What to Expect from Mindfulness-based Cognitive-Behavioral Therapy (MCBT) When You Have Depression and Anxietyby Monica A. Frank, Ph.D.
When practicing the techniques described by Excel At Life, people want to know when they should feel better. This is a difficult question to answer because it requires an assessment of each situation which is why it is best to practice these techniques under the guidance of a MCBT therapist. However, in this article I will discuss what to expect and how to assess your practice.
1) Cognitive Therapy. First, CBT is a type of treatment that focuses on how you think (cognitive) by examining the accuracy of your thoughts about yourself, others, and the problems you face. Then, when thoughts are found to be an inaccurate appraisal, cognitive therapy helps to change these thoughts by developing a more accurate (or rational) way to think or approach the situation. Once a believable rational has been developed, the idea is to frequently express this new thought to create the new pathway (connections) in the brain.
2) Behavioral Therapy. CBT uses a variety of techniques to help change a person's behavior. These methods can include goal-setting, communication training, relaxation and biofeedback, behavior modification, and exposure methods as well as many others. The commonality of these methods is they are meant to affect the behavior.
3) Mindfulness. Although a technique that has often been included under the behavioral methods of CBT, mindfulness has taken a more prominent role due to its influence upon the other methods and its overall impact in the therapy. Mindfulness is an approach that is present-focused and teaches to refocus when engaged in the depressive or anxious thoughts.
4) Mindfulness-Based Cognitive-Behavioral Therapy. CBT has a history of bringing under its umbrella any techniques that have been shown to be effective. Since cognitive therapy, behavioral therapy, and mindfulness have all been shown to be effective, they have been combined into MCBT. So MCBT isn't a new therapy, nor is it necessarily one specific treatment used for all similar cases, but it is the use of a variety of methods that are chosen based upon each individual's problem. Thus, MCBT may look very different for each client because it is specifically designed for each person and problem.
If you examine most self-help books you can see the influence of CBT running through them. Similarly, many specific therapies for certain types of problems are often just a set of methods chosen from CBT to address a certain problem. For example, when I have had discussions with DBT (Dialectical Behavioral Therapy) practitioners, I haven't been able to determine the difference between that therapy and MCBT except that DBT spells out certain specific techniques to use for treating trauma. Also, EMDR (eye movement desensitization and reprocessing) uses the CBT methods while adding in the eye movement component but has not been shown to be any more effective than CBT alone (Seidler and Wagner, 2006). I'm not saying that these methods aren't effective. I'm just saying that I would tend to categorize them under the umbrella of MCBT. Some people may swear by the differences they have experienced from these various therapies but I suspect it may be due to individual preference or a difference in the therapists seen by the individual (see my article: Does CBT Lack Compassion? It Depends Upon the Therapist).
Too often, the expectations people have regarding treatment may be unrealistic. Understanding what can be expected from treatment can be helpful when assessing the effectiveness of treatment. Generally, the purpose of treatment is to reduce the symptoms to a level where they are manageable and don't interfere with an individual's quality of life. The degree to which this may occur is based upon several considerations:
1) Illness or life problem. Expectations regarding the outcome of MCBT may need to be adjusted based upon whether the anxiety and depression is due to a life problem or due to a mental illness. Certainly, outcomes can be very high for life problems when people are already relatively healthy but need some guidance regarding a specific problem. Although MCBT is effective for mental illness, several caveats need to be considered in terms of expectations: specifically, the concept of cure versus control, degree of effectiveness, and presence of trauma.
2) Cure vs. control. Unfortunately, at this time there is not a cure for these mental illnesses. Some people, based upon their experience, may disagree: “I take anti-depressants and I'm doing well, now.” However, to understand this concept, it is necessary to define what is the difference between cure and control.
A simple way of understanding this is that if a person takes a medication for a certain period of time, gets symptom relief, and then, no longer requires medication, that person would be considered cured. Otherwise, if ongoing medication is required for symptom relief, that would be considered control. For example, someone with diabetes who takes medications and as a result has normal blood sugar would be considered to have controlled diabetes but is not cured because medication is required for ongoing control.
Similarly, with MCBT, even though a person may not require ongoing therapy, the person needs to continue using the methods to keep control over the mental illness. Frequently, I have seen that when clients return to therapy after having been successful with previous treatment, it is due to no longer using the methods that had helped them control the symptoms.
3) Degree of effectiveness. Although MCBT is effective, most research shows that it helps about 70-80% of people. What this means is that 20-30% may not experience symptom relief from MCBT. Sometimes this is due to inadequate training and follow-through with the methods. Other times it may be due to the degree of severity. The more serious the mental illness, the more likely a person may be in the group that is not helped. The same thing is true of medications. Although medications are helpful for about 60-70% of people, the more severe the disorder, the less likely medication will provide symptom relief. Therefore, it is important for those with severe depression to use the combination of medication and MCBT to effectively control the symptoms.
4) Trauma. MCBT may need to be adjusted when a person is experiencing depression and anxiety due to having experienced trauma. Trauma-focused MCBT needs to be conducted by a therapist with expertise in these methods. Otherwise, due to the intensity of some of these methods, symptoms could worsen rather than improve.
Once you have an understanding of what to expect from your efforts with MCBT, then you can assess whether you are using the best methods, the quality and intensity of your practice, and whether you are engaging in the methods correctly. Again, it is best to have someone with expertise who can help you in this assessment.
1) Quality of practice. The effectiveness of MCBT is directly dependent upon implementing the techniques correctly. Although the techniques often seem simple and direct, it is necessary to fully understand the methods, the purpose, and which are best to achieve desired goals. Quality of practice refers to how well this is attained.
In a recent PsychNote, I shared a list of ways to know if you are engaging in quality practice of mindfulness: “1) Mindfulness is not about “zoning out” or falling asleep. Mindfulness is being aware. 2) Mindfulness does not avoid certain thoughts, emotions, or sensations. 3) Mindfulness isn't an attempt to feel only pleasant emotions or experiences but to be fully open to all experiences. 4) Mindfulness is returning focus to the present-moment experience, whatever it may be, pleasant, unpleasant, or neutral. 5) Mindfulness is allowing yourself to return your attention to difficult experiences with a sense that it is “okay” to experience the emotion or sensation. 6) Mindfulness is a focus on the pure experience of the present moment without distracting thoughts. 7) Mindfulness does not try to push away thoughts or feelings but allows them to “be” while gently refocusing back to the present moment.”
Another quality of practice issue regards the implementation of the cognitive techniques. Are you routinely processing your emotions using a method such as the Cognitive Diary whenever you are feeling distressed? Are you able to recognize how the thinking is irrational? If not, do you obtain someone else's opinion? If you don't have access to a therapist, do you consult with someone who has a rational outlook on life?
Recognizing irrational thinking is an area that can be very difficult without fully understanding the cognitive therapy concepts and definitions for the different irrational thinking styles. Since the individual with irrational or inaccurate thinking often does not believe the thinking is inaccurate, input from someone else can be very helpful.
Finally, the more intense methods of MCBT should NOT be undertaken without a full understanding of the methods and proper guidance. For example, I have seen situations where a family may think that by exposing a person with Obsessive-Compulsive Disorder (OCD) to their fears they are helping, yet such an intense method as exposure treatment without proper preparation and plan may actually cause a worsening of symptoms.
2) Frequency/length of practice. When I worked in hospital-based or day treatment programs, the clients were actively working on the methods hours a day over typically a couple month period. In addition, immediate therapeutic assistance was available. Therefore, the programs were fairly effective even with serious disorders (still not in all cases, though). It is unlikely that an outpatient program approaches this level of intensity. What to keep in mind, however, is that the more intense the treatment, the more quickly it is likely to work. If your practice is somewhat infrequent, it is likely to take much longer to experience change. I typically recommend that clients engage in their treatment assignments a couple hours a day if they want to see change more quickly. Although I rarely see this level of commitment, even less intense efforts often will eventually show some result.
3) Lifestyle change. One of the main ways to assess your efforts is to determine how much you are creating lifestyle changes. For instance, is your rational thinking becoming a more automatic approach to addressing problems? Is your mindfulness practice becoming an attitude, a way of focusing even when you are not practicing? How would you rate your degree of mindfulness throughout your day? The more that you have developed healthy automatic thoughts, behavior, and lifestyle practices, the more likely you will experience long-term symptom relief.
1) Obtain education. If you assess your MCBT practice and believe that your quality of practice could be improved, the first step is to obtain further education. Plenty of education materials are available so read books or take online classes that teach the MCBT materials.
2) Obtain another perspective. You may need someone else to assess what is needed in your practice. If you have been seeing a therapist, sometimes it is helpful for you and your therapist to obtain a consultation from another therapist with expertise in your problem. A fresh perspective can sometimes provide more effective direction.
3) Assess medication. Most people are aware to assess the effectiveness of medication and whether another medication may be more appropriate. However, an issue that is often not addressed is that medication can sometimes make a problem worse. For example, the benzodiazapines (Xanax, Valium, etc.) often used for anxiety disorders can have rebound effects when they are used long-term resulting in increased anxiety. I have seen a number of clients who improved when they reduced their dependence upon these medications. However, do not stop medications without your physician's guidance.
Seider, G.H. and Wagner, F.E. (2006). Comparing the Efficacy of EMDR and Trauma-focused Cognitive-Behavioral Therapy in the Treatment of PTSD: A Meta-analytic Study. Psychological Medicine, 36, 1515-1522. Doi: 10.1017/S0033291706007963