In yesterday's post I talked generally about the presentations at the BABCP spring conference.  Today I'd like to look more closely at what for me was the day's highlight - Willem Kuyken's talk on "Compassion in mindfulness-based cognitive therapy: therapist embodiment and client change".  One reason I liked the talk a lot was that it was a good example of how painstaking research gradually adds stepping stones of knowledge across the swamp of our ignorance.  There's so much to learn.  As Ralph Sockman put it "The larger the island of knowledge, the longer the shoreline of wonder".  And it's true.  The more I know, the more questions come up about what I realize I still don't know.

So Willem reported on a mediation analysis of the great study he and colleagues have already described in their 2008 paper "Mindfulness-based cognitive therapy to prevent relapse in recurrent depression".  Their new paper - which is still under review - is currently entitled "How Does Mindfulness-based Cognitive Therapy Work?".  Willem and his co-authors (including the fine, blast-from-the-past John Teasdale) explored if benefits produced by mindfulness-based cognitive therapy (MBCT) are mediated by increases in mindfulness and self-compassion.  They also studied MBCT's effects on "cognitive reactivity" - the way that subjects who are vulnerable to depressive relapse tend to react strongly to induction techniques deliberately inducing depressed moods (through listening to sad music while thinking about unhappy memories). 

This study of treatment mechanisms was embedded in their research trial comparing MBCT with maintenance antidepressants (mADM) in a group of 123 subjects who had suffered 3 or more previous depressive episodes and who were being successfully treated with medication.  These participants were randomized either to continue their antidepressants (mADM) or to attend a mindfulness-based cognitive therapy training group and stop their antidepressants (MBCT).  The two groups were then compared for depressive symptoms and for relapse/recurrence across 15 months follow-up.  The researchers found that, as predicted, MBCT's encouraging treatment effects were mediated through increases in mindfulness and self-compassion.  Interestingly MBCT also changed the relationship between post-treatment cognitive reactivity and depression outcome.  In the mADM group, as expected, subjects with greater cognitive reactivity to sad mood induction did worse in depression terms.  However MBCT seemed to reduce this connection - so even when a subject reacted quite strongly to the temporary sad mood induction, this did not result in an ongoing increased vulnerability to developing depression.  

So overall this research highlights at least three points.  One is that MBCT does produce many of its benefits in the way theory predicts - through helping subjects become more mindful and self-compassionate.  Secondly MBCT changed the relationship between post-treatment cognitive reactivity and depression outcome.  Thirdly there was evidence suggesting that it was particularly increases in self-compassion that nullified the toxic reactivity-outcome link.  This last point is consistent with emerging evidence that a compassionate stance, when faced with upsetting thoughts and feelings, is particularly adaptive.

Fascinating.  If you know what makes a treatment effective, then you can emphasise the most relevant components when you're teaching and possibly make the treatment even better.  So in the "Bus driver metaphor" we want to emphasise that we're learning to allow the racket from our "passenger thoughts & feelings" to simply be mostly irrelevant for us - and that we want to encourage increasing kindness in the way we view our "bus driver" predicament!  

Ruth Baer et al reported linked results in their 2006 paper "Using self-report assessment methods to explore facets of mindfulness".  They wrote: "The authors examine the facet structure of mindfulness using five recently developed mindfulness questionnaires. Two large samples of undergraduate students completed mindfulness questionnaires and measures of other constructs. Psychometric properties of the mindfulness questionnaires were examined, including internal consistency and convergent and discriminant relationships with other variables. Factor analyses of the combined pool of items from the mindfulness questionnaires suggested that collectively they contain five clear, interpretable facets of mindfulness. Hierarchical confirmatory factor analyses suggested that at least four of the identified factors are components of an overall mindfulness construct and that the factor structure of mindfulness may vary with meditation experience. Mindfulness facets were shown to be differentially correlated in expected ways with several other constructs and to have incremental validity in the prediction of psychological symptoms. Findings suggest that conceptualizing mindfulness as a multifaceted construct is helpful in understanding its components and its relationships with other variables."  Three of the four facets (actaware, nonjudge, nonreact) were significant predictors, showing that each accounts for a significant portion of the variance not accounted for by the others. That is, it appears that these three facets have incremental validity over the others in the prediction of symptom level." 

See too the Five Facet and Three Facet Mindfulness Questionnaires developed from this research that I give half way down the "Compassion & criticism" webpage.  And as I point out in the Three Facet Questionnaire notes (commenting on Ruth's paper):  "Research involving 881 subjects demonstrated that of the five mindfulness facets - Non react, Observe, Act aware, Describe and Non judge - the strongest association with reduced psychological distress was demonstrated by the facet Non judging of one's inner thoughts and feelings.  Also of importance for less distress were the further two facets of Acting with awareness rather than being frequently distracted or on ‘automatic pilot', and Non reacting to distressing thoughts, images and emotions so that one notes them and lets them go without having strong or prolonged reactions to them.  It seems very likely that one can learn to Non judge better in a series of ways including a better understanding of the why & how of emotions and thoughts (evolutionary survival value in hunter-gatherer environments, genetic temperament, understandable but now-outdated patterns developed in response to earlier life situations, mistakenly taking short-term avoidance ‘rewards' at high longer-term life ‘costs', etc), realizing how common these experiences are (deeper knowledge, more open honest sharing with others, etc), challenging the judgments one typically makes (discussion, behavioural experiments, two chair dialogue, etc), acceptance from others (accepting intimate relationships, group work, therapeutic relationship, etc), as well as through practices like mindfulness meditation."

It reminds me of something I read a while ago written by Saki Santorelli, director of the University of Massachusetts Center for Mindfulness originally founded by Jon Kabat-Zinn.  In his marvellous book "Heal thy self: lessons on mindfulness in medicine", there is a chapter entitled "Quiet mind, open heart" which starts with a quote from Hazrat Inayat Khan "The mind is the surface of the heart, the heart the depth of the mind".  Saki writes "Sometimes people confuse ‘mind' in the word ‘mindfulness' as having something to do with thinking about or confining attention to cognition, imagining that we are being asked to engage in some form of introspection, discursive self-analysis, or mental gymnastics.  Simply put, mindfulness is bringing a fullness of attention to whatever is occurring, and attention is not the same as thinking.  As expressed in the quotation by the Sufi teacher Inayat Khan, the language of many contemplative traditions suggests that the words for 'mind' and 'heart' are not different.  Likewise, the artist and calligrapher Kazuaki Tanahashi describes the Japanese character for 'mindfulness' as composed of two interactive figures.  One represents mind, the other, heart.  Heart and mind are not imagined as separate.  From this perspective Tanahashi translates mindfulness as 'bringing the heart-mind to this moment'".

Good ... mindfulness ... quiet mind, open heart ... 

And for more on compassion, see the post later this week on "A better way to measure self-compassion".