfulness and Rumination. How meditation may reduce depressive symptoms, Munich, GRIN Verlag, https://www.grin.com/document/181310