Mindfulness Meditation

Integrating Mindfulness Meditation With Cognitive and Behavioural Therapies: The Challenge of Combining Acceptance- and Change-Based Strategies Mark A Lau, PhD', Shelley F McMain, PhD^ Recent innovations in psychological treatments have integrated mindfulness meditation techniques with traditional cognitive and behavioural therapies, challenging traditional cognitive and behavioural therapists to integrate acceptance- and change-based strategies. This article details how 2 treatments, mindfulness-based cognitive therapy and dialectical behaviour therapy, have met this challenge. We review the integration rationale underlying the 2 treatments, how the treatments combine strategies from each modality to accomplish treatment goals, implications for therapist training, and treatment effectiveness. In addition, we discuss the challenges of assessing the benefits of incorporating acceptance-based strategies. Both therapies have integrated acceptance-based mindflilness approaches with change-based cognitive and behavioural therapies to create efficacious treatments. (Can J Psychiatry 2005;50:863-869) Information on author affiliations appears at the end ofthe article.

Clinical Implications • This review addresses the specific challenges faced by traditional cognitive and behavioural therapists when integrating mindfulness meditation techniques. • The primary challenge is the integration of acceptance, as opposed to change-based, strategies. • In both MBCT and DBT, adding mindfulness meditation techniques to traditional cognitive and behavioural therapies resulted in the creation of efficacious treatments. Limitations • This discussion of integrating mindfulness meditation with cognitive and behavioural therapies is limited to 2 treatments for specific clinical presentations. • Only the challenges faced by traditional cognitive and behavioural therapists are discussed. • Future research is required to determine the specific contribution ofthe mindfulness meditation component to therapeutic outcome.

Key Words: mindfulness meditation, cognitive-behavioural therapy, dialectical behaviour

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peutic approaches. Western society's current fascination with *^ *^^ the East, and a broader trend toward psychotherapy mtegration. A specific example of this trend is the integration of Eastern spiritual practices with cognitive-behavioural treatments, which Hayes describes as a third epoch in the evolution of behaviourally informed therapies (5). In the first phase. 863

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leaming theory and principles were systematically applied to develop specific behavioural treatments for emotional disorders. The second phase v^'as heralded by the arrival of CT, which eclipsed purely behavioural models of psychopathology in favour of accounts featuring the role of attention, memory, and mental representation. The third phase, which is in its infancy, features treatments that combine the fundamental properties associated with the 2 earlier phases with elements derived from Eastern spiritual practices including, in particular, mindtulness meditation. However, the introduction of mindflilness-based treatments can present a challenge to change-oriented cognitive and behavioural therapists, largely because of the acceptancebased nature of mindfulness. Kabat-Zinn defmes mindfulness as "paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally" (6). This awareness is based on an attitude of acceptance of personal experience that entails being experientially open to the reality of the present moment (7). To illustrate the difference between acceptance and a change-based CT approach, consider the negative thought "I am unlovable." Mindfulness practice invites the meditator to notice and accept this thought as an event occurring in the mind rather than as a truth that defmes the self. Thus mindfulness can alter one's attitude or relation to thoughts, such that they are less likely to influence subsequent feelings and behaviours. In contrast, CT involves the restructuring and disputation of cognitions and beliefs toward acquiring more functional ways of viewing the world. The dilemma is how to integrate 2 seemingly opposed therapy goals. In this paper, we present 2 innovative treatments that have independently met the challenge of integrating mindfulness with cognitive and behavioural therapy: MBCT (8) and DBT (2). MBCT integrates mindfulness meditation practices from Jon Kabat-Zinn's mindfulness-based stress-reduction program (9) with CT to help patients with a history of major depression reduce their risk of experiencing future depressive episodes. In contrast, mindfulness in DBT is one component of a multimodal treatment developed in the context of treating individuals with multiple disorders who are diagnosed with BPD. Mindfulness in DBT is a core skill that is taught as well as an attitude that informs the therapy relationship. In this article, we first describe the rationale for integrating mindfulness into these treatments. Second, we deseribe how this Abbreviations used in this article BPD

borderline personality disorder

CT

cognitive therapy

DBT

dialectical behaviour therapy

MBCT

mindfulness-based cognitive therapy

MBSR

mindfulness-based stress reduction

integration informs the theoretical underpinnings of each treatment and, in tum, treatment delivery itself Third, we discuss the implications for therapist training. Finally, we briefly review the empirical literature supporting these integrative approaches.

Mindfulness-Based Cognitive Therapy The impetus for developing MBCT came from a growing literature that suggests depression is best viewed as a chronic, lifelong, recurrent disorder. For example, patients who recover from an initial episode of depression have a 50% ehance of a second episode (10); for those with a history of 2 or more episodes, the relapse and (or) recurrence risk inereases to 70% to 80% (11). These data, along with the limitations of traditional approaches to preventing depressive relapse, highlighted the importance of developing novel approaches to the prophylaxis of depressive relapse and (or) recurrence. The theoretical foundation for the development of MBCT is based on a cognitive vulnerability model of depressive relapse. This model attempts to explain the increased risk of relapse and (or) recurrence with increased numbers of previous depressive episodes, since there is evidence that distinct processes are involved in the onset of the first depressive episode, compared with recurrent episodes (12). Whereas major life stressors are a stronger predietor of the first onset of depression than of reeurrent episodes, dysphoric mood and dysflinctional thinking styles are more highly correlated with a history of depressive episodes, and this correlation is a better predictor of recurrent episodes than of first episodes. These results lend support to John Teasdale's differential activation hypothesis (13) as a variable risk factor for depressive relapse (14). The differential activation hypothesis maintains that repeated associations between depressed mood and negative thinking pattems during episodes of depression lead to a higher likelihood of reactivation of dysfunctional thinking in subsequent dysphoric mood states. Therefore, less environmental stress is required to provoke relapse and (or) recurrence. Rather, the processes mediating relapse and (or) recurrence may become more autonomous with increasing experienee of depression (15). This model suggests that one can reduce relapse risk, first, by increasing one's awareness of negative thinking at times of potential relapse and (or) recurrence and, then, by responding in ways that allow one to uncouple from reactivated negative thought streams. Thus interventions designed to reduce the risk of relapse should lead to a change in the pattems of eognitive processing that beeome active in dysphoric states. It is not essential, or even desirable, that treatment should eliminate sadness. Instead, the aim should be to normalize thinking pattems in states of

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mild sadness so that these moods remain mild and do not escalate to more severe affective states. Teasdale and colleagues (15) developed MBGT to achieve these aims by integrating aspects of GT for depression (16,17) with components of MBSR (9). Training in mindfiilness offers practice in "turning toward" rather than "turning away from" potential difficulties. Participants are invited to cultivate an open and accepting orientation to facilitate the development of a decentred perspective on thoughts and feelings. This is done through meditations such as the body scan, mindful stretching, and mindfulness of breath-body-soundsthoughts, which teach core skills of concentration; mindfulness of thoughts, emotions, feelings, and bodily sensations; being present; decentreing; acceptance; letting go; "being" rather than "doing"; and bringing awareness to what is being experienced in the body. This leads to an "aware" mode of being characterized by freedom and choice, in contrast to a mode dominated by habitual, automatic thought patterns. Further, increased mindfulness may allow for the early detection of negative thinking patterns that lead to relapse, thus enabling preventive action. Besides cognitive restructuring techniques, GT offers interventions that can also facilitate decentreing and awareness of negative thought streams, as well as specific interventions designed to reduce depressive relapse risk. For example, there are GT exercises designed to demonstrate how thoughts change with one's mood; these exercises facilitate "decentred" views such as "thoughts are not facts." Additional techniques such as psychoeducation about depression-related thoughts and symptoms can facilitate earlier detection of these experiences, thereby increasing the chance of timely interventions like a previously created relapse-prevention plan.

Integrating mindfulness meditation into MBGT has important implications for therapist training. Kabat-Zinn and his colleagues stress the importance of developing a mindfulness practice before instructing others. Segal, Williams, and Teasdale confirm the wisdom of this advice (8). It is important for instructors to teach from their experience and to embody the attitudes that they invite participants to practise. For example, instructors demonstrate "being present" by paying attention to what is experienced in the group moment by moment rather than giving instructions for exercises that will happen later in the session. To facilitate being present in sessions, many MBGT instructors meditate as part of their preparation for each group session and maintain their own daily practice. Finally, empirical support exists for the efficacy of integrating mindfulness meditation with GT to reduce the risk of depressive relapse and (or) recurrence. MBGT has been shown to be efficacious in a recent multicentre, randomized clinical trial (4). In this study, individuals who had recovered from recurrent depression were randomized to receive MBGT or to a wait-list control condition. MBGT significantly reduced the risk of relapse for individuals with 3 or more previous episodes. More recently, these results were replicated in a single-site trial (18). Interestingly, in both studies, individuals with a history of only 2 depressive episodes did not benefit from MBGT. These individuals may represent a different population since they reported less childhood abuse and a later onset of the first depressive episode, compared with those with 3 or more episodes (18).

Dialectical Behaviour Therapy

Thus MBGT emphasizes changing the awareness of, and relation to, thoughts, rather than changing thought content. MBGT offers participants a different way of being with emotional pain and distress. The assumption is that cultivating a decentred relation to negative thinking provides one with the skills to prevent escalation of negative thinking at times of potential relapse.

Mindfulness and principles derived from Zen philosophy came to form an important part of DBT because of the perceived limitations of traditional cognitive and behavioural approaches for the treatment of BPD (2). Linehan recognized that a major shortcoming of these approaches was their heavy emphasis on change, which was experienced as invalidating by patients with BPD. To effectively engage these patients, more attention needed to be paid to nurturing the therapeutic relationship. Linehan modified traditional cognitive and behavioural treatment by placing a greater emphasis on validation and acceptance.

Typically, one instructor teaches MBGT skills in 8 weekly 2- to 3-hour group sessions. In each session, participants engage in various formal meditation practices designed to increase moment-by-moment nonjudgmental awareness of physical sensations, thoughts, and feelings. Daily homework includes practising these exercises along with exercises designed to integrate application of awareness skills into daily life. The creation of specific prevention strategies derived from traditional GT techniques is presented in the later stages ofthe 8-week program.

Linehan theorized that individuals with BPD are highly sensitive to change strategies because these interventions parallel invalidating experiences that prototypically characterize their developmental histories (2). A central tenet of Linehan's biosocial theory is that borderline pathology develops because of a transaction between pervasive invalidating environmental experiences and the individual's biological constitution. As a result of invalidating environmental experiences, individuals with BPD leam to inhibit their emotions, leading to deficits in awareness of the basic sensory motor cues

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associated with emotional experience. They develop deficits in their ability to acknowledge, accept, and trust their thoughts and feelings as accurate and legitimate responses to intemai and environmental events. People with BPD have also failed to leam how to tolerate distressing life experiences. In sum, people with BPD fail to internalize an attitude of self-acceptance. The implication of this thesis for treatment is that individuals with BPD need to leam to tolerate distressing life experiences and to leam self-acceptance. Major emotion theories maintain that the ability to discriminate emotional experience, including the ability to perceive and accurately label experience in consciousness, is a requisite to emotional regulation and behavioural control (19-21). Failure to symbolize emotions interferes with accessing information about needs and goal priorities that motivate the individual for adaptive action. Therefore, the acceptance of experience can help to ensure adaptive functioning and decrease the likelihood of impulsive behaviours such as suicide attempts or substance abuse. In DBT, acceptance and validation by the therapist, along with mindfulness skills, are used to enhance emotional regulation. DBT was designed for individuals with multiple disorders who exhibit extreme behavioural dysregulation. In the first stage of DBT, the primary aim is to reduce extreme behaviours and achieve balance by leaming to "walk the middle path." This notion draws upon the Buddhist concept that enlightenment is achieved by avoiding being caught and entangled in extremes (22)—an issue that is as relevant to therapists as it is to patients, since therapists are also vulnerable to intense reactions. In DBT, mindfulness meditation is both a skill to be developed and a set of principles underlying acceptance-based interventions. Validation is a core strategy in DBT, used to counteract the effects ofthe invalidating environment and to foster self-validation. DBT therapists search to validate or acknowledge the "wisdom" in patients' experience. This emphasis extends from the Buddhist principle of radical acceptance and the notion that everything is perfect as it is. Patients are encouraged to understand that all behaviours can be understood in terms of logical consequences. To illustrate, in response to a patient who describes cutting his or her wrist in order to avoid shameful feelings, a DBT therapist may communicate something like this: "It makes sense that you would want to relieve yourself from painful emotions, since most people don't like to experience painful feelings." DBT therapists model an attitude of acceptance toward oneself and life in general. The therapist's genuine acceptance is an essential element in treatment. As a core skill, mindfulness is taught within a broader curriculum of skills training (23). The training format consists of a

year-long program with weekly 2- to 2.5-hour classes of about 8 patients and 2 facilitators. Mindfulness skills make up the first of 4 skills modules and involve psychological and behavioural versions of meditative techniques for cultivating awareness and acceptanee. Patients leam how to recognize different states of mind along with methods for achieving mindfulness ("what" skills) and practising mindfulness ("how" skills). Instmction involves didactic and experiential leaming opportunities supplemented by weekly homework. In contrast to MBCT, which prescribes a formal meditation practice, DBT often relies on informal mindfulness practice such as mindfulness of everyday activities (23). This difference is based on the opinion that patients with BPD are less able to productively engage in lengthy sitting practice. Although DBT therapists are not required to have a formal meditation practice, Linehan strongly encourages it (24). The principles of mindfulness and Zen spirituality play an important role in therapist training. Working with patients with multiple disorders is often stressful for therapists. Training in acceptance practices can help therapists manage their reactions to patients. Several explicit agreements, infonned by Zen philosophy and mindfulness practice, guide the therapist consultation process. For example, DBT therapists agree to remain phenomenologieally empathic, to avoid judgment, to be mindful of personal limits, to aecept that others may have different limits, to accept each other's fallibility, and to accept the inherent capacity of their patients. Linehan asserts that failure to aecept the limits of others is typically the source of "staff splitting" (2). The DBT therapist consultation team meetings and patient skills groups routinely begin with a brief formal mindfulness practice to facilitate being present in the moment. Further, probably most DBT therapists would agree that a personal mindfulness praetice improves therapists' ability to use experiential knowledge to teach mindfulness skills. A growing body of literature substantiates the effectiveness of DBT. Eight randomized controlled trials that evaluate the overall effectiveness of a comprehensive DBT treatment have been published (25-32). No studies examined the specific components of DBT, such as the effect of mindfulness training. In 5 ofthe 8 studies, DBT was evaluated against a community treatment-as-usual control program. In another study, DBT was contrasted with an approach focused on comprehensive validation plus 12-step program participation (27). With the exception of one study, which evaluated the effects of antidepressant medication plus clinical management in an elderly population with depression, with or without DBT skills training and phone coaching (29), all study samples involved individuals diagnosed with BPD. These studies investigated a range of dependent variables. DBT was associated with significantly greater reductions in parasuicidal

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behaviour (25,32), self-mutilating and impulsive behaviours (30), suicidal ideation and suicidal urges (28), and substance abuse (26), as well as with better treatment retention (25,26,30). Additionally, there is some evidence that DBT is associated with change in secondary behavioural targets, including reduced anger and dissociation (28) and less maladaptive pleasing of others (29). In the study of DBT compared with comprehensive validation plus 12-step program participation, the results supported the efficacy of both treatments in reducing substance abuse for opioid-dependent women with BPD (27).

Discussion In both MBCT and DBT, mindfulness is integrated with cognitive and behavioural approaches to enhance the psychotherapeutic work. Perhaps the main contribution from these efforts is to broaden our understanding about how to bring about change. The rationale for emphasizing mindfulness in MBCT and DBT stems from a shared philosophy: the belief that acceptance of experience, including all of life's misery, has therapeutic benefit. Both MBCT and DBT embrace the Zen idea that freedom can be achieved through nonattachment to experience. This view is based on a commitment to the belief that awareness and acceptance of experience is a critical component of the change process. In Western society, change technologies are far more developed and relied on than are tools of acceptance. This may stem from the mistaken belief that the only way to help people change is to push them to do something different. The lesson to be learned is that embracing and cultivating an attitude of acceptance can influence the quality of the therapy relationship, patients' acceptance of self and others, and clinicians' acceptance of patients. In this way, acceptance strategies can lead to behavioural changes. Further, embracing an accepting attitude can help therapists dialogue openly about different clinical perspectives, can promote cooperation among clinicians, and can foster the development of novel treatment approaches. In our view, this openness to acceptance helps to facilitate the innovative integration of 2 seemingly contrasting approaches. MBCT and DBT emphasize the importance of therapists' developing a personal mindftilness meditation practice, in that experiential knowledge enhances their ability to help patients learn about mindfulness, to provide adequate explanations of the concepts, and to model an attitude of acceptance. Mindfiilness practice is also beneficial because it offers a method to help therapists develop awareness of their reactions toward patients. Although it is normal for therapists to experience strong emotions with patients at times, the failure to observe these reactions can compromise effective treatment. Feelings of frustration, burnout, overattachment, and desire to rescue patients can hinder treatment if they develop without Can J Psychiatry, Vol 50, No 13, November 2005

awareness. Increasing self-awareness through personal mindfulness practice can help therapists become more adept at observing their reactions and modifying them as needed. Further, personal mindfulness practice can help therapists respond to patients with a relational attitude of acceptance and nonjudgment. In MBCT and DBT, mindfulness interventions are specifically tailored to better serve the needs of 2 different clinical populations. In MBCT, greater emphasis is placed on developing a formal mindfulness practice than it is in DBT. This difference appears to stem from divergence in the perceived capacity or willingness of these 2 patient groups to be aware of and attend to present experience. Nevertheless, MBCT and DBT represent modified versions, or hybrids, of the more traditional mindfulness-based programs. Moreover, several investigators have provided theoretical rationales for using similarly structured treatments to treat other disorders, such as generalized anxiety disorder (7), substance abuse (33), eating disorders (34), and couple therapy (35). Interestingly, the growing numbers of cognitive and behaviourally oriented treatments that combine acceptancebased strategies vary in the methods used to teach mindfulness. Influenced perhaps by their rational roots, both MBCT and DBT succeed in translating esoteric ideas derived from Zen teachings about mindfulness into readily definable terms that are easily understood within the context of a Western framework. Further, these 2 treatments incorporate traditional meditation practices. In contrast, acceptance and commitment therapy attains similar goals without using traditional meditation practices, relying instead on various techniques such as "willingness and exposure exercises" (36). These methods offer the benefits of teaching similar skills without requiring patients to develop a fonnal meditation practice, making acceptance and commitment therapy a much less demanding treatment. Finally, despite growing empirical support for MBCT and DBT, important limitations to this research should be highlighted. First, as mentioned earlier, the study designs for both treatments did not permit attributing treatment outcomes to the mindfulness meditation components per se. Future research is required to determine the specific contribution of mindfulness meditation techniques to MBCT and DBT outcomes. For example, studies comparing the fliU treatment with a treatment without the mindfulness techniques might allow the contribution of the mindfulness component to be determined. In addition, MBCT could be compared with a support group to rule out the effect of nonspecific group factors. Moreover, there is no evidence that mindfulness meditation techniques increase one's ability to be mindful (37). Addressing these issues has valuable practical implications, especially for MBCT, given the demanding nature of the 867

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meditation practice included in this treatment. If meditation does not increase mindfulness or if mindfulness is not a significant therapeutic component, then it is difficult to justify including such a demanding practice. Recent efforts to operationally defme mindflilness (38) and develop mindfulness. self-report measures (39,40) will further facilitate the evaluation of the unique contribution of mindfulness meditation to enhancing mindfiilness and to the outcome of these integrated treatments. A second limitation is that the 2 studies supporting the efficacy of MBCT were conducted by the treatment developers, establishing it only as a possibly efficacious treatment. Other treatment providers need to conduct fliture studies to definitively establish MBCT as an efficacious treatment. Third, it is important to assess the degree to which the treatment providers maintain their own practice to guide treatment dissemination efforts, since many clinicians do not currently practise meditation. Fourth, the question of who benefits from mindfulness-based interventions needs to be addressed. This is particularly relevant for MBCT, where individuals with a history of 2 depressive episodes do not show the same reductions in relapse risk, compared with those with more tban 2 episodes. Finally, in all but one of the DBT studies, comparison treatments were minimal or no-treatment conditions. Comparisons of MBCT with continuation pharmacotherapy, and of DBT with altemative treatments, are currently underway.

Conclusion We have reviewed 2 efforts at integrating mindfulness meditation with cognitive and behavioural therapies, namely, MBCT and DBT, focusing in particular on the challenge of integrating acceptance versus change-based strategies. Initial outcome studies have demonstrated the efficacy of both approaches. Further studies are required to address current research limitations such as the lack of knowledge about the unique contribution of mindfulness meditation to the outcome of these integrated treatments. In addition, future research will determine the efficacy of similar integration efforts in treating other disorders, such as generalized anxiety disorder.

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Manuscript received November 2004, revised, and accepted May 2005. Presented in part at the 19th Annual Convention of The Society for the Exploration of Psychotherapy Integration; 2003 May; New York (NY). 'Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Deputy Head, Cognitive Behaviour Therapy Unit, Centre for Addiction and Mental Health, Toronto, Ontario. ^Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Head, Dialectical Behaviour Therapy Clinic, Centre for Addiction and Mental Health, Toronto, Ontario Address for correspondence: Dr MA Lau, Centre for Addiction and Mental Health, 250 College St, Toronto, ON M5T 1R8 e-mail: [email protected]

Resume : Integrer la meditation de l'attention aux therapies cognitivo-comportementales : le defi d'allier acceptation et strategies axees sur le changement Les innovations recentes des traitements psychologiques ont integre les techniques de meditation de l'attention avec les therapies cognitivo-comportementales classiques, mettant ainsi les therapeutes cognitivo-comportementaux classiques au defi d'integrer l'acceptation et les strategies axees sur le changement. Cet article decrit comment 2 traitements, la therapie cognitive fondee sur l'attention et la therapie comportementale dialectique ont releve ce defi. Nous examinons le fondement sous-jacent de l'integration des 2 traitements, la fa9on dont les traitements combinent les strategies de chaque modalite pour atteindre les objectifs de traitement, les implications sur la formation des therapeutes, et l'efficacite des traitements. En outre, nous presentons les defis que represente revaluation des avantages d'incorporer des strategies fondees sur l'acceptation. En somme, les deux therapies ont integre les approches de l'attention fondees sur l'acceptation avec les therapies cognitivo-comportementales axees sur le changement pour creer des traitements efficaces.

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