Oct 9, 2018
How does mindfulness fit with CBT?
And is it all about sitting about on a yoga mat? (spoiler - it's not).
This episode delves into Mindfulness Based Therapies, including Mindfulness Based Cognitive Therapy (MBCT) and Mindfulness Based Stress Reduction (MBSR).
Prof. Willem Kuyken and Chris Henry speak to Dr Lucy Maddox.
Show Notes and Transcript:
If you’re interested in finding out more...
This is book that Willem mentions in the podcast and it comes with a CD of meditations: Williams, M., & Penman, D. (2011). Mindfulness: a practical guide to finding peace in a frantic world. Hachette UK.
These books are also good:
Teasdale, J. D., Williams, J. M. G., & Segal, Z. V. (2014). The mindful way workbook: An 8-week program to free yourself from depression and emotional distress. Guilford Publications.
Segal, Z. V., Williams, M., & Teasdale, J. D. (2018). Mindfulness-based cognitive therapy for depression. Guilford Publications.
Headspace has lots of animations about mindfulness and an app you can download to your phone (they do a free trial so you can see if you like it). https://www.headspace.com/
This organisation are bringing mindfulness to schools with several specially devised programs: https://mindfulnessinschools.org/
Here is the organisation that Willem works at: http://oxfordmindfulness.org/
And in particular this page has lots of resources you can access for free: http://oxfordmindfulness.org/for-you/
British Association for Behavioural and Cognitive Psychotherapies website is here: https://www.babcp.com/
Willem: Mindfulness is a human capacity that we all have in any moment of our life. So, in that sense, anybody can do it anywhere and anytime. There's no particular person or particular way of doing mindfulness. It's a way of meeting our minds, meeting our experience, meeting our world in a different way.
Chris: If I'm anxious, at my wit's end, worried about things, then the one thing that I'm absolutely not is balanced or on an even keel, as it were. And the amazing thing is that that kind of pressure of stress and feeling there's no way out or no light at the end of the tunnel, in a worst scenario...
Whenever I have practised mindfulness meditation, if I've been feeling a bit troubled or a bit down or, on occasion, very, very worried about something, invariably I always feel better afterwards.
Lucy: This is Let’s Talk about CBT and I'm Dr Lucy Maddox. This series of podcasts, brought to you by the BABCP, explores cognitive behavioural therapy or CBT. What it is, what it's not and how it can be useful.
Today, we're thinking about mindfulness-based therapies. These are some of the wider family of CBTs or cognitive behavioural therapies. I'll be talking to Willem Kuyken and Chris Henry about mindfulness-based stress reduction and mindfulness-based cognitive therapy. I met Willem in Oxford and asked how he would describe mindfulness.
Willem: There's a short answer to that, which is that mindfulness is a capacity that we all have to bring a certain kind of awareness to our experience. An awareness that has curiosity, interest and care.
A longer answer is that mindfulness is something that has three different elements to it. It's the ‘what?’ Our attention and our awareness. The ‘how?’ That is cultivating a certain mode of mind, if you like. A certain way of thinking. Of meeting our experience,
meeting our world, with curiosity, kindness, care, equanimity and patience. We're not just reacting to the world, we're actually meeting the world in a very particular way. Meeting our experience in a very particular way.
Then I think the third part of it is the ‘why?’ Why are we doing this? It's not just for fun or just for no good reason. In the case of mindfulness-based cognitive therapy for depression, it's to help people with a very long history of depression begin to see the patterns of thinking, the patterns of behaviour and the patterns of reacting that's lead to depression in the past. And learn new ways of responding. So, there's a what? How? And why? to mindfulness.
Lucy: Could you say a little bit about what got you into mindfulness-based therapies?
Willem: Yeah. When I was a young, clinical academic in my 20s, I became interested in mindfulness as something for myself. In those days, it wasn't really in the mainstream. It certainly wasn't in the mainstream of academia. I found it personally very helpful in all aspects of my life.
It was then, in the late 1990s, I went to a conference called East Meets West. There were a range of people talking about how mindfulness could be applied in health. They were just beginning to think about mindfulness for depression. It was a wonderful opportunity for something that had been personally important to me for, at that point, more than 10 years, and was also a professional interest.
Lucy: Who is mindfulness particularly useful for?
Willem: Okay. I'm going to answer that question as a scientist and point to the areas where I think the evidence is strongest. I think the first area where the evidence is strongest is for people with chronic physical health problems. Jon Kabat-Zinn developed something called, Mindfulness-Based Stress Reduction, which is an eight-week programme that helps people to find ways to live better with long-term physical health problems for which there may not be a physical cure.
The second area where the evidence is very strong is with mindfulness-based cognitive therapy for recurrent depression. This is for people with a long history of depression to learn ways to see how they can respond differently to the early warning signs of depressive relapse. To find ways to recover from depression in the long-term. And through our own work, as an alternative to staying on medication long-term.
I think a third area where the evidence is pretty strong is for people with substance misuse problems and addiction. A programme called, Mindfulness-based Relapse Prevention helps people who are in recovery from addiction to learn ways to see their cravings, to see their addictive patterns. Again, the phrase that's used here is, ‘crave surfing’. (Laughs) To see the cravings for whatever addictive substance and to learn to surf on those cravings.
Lucy: You mentioned, there mindfulness-based stress reduction and mindfulness-based cognitive therapy. Could I ask you just to explain, in a nutshell, what the difference between the two is?
Willem: The way I think I'd describe it is that these different programmes have got different people in mind. Mindfulness-based stress reduction has got somebody with long-term physical health problems in mind. It's trying to help them find a way to navigate the stress of chronic pain or the stress of cancer, or whatever it might be.
Mindfulness-based cognitive therapy has a very particular understanding of depressive relapse. Of what it looks like when somebody goes into a downward spiral of depressive thinking. It helps that group of people, people with recurrent depression, see those moments and learn to respond differently.
Lucy: What do they look like, I guess, for people who might be signing up to one? What can they expect?
Willem: They're both group-based programmes. There are groups of about 15 people with one mindfulness teacher. It's more like an adult evening class than it is therapy, in that sense. What people are doing is they are learning new skills. They're learning about their own minds, they're learning about their own behaviour and they're learning in a way that I think is actually – and it's a rather long word – emancipatory.
What you're teaching people is the skills whereby they themselves can navigate themselves out of tricky situations. They can navigate themselves out of habits of mind that have, often over many years, got them into patterns of suffering and repeated negative thinking. That can be an extraordinary insight for people. An extraordinary change for people.
The other thing that I think is very powerful about mindfulness-based programmes is a sense of common humanity that comes out. That people will sit around a table or a room and they will say, "Gosh, I thought this way of thinking was just me. That my negative thinking about myself as a loser or being no good was unique to me. But there's a primary school teacher, there's a builder, there's somebody who works in an office, and they look just like me and their mind is just like mine."
There's a tremendous sense of common humanity that I think is also very healing about mindfulness-based approaches taught in a group format.
Lucy: Although anyone can practise mindfulness, Willem told us there about two specific types of group programme. Mindfulness-based stress reduction and mindfulness-based cognitive therapy.
Chris has experienced mindfulness-based cognitive therapy. I went to London to meet with him at King's College Hospital. Here's his story.
Chris: I came to mindfulness meditation as a result of being diagnosed with a chronic heart condition and following open heart surgery. So, the potential for this therapy to help me keep my blood pressure at a reasonable level, to deal with the occasional stresses which arise in daily life and to avoid unnecessary stress is extremely helpful.
I found myself, when I first learned the therapy... having been reasonably healthy, to be told that I needed open heart surgery. That, as for a lot of people, I think is fairly life changing. It's a big shock. Also, what's absolutely key and what every cardiac patient learns in rehab, is the importance of changing lifestyle to maximise heart health. That involves quite a lot of lifestyle changes.
All of this upheaval, for me, and accommodating those changes was definitely helped by using mindfulness meditation. To put it into perspective, to not allow myself to panic or get things out of proportion. Also, not to succumb to the everyday temptations, either eating or drinking or whatever, which would be bad for my heart health.
I think the major way that the therapy has helped me is because, whilst my surgery was very successful and I responded well to the rehab advice and support, what the whole process left me with was high levels of anxiety. I had problems with insomnia, simply becoming anxious. There were a number of changes around work that I needed to address.
Gradually and over time, I think the centring effect – if I can put it that way – of the therapy, practising on a fairly regular basis, helped me deal with those challenges in a way that I would have found much more difficult had I not had that support.
Lucy: I asked Willem to describe some mindfulness exercises.
Willem: There are a range of different mindfulness practices. I'll describe one, which is the body scan practice. In the body scan practice, what people are invited to do is to bring their attention, with a quality of interest and care, to scan all the way through the body, from the very tips of the toes all the way to the top of the head.
They're being asked to do that for a number of reasons. The first is to stabilise their attention so that they can actually choose where they focus their attention. It just happens to be the body in this practice.
The second is to cultivate these different ways of being and knowing. So, to be curious. To be patient. To be present. To be non-judgemental. This sounds simple but actually, our normal way of thinking is often to be quite automatic. To be quite judgemental. We can often do that without being aware that we're even doing it. So, it's bringing a certain quality to our attention and awareness. That is a training that can then be used in all parts of people's lives.
I, for example, am the father of two daughters. I remember when they were teenagers, it was very easy to be reactive. It was very easy to see things that they said or did and to find myself wanting to speak and act in a particular way. Mindfulness enabled me to see that. To see that happening and to say, "Actually, I'm not going to do that. I'm going to choose to bite my tongue." Or, "I'm going to choose to respond in a different way."
These practices of focusing on the body, focusing on the breath, mindful movement – yoga, if you like – are in the service of helping us to better understand our minds, train our mind and actually transform our minds. Because, you know, it's a lifetime of practice. Because I've just turned 50, my mind has had 50 years to develop a particular way of thinking and reacting. To turn that around is not easy.
Many people with mental health problems will recognise that. People with a background of generalised anxiety, depression or health anxiety. These are very sticky mental habits that people are trying to recognise, understand and transform.
One of the practices that many clients find tremendously helpful is called the three-step breathing space. It involves three steps. The first step is to help people to recognise what's happening right now, in my mind, in my body, in my emotions? It's just a stopping and a recognition of what's happening.
The second step is then an anchoring. People are anchoring their attention, anchoring their awareness. Typically, on their body or on their breath. "Okay, can I step out of reactivity and just anchor myself in my body and in my breath?" That can take 30 seconds. It can take a couple of minutes. It can take a bit longer.
Then the third step, having anchored ourselves, is to broaden out to a broader awareness of what's happening in my body and in my wider world.
What we're doing with that three-step breathing space is we're helping people to recognise automaticity and reactivity, to step out of it and anchor themselves, and then, in a way, re-engage or re-meet the world but from a different place. And in a place that I think can unlock a whole repertoire of different ways of responding.
Lucy: That's a really nice example because that's actually quite a quick one, isn't it. That people could do and other people might not even know they're doing it, even in a public place, for example.
Willem: Yes. Yeah. And I think it's the sort of place where, if you like, the rubber meets the road. People can do that practice and then they can apply it in all sorts of different places.
For example, a young person at school going into an exam can be completely crippled by anxiety. At that moment, they could do a three-step breathing space and recognise the anxiety, the catastrophic thoughts, the contraction. Stabilise themselves, have this different way of being and knowing and go, "You know what I need to do right now, just before the exam? It's X, Y and Z." It's the shift that can make all of the difference.
I had a teacher once who told me that she did this all the time at parents' evenings, when she knew that she was about to have a difficult interaction with a parent. She would take a three-step breathing space. And she would end the three-step breathing space, really interestingly, with having some compassion for the child and the parents. It just completely reframed the conversations for her.
So, it's just a very simple tool that people who have learned mindfulness can switch from an automatic, reactive way of interacting with the world to a more intentional, embodied, compassionate way, if you like, of interacting with the world.
Lucy: To recap, the sorts of mindfulness practices that you might do in a group include the full body scan and three-step breathing, although you can be mindful anywhere. What about the effects of the practice?
A clinical psychologist recommended a mindfulness course to Chris whilst he was in hospital for cardiac rehab. So, his first experience was an eight-week course, two hours per week, in a group of around eight people from all sorts of different backgrounds.
Chris: The teacher explained the process, a very simple and straightforward process, of meditating. And practised with us. Gradually, over the period of eight weeks, we built up both the length of time that we were meditating in the sessions and we also regularly, over the eight weeks, had homework, as it were, which we practised at home.
One of the ways in which the therapy has really helped me is that, in being very anxious post-surgery, I also had difficulty deciding, as objectively as possible, how well I was doing. Was I recovering? Was I going to be okay? Were things going to go back to normal, as it were?
Professionally, I had worked for a large organisation in the business of measuring standards. So, in my day-to-day work I had been judging performance, looking at how well people were doing, taking a hopefully even-handed but critical eye as to how things were going.
And what mindfulness showed me was how easy it was for me, as I did at the time, to turn that critical eye of myself and judge myself. And, as it were, beat myself up if I didn't practise on my own each day and so on.
Over a period of time, and also reading around the subject a little bit since completing the course, I have taken the approach that, although it would be great to practise every day, life happens. I'm not going to beat myself up if I don't. I shall aim to practise most days. That's what I do. And that's been quite a useful revelation.
I think the other thing is that, to put in a straightforward way, it's helped me accept that I'm probably okay (Laughs). And also that, with the prospect of needing, as I now do, to monitor lifestyle and health issues in terms of my heart condition, it's helped me to take an approach to the future which is based around, "I want to enjoy time and value the people and the things that are important to me."
And to try and not waste time being concerned, angry or critical of things over which I have no control. Also, to not judge when people are difficult, different, problematic, upset or annoying me in some way.
Lucy: Could you explain, just to help people understand, how you got from the practice of meditation and sitting with yourself to having those understandings, which sound really important?
Chris: The difficulties with which mindfulness meditation helps me are to do with anxiety and feelings of stress. The way I experience that stress and anxiety is largely by feeling that my mind is crowded with issues, I turn things over and over in my head, I lie awake at night worrying about something.
What practising mindfulness helped me do is simply to provide, if you like, a quietness from all of those things. To actually, simply, mentally put them to one side. Understanding that they're still there. And to then methodically address issues in a way which is not hindered by the mental noise of a lot of competing factors.
I used to put things off and I used to prevaricate hugely. I would have things that I knew I needed to do and they'd be playing on my mind. They'd add, obviously, to the stress. What I learned was that, actually, a good approach for me if I'm concerned about something – thinking about practical things – is just to deal with it at the time. To actually remove it from the mental or anxiety in-tray, as it were, and then it's out of the way.
Lucy: As someone who has practised mindfulness for most of his life and who now researches its benefits, how does Willem see it?
Willem: The question that arises sometimes is, "What is the purpose of mindfulness practice?" There's a story of that being asked of a sage, if you like. He answered, "Well, the point of a lifetime of practice is an appropriate response." What does that mean? It means that, in the midst of a challenging situation or in the midst of something important, knowing what the right thing to say or to do is.
The practice, as I said before, has got a purpose. It's got an intention. The intention is to support people to lead a life that is aligned with their values, that feels meaningful, that feels enjoyable.
Of course, mental health problems like anxiety and depression are very disabling. If people can learn to live with and to transform those conditions with mindfulness, not only does it help them with their mental health problem but I think it has a broader impact on their lives, on their relationships, on their work. On their life more generally.
We hear that a lot from people going to mindfulness classes. That it's helped them with why they first came. So, when I ran mindfulness classes for depression on a regular basis, I would give people a form at the beginning and I'd say, "What are the three reasons why you want to attend this class?" I would say 99% of people would say, as their primary reason, "I don't want to get depressed again." Then they would have a couple of other reasons which were variants of that.
When you then ask them at the end of the class what did they get out if it, it actually looks rather different. In fact, we wrote a paper in the BABCP journal and the title of the paper was a quote from one of the participants who said, "It changed me in just about every way possible."
By starting to see his life through his mind and his life through a different lens, not only was the depression transformed but actually relationships were transformed, his work was transformed, in good ways and bad.
I remember one participant once telling me that he had had Pot Noodles every day for lunch for years. What we ask people to do in a mindfulness class is to bring their full awareness to something that they do every day in a routine way.
He came back and he said, "I'm really upset because I've discovered I hate Pot Noodles. (Laughs) They're chemically, they don't taste nice, it feels like I'm polluting my body. This awareness has ruined my enjoyment of Pot Noodles!" So, it changes the way we interact with many aspects of our life, I think.
Lucy: I asked Chris about some of what was hard about practising.
Chris: Halfway through the course, I was troubled because I was thinking about things and reading things to do with the course. Trying to take on board what we were being told and explained. It felt almost as though mindfulness was just about lying back and letting everything happen that happens. Not getting worked up and not caring about issues.
Having spent time thinking this concern through, I realised that that was a misunderstanding on my part. I think there is a mindful way to express disagreement. There's a mindful way to resist. There's a mindful way to oppose. I hope that I can find that when the need arises, without either being aggressive or objectionable or whatever to the person I'm speaking to.
Equally, particularly in my own health circumstances, not allowing that expression to be at the cost of my own heart health. So, not getting worked up by stuff, losing it, venting my disagreement with somebody and my blood pressure going through the roof.
I'm 60. I'm a man. In society, and certainly in my generation, we have been, in the world of work particularly, expected to be fairly direct. At times, aggressive and so on. The process of this therapy has helped me to see how damaging those approaches are in our interaction with one another. And also in our interaction with the people we care for.
Lucy: The impact of mindfulness is far reaching and varied. It's currently offered to MPs in Parliament, prisoners in high-security settings and now Willem's team are involved in researching whether teaching it to young people can help prevent the onset of depression.
When mindfulness is so widespread, what are Willem's concerns for its use?
Willem: I think one of the challenges for the mindfulness-based area is to proceed carefully and with humility. Because mindfulness-based approaches have been in the media quite a lot, and I think there are quite a lot of strong advocates of mindfulness, there can sometimes be... The enthusiasm gets ahead of the evidence.
One of the challenges for the mindfulness area is to actually progress in line with the evidence and not to get too far ahead of ourselves.
Lucy: Some people talk about, ‘McMindfulness’ don't they? It's a term that's used.
Willem: Yeah. ‘McMindfulness’ is a term I've heard quite a lot. I think it's a real caution, isn't it, to think about, "If I'm going to offer mindfulness to this group of people in this context, what is the best format? What's the best way to do this? There's quite a lot of pressure in the health service to conserve resources. What is the minimum amount? The smallest format to effect this change?” That is a legitimate question. Of course it's a legitimate question.
My own view is that, actually, the mind is a tremendously complex organ. If we are going to look at changes which are transformative, that can't be done with a sticking plaster. It can't be done with a brief intervention.
I think some of these interventions, like helping somebody with a long history of depression stay well in the long-term, aren't going to be done with a sticking plaster or a really short form. We need sometimes to accept that, actually, this is going to be an intervention that takes more time, more energy, more effort.
Chris: It's incredibly beneficial. It just makes you feel better. On occasion, not unusually, if things... we all have bad days now and again. If I've practised for half an hour or so, it's as though—and there may have been no change in the weather—the sun has come out. That might sound airy fairy or whatever but that's the only way I can describe it.
It's been an incredible support through a very difficult period. It's one which I am sure has helped me deal with issues. It's something which I want to continue with into the future because I like the effects that it can bring. And, through one or two comments by my partner and family members, in their view it's having a positive effect, as well! (Laughs)
Willem: I once had a client who said to me... She had had a heart and lung bypass and a history of depression. She said she would rather have another heart and lung bypass than another episode of depression. Absolutely. Depression is a devastating disorder.
Many people's lives are really badly affected and, in some cases, ended through suicide. I think a world without the devastating effects of depression, where approaches like CBT and MBCT help people to recover and stay well, is absolutely an aspiration for us to work towards.
Somebody once described mindfulness as being a bit like a lemon. It's really difficult to describe what mindfulness is. But actually, you can get a sense of what it is by tasting it. I think for people to actually experience mindfulness, to maybe buy a book like Mindfulness: Finding Peace in a Frantic World, which has got a CD set in the back, and trying it for themselves. And actually trusting their own experience.
I think mindfulness is one of those things where practices are offered and people are then invited to learn from their experience. So, try it and see what you think.
That being said, if you're looking for a teacher, I think it's really important to find a good teacher who can teach it well. The BABCP website has got a ‘Find a therapist’ tab on it, which is a way of finding a good CBT therapist, some of whom are now also trained in mindfulness-based approaches.
Lucy: So, that's all from me. I hope that's been helpful in understanding more about what mindfulness-based therapies are. For more information, have a look at the show notes on the podcast website, which has got loads of links to lots of resources, including some links to free mindfulness meditations that you can try for yourself.
This is actually the last episode in the current series about different forms of CBT. We do have one more bonus episode coming up for you, though. A short episode of interviews recorded at a special outreach event in a local Glasgow mosque up at the BABCP conference in the summer. That will be out next week.
Meanwhile, if you've got any feedback or ideas for future podcast topics, please do let us know. I'd definitely like to make some more for you and I'd really like it if they were on topics that you wanted to hear about.
Please share the podcast with people you think it might be useful for and rate us on iTunes if you've enjoyed the show. It helps other people to find us.
This podcast is brought to you by the British Association for Behavioural and Cognitive Psychotherapies, or BABCP. For more information about BABCP and about cognitive behavioural therapies, including a list of BABCP accredited therapists, check out BABCP.com.
Thanks to Gabe Stebbing for the title music, Origamibiro for the incidental music, Professor Willem Kuyken and Chris Henry for speaking to me and Eliza Lomas for the editing consultation.
END OF AUDIO