CBT and Mindfulness for Depression
Clinical Psychologist at Beck Institute
Mindfulness-based interventions have been becoming more popular in psychotherapy. One such treatment, Mindfulness-Based Cognitive Therapy (MBCT), has specifically been developed to prevent relapse in clients who have experienced recurrent major depressive episodes (Segal, Williams, & Teasdale, 2001). We have incorporated mindfulness strategies into our work at the Beck Institute. Instead of thinking about mindfulness-based interventions as separate treatments, however, we think about mindfulness as a potential strategy to use in a larger CBT framework. I’ll review one common mindfulness technique we use with our non-suicidal depressed clients.
A body of research has demonstrated rumination to be an important factor in maintaining depression (e.g., Nolen-Hoeksema, 2000). We view rumination as a strategy clients use to cope with depression. For example, Mark, a client I recently treated, felt depressed, then ruminated to try to figure out why he felt depressed. His ruminative thoughts included, “Why do I feel so depressed? What’s wrong with me? I just can’t do anything right, like I got a bad review at work. My friends don’t try to call me either. . .” I worked with this client to help him identify his beliefs about the rumination process instead of solely evaluating the content of each thought.
First I help clients identify, and then evaluate, beliefs about rumination. I start this way (instead of going straight into mindfulness) because clients tend to continue to use strategies that they view as helpful. I want them to recognize that rumination is doing them more harm than good. One way to identify beliefs about rumination is to complete a cost-benefit analysis, eliciting from clients the advantages and disadvantages of rumination. Instead of using the term “rumination,” I asked them what they call the strategy (e.g., “asking myself why,” “listing all of my problems,” “trying to think my way out of depression”).
Typical advantages include “It helps me figure out my problems;” “I can come up with solutions.” “I’ll be able to know what to do next time I feel depressed.” Next we list the disadvantages, such as: “It makes me feel worse.” “Once I start, it’s hard to stop.” Then we evaluate each advantage. For instance, I asked Mark, “How often do you come up with a specific solution?” and “If ruminating helped you solve your problems, do you think they would be solved by now?” Next we evaluate whether the advantages or disadvantages are stronger. Clients have effectively assessed their positive beliefs about rumination when they conclude that the disadvantages outweigh the advantages. A list of the advantages and disadvantages shows clients the consequences of rumination and acts a motivator to stop the unhelpful strategy. (If the advantages are still stronger, you’ll need to either spend more time evaluating the advantages or add to the disadvantages.)
The next step is to teach clients how to use mindfulness as a strategy to disengage from rumination. I record the mindfulness exercises (usually using clients’ cell phones) to make it easier for them to practice. Before I start, I guide clients through a rumination induction by having them close their eyes and actively think about a topic involved in their typical ruminations. I get them to simulate the process of ruminating in session so they can experience being able to disengage from the rumination process. As I noted before, this strategy should not be used with actively suicidal clients because it can increase their depressed mood and sense of hopelessness.
Once clients have been ruminating for about 30 seconds, I ask for a rating of their depressed mood from 0-10, turn on the recording app on their phone (“voice memos” on iPhones or “voice recorder” on Androids), and begin guiding them through a mindfulness of the breath exercise that lasts for 5 minutes. At 5 minutes, I get another mood rating, end the exercise, and ask them about the experience (e.g., “What did you notice?” “Were you able to let go of ruminative thoughts and refocus on breathing?” “What happened to your mood over time?”) The vast majority of clients learn that it’s possible to disengage from rumination, and that by not actively ruminating, their mood gradually improves. I make sure to emphasize that mindfulness is not for the purpose of making them feel better or suppressing thoughts but is a strategy to help them relate to their thoughts in a different manner. Their action plan then consists of listening to the recording every day (preferably at the beginning of the day to serve as a reminder to use mindfulness throughout the day) and to use mindfulness by letting go of thoughts and refocusing on the breath with their eyes open whenever they notice themselves ruminating during the day.
Dr. Hindman will be teaching mindfulness exercises as part of the CBT for Depression - Core 1 workshop at Beck Institute in March and the CBT for Anxiety workshop in Chicago in April.
Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/depressive symptoms. Journal of Abnormal Psychology, 109, 504-511.
Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2001). Mindfulness-Based Cognitive Therapy for depression. New York: Guilford Press.