Adapting Ancient Wisdom for the Treatment of Depression: Mindfulness-Based Cognitive Therapy Group Training

Abstract

This paper outlines and discusses two models of training for group Mindfulness-Based Cognitive Therapy (MBCT) which we have called In vivo and Intensive. MBCT training and practice focuses on present moment experience versus content, focused on gaining a metacognitive perspective on one's thoughts and internal processes. Trainees and trainers share their reflections on the training process as well as the experiential and acceptance-based framework of MBCT reflected in the training process itself. Suggestions for optimizing training across multiple mental health disciplines and settings are also discussed.

Introduction

This paper is a reflective description of Mindfulness-Based Cognitive Therapy (MBCT) training program to treat depression at the University of California-San Francisco (UCSF), Langley Porter Psychiatric Institute (LPPI). At LLPI, group MBCT is offered to patients with depression several times a year. Trainees across mental health disciplines have a variety of opportunities for training as group leaders in this modality.

MBCT holds decentering', or gaining a certain level of objective distance, from thoughts and other internal experiences as a central focus. This is accomplished through the teaching and real-time practice of various mindfulness exercises and discussion of experiential metaphors in the group setting. Mindfulness, defined as paying attention, in the present moment, on purpose, without judgment (Kabat-Zinn et al., 1991), is combined with the presentation of a new way of relating to internal processes that can profoundly shift the experience of depression and an individual's self-perception. There is increasing empirical support for MBCT and the treatment of depression (Eisendrath, et al., 2008: Finucane & Mercer, 2006: Kenny & Williams, 2007) and prevention of relapse (Kuyken, et al., 2008; Ma & Teasdale, 2004; Teasdale, et al., 2002).

Research on the training of group psychotherapies has found that the teaching most often naturally flows from the theoretical foundations in which they are rooted. For example, psychodynamic group psychotherapy training has been described as a developmental process where a trainee goes through multiple stages that meet operational goals based both on dynamic group theory and training needs. These goals include (but are not limited to): assessing and selecting appropriate participants, learning fundamental psychotherapeutic technique with variations in a group setting, developing appreciation and understanding of group phenomena, and building skills for recognizing and understanding issues related to transference, counter transference and termination in the group setting (Gallagher. 1994).

In contrast, Cognitive Behavioral Therapy (CBT) group training has a different set of operational goals based on theoretical foundations that emphasize the relationship between thought, feeling and behavior. Therapists educate and encourage participants to learn specific skills, such as the identification of thought distortions and use of thought records to influence maladaptive thought patterns. In comparison to psychodynamic group therapists, CBT group therapists have been observed to use more cognitive, behavioral and psychoeducational strategies, to foster self-efficacy, and to be more supportive and empathic compared to psychodynamic group therapists that use more interpretative and confrontative interventions and focus on interactional and dynamic aspects (Watzke et al., 2008).

As with CBT, the main focus of MBCT is on skill development rather than on understanding unconscious interpersonal mental processes, as in psychodynamic group therapy. However, the skills taught in MBCT differ from traditional CBT by helping individuals develop a different relationship to their thoughts, rather than changing specific thought content. Thoughts are dealt with as impermanent mental events that come and go. The patient is encouraged not to view them as valid factual representations of the world. In this way, MBCT represents a more “metacognitive” therapeutic process, allowing patients to observe their own thought processes.

A key component of MBCT is the experiential process that occurs during group, and outside group through “homework” that includes meditative practices. Just as patients learn these new skills through experience, the training required to learn to deliver this modality demands no less of the trainees. MBCT therapists must have well-developed, experiential knowledge that has been developed through their own practice of mindfulness and acceptance which is reflected in this training model. The authors of this paper, all trained in MBCT, represent mental health professionals at various levels in psychiatry, psychology and marriage and family therapy. All have had a range of previous training in other psychotherapeutic modalities, as well as experience with mindfulness in professional and personal contexts.

This paper describes two primary models of training for the delivery of an eight-week, group MBCT intervention. We have called them the In Vivo Model and the Intensive Model, which are described in detail below. We also reflect on the training experiences from the perspective of both the trainees and trainers. We conclude with summary thoughts on delivering this type of training in a university-based, medical school environment.

In vivo Training Model

Trainees in the LPPI psychiatry residency program are given a choice of a number of different time-limited groups to co-lead in the third year of training, including MBCT for depression and CBT-based groups for treatment of depression, anxiety, eating disorders and chronic pain. Some trainees are particularly interested in learning MBCT because of a previously established interest or experience with meditation and/or mindfulness-based therapies, whereas other trainees may be assigned to co-lead an MBCT group without any previous interest, experience or particular desire to learn MBCT as a therapeutic modality.

MBCT groups are principally run by two senior clinicians, a psychiatrist and a master's level clinician, who have completed professional training in MBCT. The trainee serves as an additional co-leader to gain experience by engaging with the group as a leader and a participant-observer. The trainee's level of participation may vary depending on level of interest, comfort as a group leader and previous experience with meditation and mindfulness-based interventions.

Trainees attend all eight sessions and are encouraged to develop a mindfulness practice during the sessions similar to what patients are asked to do, if they do not already have established practice of their own. Reading materials recommended in preparation for sessions include an instructor's manual developed by the senior group leaders and Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse (Segal, Williams, & Teasdale, 2002). Trainees are typically given a portion of each session to lead for which they prepare in advance, and they participate in exercises along with group members. The trainee's level of leadership may increase as he or she becomes more familiar with the principles of MBCT and accustomed to the particular group members and format. Trainees are asked to do the same “homework” that group members do while in the group, including 45 minutes of mindfulness practice (e.g. body scan, yoga, sitting meditation) at home six days a week.

Prior to the start of each group, the trainers meet with the trainees to discuss the MBCT group structure, rationale (including differences from other modalities), and expectations (based on trainee's interest, experience, and comfort in the group setting). The trainees are given a Mindfulness-Based Stress Reduction video to orient to the general class structure, readings on mindfulness, and the MBCT Instructor's manual. Trainees also participate in a pre-group screening process after which the trainers meet with trainees for one to two follow-up meetings to review patient interviews, answer any questions about the training process, and to discuss trainees' concerns about starting the group and how active to be in it.

The MBCT group trainers take the lead roles in presenting MBCT to the group members, such as rationale, attitudes, and mindfulness practices. This is typically challenging for beginning trainees to explain effectively. This material should be conveyed in an authentic manner by experienced meditators, rather than by reciting from a manual. Trainees are encouraged to lead some of the experiential practices starting with simpler exercises, such as eating a raisin mindfully, and those most familiar to them such as the CBT exercises (identifying thoughts, feelings, and consequences of behavior) or discussion of DSM-IV symptoms of depression.

Following each of the eight sessions of MBCT groups, trainers and trainees discuss group process and content for 30-45 minutes. Trainers answer trainees' questions and provide feedback about how different tasks and exercises were handled. The leaders then distribute tasks for the following session with an explanation of the rationale. After completing the eight sessions, the trainers give overall feedback to the trainees in person and complete an electronic evaluation that is transmitted to the residency training program. Trainees are also offered a reciprocal opportunity to give feedback to the trainers about the learning experience.

Some former trainees were asked to comment on their experiences as co-leaders of MBCT groups in this training model. All felt that participation in the MBCT program was positive both personally and professionally. Former trainees commented:

• “I had a misunderstanding of what mindfulness was before participating in the group. Now I know it's not about trying too hard to concentrate.”

• “I still use some of the techniques myself, especially when I'm really stressed out.” “I really enjoyed hearing the patients' experiences and watching them make new discoveries about their own minds.”

• “I especially enjoyed the focus on the body using yoga and the body scan.”

In contrast to other group therapy experiences, former trainees commented:

• “This training was more focused on a teaching model than on group process. In many ways it is simpler”.

• I like the manualized approach better. I knew what I was supposed to be doing”.

• “I don't like leading groups, but in the MBCT group. I felt more like a teacher. That was better for me.”

Some trainees found co-leading the MBCT groups challenging. Some found the reading and/or mindfulness practices done at home too time consuming and did not do them. Some found learning how to meditate difficult. One former trainee commented, “I didn't know anything about MBCT prior to the experience, so I felt like I was winging it.” This is consistent with recent data that new group therapists often feel uneasy about leading groups, stemming from a fear of public exposure about revealing lack of competence (Hahn, 2009).

There were also some challenges in titrating the right amount of clinical responsibility to give each trainee. For example, one trainee had a good deal of prior meditation experience and felt she was not given enough to do as a co-leader in the group. Some other trainees, especially those without any prior meditation experience, were anxious about assuming a leadership role and preferred more of an observer status for the mindfulness components. Commenting on using the training in MBCT after the initial experience, trainees reflected:

• “Although I feel MBCT and mindfulness techniques are very useful, I have found it difficult to find a way to bring the principles into my work with individuals. I find it difficult to convey the paradox of not ‘trying to get better’ while a patient is in treatment.”

• “I feel much more able to make an appropriate referral to a mindfulness-based therapy.” “So many people in the San Francisco Bay Area have experience with meditation or yoga. Going through the experience with MBCT has given me a common language to discuss these topics with patients.”

Intensive Training Model

The trainers also offered Intensive Training in MBCT. Its primary purpose is to provide an in-depth training experience for therapists in preparation for co-leading MBCT groups for an upcoming randomized clinical trial using MBCT for Treatment- Resistant Depression being conducted at UCSF. The training was expanded to involve other clinicians interested in learning MBCT, including psychiatrists and psychologists at various levels of training. This enriched the overall training experience for trainers and clinicians. This in-depth training was ideally to be paired with the In Vivo experience described above before a therapist was considered competent to conduct MBCT groups independently.

The training began with a detailed presentation on MBCT including the development of the process, the theoretical and technical rationale, and a discussion of the research findings supporting its applications. The format followed the eight-session model of MBCT, with two-and-a-half-hour weekly sessions devoted to reviewing and practicing mindfulness exercises. The trainers and study therapist presented the meditation practices experientially, followed by group discussion of the practice. The trainees were then able to practice delivering the class content to each other with immediate feedback from the instructors. Practice was followed by a review of session goals and discussion of the mindfulness skills taught that session, followed by a discussion of the techniques.

Due to the experiential nature of MBCT, concepts were presented and practices delivered in much the same way as to a patient population, but with additional emphasis on the theoretical and empirical underpinning for each exercise. This type of group MBCT training does not include co-leading an MBCT group; clinical applications were carried out in more heterogeneous settings. Some trainees, especially those with previous mindfulness training, started to use the MBCT techniques they had learned in the intensive training model with their patients struggling with depression in various settings.

• “Although I was not leading an MBCT for depression group at the time, I would apply exercises brought up in the training with individual patients addressing depression or self-critical thinking.”

• ‘The main difference between group MBCT training and group therapy supervision, in my experience, was the emphasis on mindfulness-based experiential exercises and the lack of emphasis on psychological content of thoughts or emotions which might arise.” Some trainees thought the manuals were somewhat confusing and that practicing in a group with other mental health providers would not provide an adequate real-life, patient experience of potential barriers to these ideas.

Others commented on the training in the evaluation:

• “It was good to experience the whole session like patients. It was really helpful to notice or imagine how a patient might feel.”

• “Lots of hands-on practice in the sessions - forces you to jump in and do it!” “I have either been to large conferences or have had one-on-one supervision for my patients. This short-term, small group training that was not focused on a specific case was very different and felt more intimate than a conference.”

• “I appreciated the opportunity to lead meditations with peers and receive feedback.”

• ‘This was a good introduction to MBCT, especially for clinicians already familiar with mindfulness-based psychotherapies and groups.”

Combination in Vivo and Intensive Training

Some trainees experienced both the In Vivo and Intensive models. Trainees felt that the first step of In Vivo training (reading the MBCT materials and co-leading a group) provided immediate, active application of the MBCT exercises and principles to patients, in a supported context. Others felt there was less time and space to integrate mindfulness principles personally before being asked to address patient issues. The second step in Intensive (participating in the group training in MBCT) provided supervision outside the selling of patient care and involved a peer group of mental health professionals demonstrating interest in, and openness to, mindfulness. The experience of participating in both ways of being trained in MBCT was thought to be synergistic, offering both a supportive learning environment and a practical sense of how MBCT might be offered in a group setting for patients with depression with real-time modeling by seasoned faculty.

The MBCT Trainers

From the trainers' perspective the combination of In Vivo and Intensive training is an ideal way to fully prepare the trainees for being independent practitioners of MBCT. Due to time constraints, however, most of the trainees chose one method of training yet gained considerable skills. The challenge for many in learning MBCT is similar to that of the patients: changing from a doing to a being mode. Many trainees approach troubled patients by trying to help them change depressogenic thoughts or alter cognitive distortions. MBCT shifts this type of doing so as to allow those thoughts but help the patient to change the relationship to them and allowing them to just “be” and pass from consciousness with the next thought. This metacognitive shift can be challenging, but, as trainees grasp this therapeutic stance, also rewarding. Trainees often comment that they feel less in a debate mode with chronically depressed patients attached to negative cognitions.

Similarly, helping patients shift their attitude towards accepting dysphoric states rather than trying to eliminate them differs from other therapeutic approaches. MBCT emphasizes the role of acceptance as laying the groundwork for skillful responses, rather than reflexive reactions. This is also distinct from passivity or lack of response, which is often how the stance of acceptance is misinterpreted. Some of the trainees have to make a paradigm shift to relinquish an attitude toward dysphoric states which views them as something to be attacked. When they are successful, there is a qualitative shift in understanding the power of a mindfulness approach.

Summary Thoughts

We have discussed two primary modes of training in MBCT, one of which allows for real-world patient experience and supervision (In Vivo), whereas the other is more experiential, in a group of professionals training together without the benefit of real patient contact and close supervision (Intensive). Ideally these two models would be paired to provide the optimal group training experience. Most trainees only completed one of the two models, and reported exporting MBCT techniques and strategies to work with depressed patients into their clinical practice. It is likely that the extent of previous and current exposure to mindfulness and group therapy greatly impacts this training experience.

MBCT training and practice focus on experience in the moment, working towards greater acceptance of self and internal processes. Thoughts come to be seen as events in the mind, independent of their content and emotional charge. They need not be disputed, fixed, or changed but are held in a more spacious awareness. Depressive thoughts can then be seen as transient mental events, rather than as a core identity of the depressed individual. Trainees may encounter multiple challenges as they begin to understand how their own mind operates and impacts their experience of the world around them, just as group participants do. MBCT training differs from many group therapy trainings by emphasizing that the clinician develop his or her own mindfulness practice and self-inquiry to bring authentic self-knowledge to bear on helping clients in emotional distress.