Mindfulness-Based Cognitive Therapy:
Chronology, Efficacy and Integrity
Zindel V. Segal, Ph.D
Distinguished Professor of Psychology in Mood Disorders
University of Toronto Scarborough
Collaborators and Support
Support
National Institutes of Mental Health, Canadian Institute of Health Research, Medical Research
Council, UK, John D. & Catherine T. McArthur Foundation.
MBCT
John Teasdale and Mark Williams.
MBCT Efficacy Studies
John Teasdale, Mark Williams, Mark Lau, Ferris Urbanowski,
Peter Bieling, Robert Levitan, Susan Woods, Theresa Casteels.
MBCT Neuroscience Group
Adam Anderson, Norman Farb.
eMBCT Dissemination Study
Sona Dimidjian, Arne Beck, Brian Knudson.
MBCT Training Integrity
Susan Woods, Willem Kuyken, Rebecca Crane, Sona Dimidjian.
Depression: Course and Outcome
Remission
Recovery
Well
Symptom
Syndrome
Response
Improvement
Treatment Phases
Kupfer DJ. 1991
Acute
Continuation
Maintenance
Early Evidence of Psychological Prophylaxis Against
Depressive Relapse (Frank et al., 1990)
Acute Phase Cognitive Therapy as Effective as Maintenance
Pharmacotherapy in Relapse Prevention
Hollon, et al., 2005
How Does Cognitive Therapy Reduce
Relapse?
The Thought Record
Situation
Emotion Automatic
Thought (AT)
0 - 100%
I asked my sister
to look after my
son so that my
husband and I
could go out for
dinner.
She said no. She
said I should
spend more time
with him now
that I am back
from the hospital.
Guilty
70%
Rejected
80%
She is telling me
how to raise my
son.
I am a bad
mother.
Evidence
to support
your AT
Evidence
Against
your AT
My son said he is My son has made
worried about me. 2 new friends at
school.
My husband is
doing most of my I make sure to
chores.
read to my son
every night
before bed.
Balanced/
Alternative
Viewpoint
Re-rate
Mood
Having depression
doesn’t
automatically make
me a bad mother.
Guilty
40%
When I condemn
myself it is often the
depression speaking.
0 –100%
Rejected
40%
MBCT: Chronology
1991- 93:
McArthur Foundation funds the development of
a maintenance version of CBT.
1992:
Marsha Linehan on sabbatical at
Cognition and Brain Science Unit, Cambridge
1993:
John Teasdale writes Jon Kabat-Zinn
asking whether we can visit.
1993- 94:
Observe MBSR groups led by Jon Kabat-Zinn
Saki Santorelli, Ferris Urbanowski, Pam Erdman,
Florence Meleo-Myer, Elena Rosenbaum, and Melissa
Blacker.
1995:
NIMH Funding for
Attentional Control (Mindfulness)Training.
1995 - Attention Control (Mindfulness)
Training
S1 : Ongoing Treatment and Recovery
S2: Assessing Your Vulnerabilities
S3: Activity and Inactivity in Recovery
S4: Staying Present
S5: Self-Talk and Emotional Reactions
S6: Assumptions about Worthiness
S7: Considering the Interpersonal World
S8: Balancing Acceptance and Change
Attentional Control
Training (1995)
Staying with a focus
on thoughts and
feelings, as in
Cognitive Behaviour
Therapy, but not
intervening at the level
of content.
Attentional Control
Training (1995)
Value of attending
to the breath as a
way of removing
processing
resources from
negative thought
and feeling loops.
Attentional Control
Training (1995)
Less processing
leads to a lower
likelihood of
continued activation
and lets the person
step out of the
downward spiral.
MBCT: Chronology
1998:
Reality check via results of first
pilot groups.
1999-2001:
Personal practice.
2002:
Mindfulness Based Cognitive Therapy.
2002:
Training guidelines for MBCT instructors
predicated upon a personal practice.
Shift in CBT and Mindfulness
Emphases in MBCT
Attentional Control Training (1995)
MBCT (2012)
S1 : Ongoing Treatment and Recovery
S1: Awareness and Automatic Pilot
S2: Assessing Your Vulnerabilities
S2: Living in our Heads
S3: Activity and Inactivity in Recovery
S3: Gathering the Scattered Mind
S4: Staying Present
S5: Self-Talk and Emotional Reactions
S6: Assumptions about Worthiness
S4: Recognizing Territory of Aversion
S5: Allowing / Letting Be
S6: Thoughts Are Not Facts
S7: Taking Best Take Care of Myself
S7: Considering the Interpersonal World
S8: Maintaining and Extending New
S8: Balancing Acceptance and Change
Learning
MBCT: Scope of Clinical Application
Depression Relapse Prevention (Teasdale et al, 2000)
Treatment Refractory Depression (Eisendrath et al., 2008)
Non Melancholic Depression (Manicavasgar et al., 2011)
Bipolar Disorder (Miklowitz, Weber et al., 2010)
GAD (Evans et al., 2008)
Panic Disorder (Kim et al., 2010)
Cancer: Mood symptoms (Sharplin et al., 2010), Fatigue (van Der Lee & Garssen, 2010)
Quality of Life (Foley, 2010)
Insomnia (Britton et al., 2010)
Hypochondriasis (Lovas, 2010; Williams et al., 2011)
Anxiety Disorders in Children (Semple & Lee, 2010)
Chronic Fatigue Syndrome (Rimes & Wingrove, 2011)
Tinnitus (Philippot et al., 2011)
Social phobia (Piet et al., 2010)
Kuyken et al., 2015
Cumulative proportion of unstable remitters who survived without
relapse during maintenance/follow-up
Segal et al., 2010.
Does MBCT Address Mechanisms that Confer Relapse Risk?
Segal,
V. al.,
et al.2006
Arch Gen Psychiatry 2006;63:749-755.
SegalZ.et
MBCT Leads to Greater Reductions in Cognitive
Vulnerability Compared to Antidepressants
Kuyken et al., 2010
Dosage Effects: Looking at Real
World Practice Following MBCT
70
% Practicing
60
50
40
30
1 Yr F.U.
20
10
0
Body
Scan
Sitting 3 MBS
Infor.
Bondolfi et al., 2010
Prevention Effects of Formal Sitting Practice >3
or <3 /wk During MBCT
Crane et al., 2014
Neural Changes Associated with
Mindfulness & Sad Mood Induction
Neutral Clips
Sad Clips
Vs.
HGTV (Crafts & Gardening)
The Champ (1979)
Terms of
Endearment (1983)
Following exposure to sadness...
Evaluation network
goes up…
Present moment network
goes down..
Mindfulness Training: Reducing
the Tradeoff…
x=8
0.35
0.3
0.25
Post. Midline
Reduced
0.2
0.15
0.1
0.05
0
Control MBSR
x = 35
0.05
0
Insula /
Claustrum
Restored
-0.05
-0.1
-0.15
-0.2
-0.25
Control MBSR
Sensory Representations Matter
Right insula reductions
may be maladaptive…
Restoration of activity
to baseline during
emotion challenge is
protective
Farb et al, 2010
Problems with Scaling MBCT Require
Innovative Delivery Models
Patten & Meadows, 2009
Public Health Significance is Still Aspirational
Dimidjian & Segal, 2015
Mindful Mood Balance: Web-Based Delivery of
MBCT
R34 to develop a web-based version of MBCT
•
Mindful Mood Balance (MMB) (N=100) open trial.
R01 to evaluate a web-based version of MBCT
•
Mindful Mood Balance compared to Usual Depression Care
(N=460) within Kaiser Permanente Colorado.
Learning Engine at the Core of MMB
In Person MBCT
• Practice
• Inquiry
• Teaching Points
• Group Input
MMB
•
•
Same content over 8 weekly
sessions.
Each practice cycles through
3 modes of learning.
1. Audio guided mindfulness
practice
2. Listing post-practice reflections
3. Video supported vicarious
learning from inquiry of the same
practice in an in-person MBCT
group.
•
Social Networking
– FAQ from active and past
users.
– weekly email reminders for
home practice.
Increasing Engagement
Photo source: Nogginlabs
Engagement with MMB and Taught
Practices
• 52% completed at least 4 sessions
• 42% completed all 8 sessions
• mean weekly freq. of formal practice
was 2.56 times (SD = 2.15)
• Mean weekly freq. of breathing space
practice was 8.91 times (SD = 7.34)
MMB Reduces Residual Depressive Symptoms
Compared to Usual Depression Care
Dimidjian et al., 2014
www.mindfulnoggin.com
The MBCT Training Pathway: A Template For
Ensuring Standards and Treatment Integrity (Segal,
Williams, Teasdale, Kuyken, Woods, Crane, Dimidjian & Ma, 2016)
Coherent Stepped Approach Integrating Formal Teaching
with Retreats, Skills Training and Supervision
MBCT Training Pathway Will Support Wide Scale
Adoption of MBCT Within the NHS
Recognizing Certified Instructors and Offering
Quality Assurance for Consumers
ACCESS MBCT
International Registry of Mindfulness-Based Cognitive
Therapy Instructors