Amity Journal of Applied Psychology
Vol. 2, No. 2, July 2011 & Vol. 3, No.1, January, 2012
Copyright 2012 by AIBAS,
Amity University Rajasthan (ISSN 0976-6731)
Effects of Mindfulness-based Cognitive Therapy on Mindfulness Skills, Acceptance
and Spiritual Intelligence in patients with Depression
Diya Nangia*
NIMHANS, Bangalore
Mahendra P. Sharma**
NIMHANS, Bangalore
The present investigation was aimed at examining the effects of Mindfulness-based Cognitive Therapy (MBCT) on mindfulness
skills, acceptance and spiritual intelligence in patients with depression. Sample consisted of five patients with a diagnosis of
Recurrent Depressive Disorder as per ICD-10. A single case design with pre- and post-intervention assessment was adopted. The
sample was assessed on Socio-Demographic and Clinical Data Sheet, Beck Depression Inventory, Kentucky Inventory of
Mindfulness Skills, Acceptance and Action Questionnaire-II, Integrated Spiritual Intelligence Scale and Therapeutic Experience
Schedule. Quantitative analysis revealed clinically significant reduction in the severity of depression and considerable to
significant improvements in acceptance, improvement in mindfulness skills and spiritual intelligence. Qualitative analysis
revealed themes of ‘awareness’, ‘acceptance’ and ‘enhanced coping’.
Keywords: mindfulness, mindfulness-based cognitive therapy, mindfulness skills, acceptance, spiritual intelligence, depression.
In the last 25 years, mindfulness and
intervention based on it has become the focus of
considerable attention for a large community of
clinicians and researchers. Mindfulness has been
described as a process of bringing a certain quality of
attention to moment-by-moment experience (KabatZinn, 1990). Mindfulness in contemporary
psychology has been adopted as an approach for
increasing awareness and responding skillfully to
mental processes that contribute to emotional
distress and maladaptive behavior. Much of the
interest in the clinical applications of mindfulness
has been sparked by the introduction of
Mindfulness-Based Stress Reduction (MBSR), a
manualized treatment program originally developed
1
for the management of chronic pain (Kabat-Zinn,
1982).
Depression is one of the most common
psychological disorders affecting 340 million people
in the world today. In India, the prevalence rate for
1
*M. Phil. Scholar, Department of Clinical Psychology, National
Institute of Mental Health and Neuro Sciences (NIMHANS),
Bangalore.
**Additional Professor, Department of Clinical Psychology,
National Institute of Mental Health and Neuro Sciences
(NIMHANS), Bangalore.
**Corresponding author, email: [email protected]
major depression was found to be 31.2 per 1000
(Murali, 2001). Even after successful acute
treatment, depression is known to have a high risk of
relapse which increases dramatically with numbers
of previous episodes (Solomon et al., 2000). The
majority of the burden attributable to depression
could be offset through interventions aimed at the
prevention of relapse/recurrence (Vos et al., 2004).
Mindfulness-based Cognitive Therapy (MBCT) is a
promising relapse prevention program, developed
by Segal, Williams and Teasdale (2002), was
specifically designed to target vulnerability processes
that cognitive research has identified as playing a
causative role in depressive relapse. It is eight-week
program that combines training in mindfulness
meditation, following the approach developed by
Kabat-Zinn (1990), with interventions from cognitive
therapy (Beck, Rush, Shaw, & Emery, 1979), with the
emphasis of treatment on acceptance, change,
integrating spiritual component of mindfulness into
traditional cognitive behavior therapies (Hayes,
2004).
MBCT teaches as its core skill the ability to
become more aware, to recognize and disengage
from habitual (automatic) dysfunctional cognitive
routines, in particular depression-related ruminative
thought patterns, and to adopt a stance toward
experience, which is characterized by openness,
Amity Journal of Applied Psychology
Vol. 2, No. 2, July 2011 & Vol. 3, No.1, January, 2012
curiosity and acceptance, rather than experiential
avoidance, as a way to reduce future risk of relapse
and recurrence of depression (Segal, William, &
Teasdale, 2002; Ma & Teasdale, 2004). Integral to
the technique of mindfulness, are mechanisms of
exposure, acceptance and cognitive change (Hayes,
2004), and it is also implicated in increasing empathy
and spirituality (Shapiro, Oman, Thoresen, Plante &
Flinders, 2008). Spiritual intelligence has been
defined as the intelligence with which we address
and solve problems of meaning and value, the
intelligence with which we can place our actions and
our lives in a wider, richer, meaning-giving context
(Zohar & Marshall, 2000) and as the ability to draw,
apply and embody spiritual resources and qualities
to enhance daily functioning and wellbeing (Amram,
2007). The practice of mindfulness appears relevant
in the development of these qualities.
Mindfulness-based Interventions have been
applied to a variety of stress related conditions,
medical conditions, and emotional disorders and
have been found to be efficacious (Bishop, 2002;
Baer, 2003; Grossman, Niemann, Schmidt & Walach,
2004; Fjorback, ArendtØrnbøl, Fink, & Walach,
2011). In India, few studies have provided evidence
for their usefulness and efficacy in clinical and nonclinical samples (Sharma, Kumaraiah, Mishra &
Balodhi, 1990; Mao, 2003; Goyal, 2004; Narayan;
2005; Majgi, Sharma & Sudhir, 2006; Parswani, 2007;
Majgi 2009; Kaur; 2010). Recently, there has been a
shift in the interest of researchers from efficacy
based research to process based research in the area
of mindfulness. Research has suggested that
mindfulness cultivated during MBSR and MBCT
decreases ruminative thinking by switching
emotional processing modes by intentional
redeployment of attention, dysfunctional beliefs,
and significantly increases meta-cognitive awareness
with respect to negative thoughts and feelings
(Teasdale, 1999; Ramel, Goldin, Carmona, &
McQuaid (2004) that significantly reduced relapse in
depression (Teasdale et al., 2002).
Qualitative studies have identified areas of
therapeutic change such as awareness, 'coming to
terms', development of mindfulness skills, an
attitude of acceptance without judgment and 'living
Copyright 2012 by AIBAS,
Amity University Rajasthan (ISSN 0976-6731)
in the moment', positive change in levels of
acceptance and changes in participants’ way of
thinking and feeling, and in their relation with the
others (Mason & Hargreaves, 2001; Shapiro, Oman,
Thoresen, Plante, & Flinders, 2008; Cebolla & Miró
Barrachina, 2008; Jimenez, 2009; Splevins, Smith, &
Simpson, 2009) Mindfulness was positively
associated with greater psychological well-being and
spiritual experience (Astin, 1997; Brown and Ryan,
2003). Five major themes namely opening to
change, self-control, shared experience, personal
growth, and spirituality have been reported by
Mackenzie, Carlson, Munozl, and Speca (2007).
Though there is considerable evidence for the
efficacy of mindfulness-based interventions in
variety medical and psychological conditions, there
is a paucity of research examining variables that
make therapies efficacious and whether they can
also contribute to bringing a change in the spiritual
wellbeing in clinical samples. Sharma (2002) has
observed that research on mindfulness in India is in
its initial stage with limited work examining the
efficacy of this therapy. The aim of the present
investigation was to examine the effects of MBCT on
mindfulness skills, acceptance and spiritual
intelligence in patients with depression, with the
objectives to examine the efficacy of MBCT in
reducing the severity of depression, to explore and
document changes in mindfulness skills, acceptance
or psychological flexibility and spiritual intelligence.
Method
Participants
Five patients (3 females and 2 males)
with a ICD-10 (World Health Organization, 1992)
diagnosis of Recurrent Depressive Disorder were
recruited from the outpatient services of NIMHANS,
Bangalore. The patients met the inclusion criteria of
diagnosis of mild-moderate depression or recurrent
depression, BDI score of 14-28, age range between
18-55 years, stabilized on medication for a period of
2 months, minimum educational qualification of X
standard and an ability to comprehend English
language. Patents were excluded if they had history
of organicity, neurological defects, mental
retardation, serious medical conditions, dysthymia
Amity Journal of Applied Psychology
Vol. 2, No. 2, July 2011 & Vol. 3, No.1, January, 2012
or chronic depression/depression with psychotic
symptoms, other axis I disorders or personality
disorders, and having undergone any psychological
intervention for depression in the last 1 year. The
research protocol of the study was reviewed and
approved by Department of Clinical Psychology’s
Protocol Review Committee for technical and ethical
purpose. Informed consent was obtained from the
patients, participation was voluntary and no
incentives were offered.
Design
A single case design with pre and post
assessment was adopted to evaluate the changes in
the sample in response to the intervention.
Measures
1. Socio Demographic and Clinical Data Sheet (SDCS):
This data sheet was developed to obtain information
about socio-demographic characteristics of patients,
including details of illness and treatment history.
2. Beck Depressive Inventory (BDI): The BDI is a 21item self-report widely used measure of depressive
symptoms with good psychometric properties
(Rabkin & Klein, 1987).
3. Kentucky Inventory of Mindfulness Skills (KIMS):
Developed by Baer, Smith, & Allen (2004), this is a
39-item self-report inventory that was used for the
assessment of mindfulness skills on mainly four
aspects, i.e., observing, describing, act with
awareness, and accept without judgment.
4. Acceptance and Action Questionnaire II (AAQ-II):
This scale developed by Bond et al., (2011) was used
to assess patient’s experiential avoidance - the
attempt to alter the form, frequency, or situational
sensitivity of negative private events (e.g., thoughts,
feelings, and physiological sensations; and
acceptance - the willingness to experience (i.e., not
alter the form, frequency, or sensitivity of)
unwanted private events, in the pursuit of one’s
values and goals.
5. Integrated Spiritual Intelligence Scale (ISIS): This
scale was developed by Amram and Dryer (2008) as
a measure of spiritual intelligence. It is a 45-item
self-report instrument and has shown satisfactory
factor structure, internal consistency, test-retest
reliability and construct validity. It contains 22
Copyright 2012 by AIBAS,
Amity University Rajasthan (ISSN 0976-6731)
subscales assessing separate spiritual intelligence
capabilities.
6. Therapeutic Experience Schedule (TES): It was
developed for the present study to gain qualitative
insight into patients’ experience and gains from
therapy and to substantiate the findings obtained on
the above mentioned measures.
Procedure
The study was carried out on 5 patients.
The therapeutic program consisted of 8, weekly
sessions, lasting approximately 90 minutes each,
held with each patient individually. A total of 11-12
sessions spread over a period of 9-10 weeks having
specific goals and tasks for the specific week,
including the 8 therapy sessions, and pre- and postintervention assessments. The contents of
intervention program were adapted from Segal,
Williams, and Teasdale’s (2002) work with few
modifications, as the present study entailed
individual therapy. After the completion of the
therapy, lasting 8 weeks, the post-intervention
assessment was carried out using quantitative and
qualitative measures.
The data was quantitatively analyzed by
comparing the pre-intervention and postintervention assessment scores to assess the effects
of therapeutic intervention using Blanchard and
Schwarz’s (1988) formula for clinically significant
change (i.e. 50% and above). Responses obtained
from the participants on the Therapeutic Experience
Schedule (TES) were qualitatively analyzed using
thematic analysis (Braun & Clarke, 2006).
Results and Discussion
The present investigation was undertaken to
examine the effects of MBCT on mindfulness skills,
acceptance and spiritual intelligence in patients with
depression. Sample of the present study comprised
of 3 male and 2 female patients with a diagnosis of
Recurrent Depressive Disorder in age range of 29
years to 50 years (mean age = 38.40 years), 3 were
Hindus and 2 were Christians, 3 were married and 2
unmarried 3 were married and 2 unmarried, 4 were
graduate and 1 was post graduate, 3 were IT
professional and 2 were homemakers, and all were
Amity Journal of Applied Psychology
Vol. 2, No. 2, July 2011 & Vol. 3, No.1, January, 2012
Copyright 2012 by AIBAS,
Amity University Rajasthan (ISSN 0976-6731)
from nuclear families. Duration for illness ranged 9
years to 14 years (mean=9.60 years). All were
stabilized on medication for at least for 2 months
and their medication status remained the same
during the study.
Results in terms of pre- and postintervention assessment scores and improvement
percentage on all the measures for all the 5 cases
are shown in Table 1. Scores on Beck Depression
Inventory (BDI) reveal clinically significant reduction
in the symptom severity of depression for all the 5
cases. The improvement ranged between 62.5 –
81.5%, which was clinically significant. The finding of
the present study is similar to those reported earlier
(e.g., Kenny & Williams, 2007; Splevins, Smith, &
Simpson, 2009) where MBCT was found to be
efficacious in improving depression scores in
currently actively depressed patients from pre to
post
assessment.
However,
methodological
differences exist between the reported studies and
the present study in terms of sample size and
individual case format of the study, as opposed to
the group format. This reduction in severity of
depression may be explained on the basis of
reduction in ruminative patterns of thinking,
increased accessibility of meta-cognitive sets,
improvement in mindfulness skills, and other
mechanisms associated with the practice of
mindfulness meditation (Ramel, Goldin, Carmona, &
McQuaid, 2004; Mason & Hargreaves, 2001; Shapiro,
Oman, Thoresen, Plante, & Flinders, 2008; Cebolla &
Miró Barrachina, 2008; Jimenez, 2009; Splevins,
Smith, & Simpson, 2009).
Table 1
Pre-intervention and post-intervention assessment scores with improvement percentage for five patients with
depression
Index
Case
No.
BDI
KIMS
AAQ-II
ISIS
Pre
Post
IP
Pre
Post
IP
Pre
Post
IP
Pre
Post
IP
1
27
10
62.9*
110
134
21.8
36
55
52.8*
125
175
40.0
2
16
5
68.7*
90
120
33.3
32
48
50.0*
123
135
9.6
3
24
9
62.5*
108
128
18.5
28
40
42.8
116
128
10.3
4
28
8
71.4*
85
129
51.8*
31
57
83.8*
88
129
46.6
5
27
5
81.5*
117
132
12.8
33
53
60.6*
179
217
21.2
IP = Improvement Percentage (in %), * Clinically Significant
The results also indicate improvement in
mindfulness skills from pre-intervention to postintervention assessment as measured on Kentucky
Inventory of Mindfulness Skills (KIMS) was observed
in all cases, however, only in 1 case satisfied the
criterion of clinically significant improvement (Case
IV-51.8%). The range of improvement for the
remaining 4 patients was observed to be between
Amity Journal of Applied Psychology
Vol. 2, No. 2, July 2011 & Vol. 3, No.1, January, 2012
12.8 – 33.3%. The results are similar to the findings
of Mason and Hargreaves (2001), Splevins, Smith,
and Simpson (2009) who also reported significant
improvement of mindfulness skills subsequent to 8weeks of MBCT. Carmody and Baer (2008), Shapiro,
Oman, Thoresen, Plante, and Flinders (2008) have
also reported similar results. However, the degree of
improvement may not comparable owing to
methodological differences between these studies
and the present study.
Results indicated that enhanced acceptance
in all 5 cases, as measured by the Acceptance and
Action Questionnaire (AAQ-II) following MBCT. The
scores were observed to improve from preintervention to post-intervention assessment and
improvement ranging from 42.8 –83.8%, implying
clinically significant improvement in 4 out of 5 cases.
These findings are similar with previous research
findings of Mason and Hargreaves (2001) and
Cebolla and Miró Barrachina (2008), who reported
that 8-weeks of MBCT led to the development of
good levels of acceptance and participants noticing
changes in their way of thinking, of feeling, and in
their relation with the others. Development of
acceptance is appears to be mediated by to the
cultivation of mindfulness skills. Mason and
Hargreaves (2001) in their qualitative analysis of
participants’ account on MBCT have reported the
important areas of therapeutic change such as
‘coming to terms’, development of mindfulness
skills, an attitude of acceptance and ‘living in the
moment’.
Results indicated improvement in scores on
the Integrated Spiritual Intelligence Scale (ISIS),
measuring spiritual intelligence, from preintervention to post-intervention assessment on all 5
cases, however, not satisfying the criterion of clinical
significance. The improvement was observed to
range from 9.6 – 46.6%. These findings are similar to
the findings reported by Astin (1997), and
Mackenzie, Carlson, Munozl, and Speca (2007), who
reported that 8-weeks practice of mindfulness
meditation, was related to higher experience of
spirituality. Jain et al. (2007) have observed no
significant effects on spiritual experience in their
study. It may be possible to assume that patients
Copyright 2012 by AIBAS,
Amity University Rajasthan (ISSN 0976-6731)
with clinical depression, would be significantly
distressed and lacking this resource (Hale, 1997).
Recovery from the active phase of depression would
be a prerequisite to developing more adequate
internal resources. Hence, the findings of the
present study are encouraging to demonstrate
improvements in spiritual intelligence in patients
with active depression, even thought not satisfying
criterion of clinical significance.
Qualitative analysis of responses on the
Therapeutic Experience Schedule (TES) revealed
themes of ‘awareness’, ‘acceptance’ and ‘enhanced
coping’. Another theme that emerged from the
qualitative analysis of the patients’ responses on the
Therapeutic Experience Schedule was ‘enhanced
coping’. This theme was related to the subthemes of
sense of control, management of anxiety, sense of
stability, management of feelings/moods, sense
control over impulsivity, and enhanced functionality.
According to Baer (2003), improved self-observation
resulting from mindfulness training may promote
use of a range of coping skills, by recognition of early
signs of a problem. The enhanced coping is an aspect
of spiritual well being, thus, the theme of ‘enhanced
coping’ that emerged from the qualitative analysis of
the TES, substantiates the improvement observed on
the ISIS.
There are certain limitations to the study
such as having a limited generalizability because of
the small sample size. The present study could not
establish the maintenance of the therapeutic gains
over a sufficient period of time, because of the
inability to carry out follow-up assessments on all
patients, due to time constraints. To improve the
strength of research in this area, larger sample sizes
would be able to enhance the generalizability of
results and the confidence in the findings and followup assessments would be able to establish the
effectiveness of the therapeutic gains over a period
of time. The use of a semi-structured interview as a
tool would be able to provide deeper insights into
the therapy process and outcome.
Amity Journal of Applied Psychology
Vol. 2, No. 2, July 2011 & Vol. 3, No.1, January, 2012
Conclusion
Subsequent to the 8-weeks of MBCT,
patients diagnosed with depression were found to
have reductions in the severity of depression to
clinically insignificant levels, improvement in
mindfulness
skills,
especially
awareness,
improvement in acceptance, and spiritual
intelligence. The present study is among the initial
attempts made in India to study the effect of MBCT
on factors mediating the improvement in
depression. The findings of the present study
provide important information about the mediatory
factors, which would help in planning more effective
interventions and implicates the role of the practice
of mindfulness meditation in developing mindfulness
skills, acceptance and spiritual intelligence, in not
only healthy groups, but in clinical groups as well;
thus, contributing towards developing cost-effective
interventions for depression in the Indian setting.
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Amity University Rajasthan (ISSN 0976-6731)