The MBCT intervention used to treat Jean followed the manual developed by Segal et al. (Segal, Williams, & Teasdale, 2002
) with specific modifications for TRD, which aimed to promote enhanced emotional regulation through increasing nonjudgmental awareness of emotional experience in the present moment and to build skills in decentering from thoughts and feelings, enhancing acceptance, and decreasing experiential avoidance. Modifications to the MBCT manual were necessary because the original version was designed for individuals in remission with a focus on relapse prevention. Our population consisted of actively depressed individuals, thus the following adaptations focus on current depressive symptoms specifically. For example, phrases like “when you become depressed”, were replaced with: “notice what the experience of depression is like for you right now”. In addition, we added several exercises and metaphors commonly used in Acceptance and Commitment Therapy (Luoma, 2007
; Zettle, 2007
) to help patients relate mindfully to their current experience.
In the first group, psychoeducation about the natural course of depression and relapse prevention in the context of acceptance was discussed. Data from published studies, including graphs and illustrations of depression as a chronic disease with relapses over the lifespan were presented (Greden, 2001
) This information helped to diminish guilt about persistent symptoms and recurrent exacerbations while at the same time highlighting the importance of developing effective treatment and prevention strategies.
Also in the first group, the Chinese woven finger trap (Hayes, 1999
) exercise was introduced. Participants quickly learn that trying to pull one’s fingers out of the woven trap, only produces a snugger ensnarement. The counterintuitive solution is to stop trying to pull one’s fingers out and gently move them closer together first. Getting “in close” is also a way of reducing the struggle against depression. This exercise was used as a metaphor for how acceptance and relinquishing the struggle to escape may set the path for recovery. Acceptance (e.g. stop attempting to try pull out of the trap) was contrasted with resignation. It involves seeing things as they are so an action can be skillfully chosen, not as a result of the impulse to override, or struggle to get out of the trap, in this case depression. Jean began to understand that trying to escape her depression might not be the only approach she had to take in response to it and that in fact, that tactic might be counterproductive.
In the second group session, Jean was presented with the following equation: SUFFERING=RESISTANCE X PAIN (e.g. physical pain or emotional pain like depression) (Young, 2004
). Several examples were used to illustrate this equation. If an individual has difficulty falling asleep and tries to resist that difficulty by forcing themselves to get to sleep, he or she is rarely successful. On the other hand, accepting that one is not going to get much sleep on a particular night (i.e. lowering the psychological resistance to not being able to fall asleep) may counter-intuitively allow a person to fall asleep more rapidly, or at the very least can help reduce the additional suffering that is the natural byproduct of resisting the present moment experience.
Applying this concept to depression, the MBCT group discussion elaborated that trying to avoid feeling depressed actually may contribute to the suffering of depression. Avoidance attempts may feel like they help in the short term, but not only do they fail to fix the problem long-term, they can actually make depression worse (Zettle, 2007
; Zettle, 2002
). Through attempts to avoid her depression, Jean buried herself in work and began to isolate herself socially, even from her family. Through MBCT exercises aimed at describing pleasant experiences, she realized she had cut herself off from things that had added pleasure to her life and began to reverse this.
Through observation of body sensations and thoughts associated with depression, Jean became more aware and mindful of both the positive and negative experiences linked to her depression. For example, noticing when she began to feel more depressed, helped Jean to activate an inventory of how she had been handling some of the interpersonal interactions in her life; this in turn put her in a position to alter those situations she felt dissatisfied with rather than being unaware of what had influenced her moods.
In the third MBCT group, a metaphor was introduced that many TRD patients have found very helpful. Winston Churchill talked about his depressive states as the “black dog” (Johnstone, 2006
), and a depressed day as one in which “the black dog has returned”. This metaphor was presented in the context of an individual’s reaction to depression. There are a range of possible reactions to a large black dog, from terror to curiosity. The discussion of this metaphor invites patients to conceptualize their depression as something that they can react to in a number of different ways. This was particularly salient for Jean who began to shift her relationship to her depression, entertaining the idea that like a big black dog, depressive symptoms could be a signal about something in her life and not just a terrifying entity. In her case, Jean realized the black dog could be a signal that something was not working in her life and saw the relevancy to her relationship with her supervisor at work. She even had moments of seeing her depression not just as the enemy, but as something she could live with, and not just cower in the face of or live in fear of it returning.
Another modification made to MBCT was an exercise aimed at underscoring the mindfulness concepts of acceptance by talking about it in terms of allowing
or letting it be
. Jean was asked to write down something she believed had to change before she could move on with her life. She chose to change her depression. She believed that she could never lead a fulfilling life or really enjoy her life if she didn’t first get rid of her depression. Jean wrote this down on a card and put it in her pocket while the ‘donkey standoff’ metaphor was presented (Luoma, 2007
). The harder one pulls on a donkey by the lead rope, the more it resists. The way to get a donkey to move is to actually move along side it and look in the direction you want to go. When this was applied to Jean’s depression, she began to see, in an experiential way, that having a full and meaningful life is not about getting rid of her depression, but rather coming alongside of it and moving with it rather than resisting and fighting it. In that way, she began to see that she could actually live her life and have depression at the same time, instead of putting her life on hold until the depression was resolved. Jean realized that despite her depression she could continue to function in her roles in her family and at work, albeit without her usual efficiency. She began to see that her functioning was not the completely negative view she originally had. She even began to assert herself in interactions with her boss, despite continuing depression, which in turn, diminished her sense of helplessness.
An important effect of MBCT for Jean was to start to see her thoughts as thoughts, and not facts. A standard MBCT exercise that resonated with her was to do a short sitting meditation focused on the breath, in which she could start to see her thoughts as they were occurring. In a modification done in the group, Jean was instructed to ask herself, “What is Jean thinking?” every few minutes. Part of what she realized through this exercise was that she could actually observe her thoughts, getting to the place where she was having thoughts rather than being what they were telling her.
Another modification was introduced towards the end of Jean’s group treatment aimed at helping her change her relationship to depression. In a group activity, self-care was discussed through the “Frankenstein exercise” which was originally observed in a mindfulness-based stress reduction class. The exercise was previewed prior to the exercise with a comment that the exercise might raise a variety of feelings that we would be discussing immediately after. In the group, Jean was paired with another group member. She took on the role of ‘victim’ and her partner assumed the role of ‘monster’. Then they reversed roles. The ‘Frankenstein monster’, as many group members spontaneously voiced could represent depression coming towards them in a hreatening way. As the ‘victim’, Jean had several options. She could freeze and cower in front of the attack, she could try to sidestep it, or she could approach the monster, hold its arm and lead it in the direction she wanted to go. Each of these possibilities was acted out by the pairs of “monsters” and “victims”. These enactments were discussed as metaphors for alternative ways to approach a difficult situation or experience and highlighted the way a mindful stance doesn't change the monster, but can make it less overwhelming and scary. The mindful, assertive response (holding the arm and leading it) allowed Jean to start to take back control of her life without necessarily needing to change or fight the depression in order for some sense of control to return. Jean then began to see that she could start trying to do more of the previously enjoyable things in her life that she had avoided despite remaining depressed. She did not have to wait for the depression to vanish before she could resume her life. This was particularly evident in her becoming increasingly more active in physical activities with her family.
The last modification to MBCT that was helpful to Jean was a discussion of expectations, and their relationship to depression and self esteem. Helping individuals with active depression set expectations at realistic levels is often critical to maintaining self-esteem. These individuals often set unrealistically high expectations and then feel critical of themselves for not achieving them. We used the following equation as a simple way of viewing the relationship between self esteem, achievement, and expectations:
Adjusting expectation levels to realistic levels is much more rapidly accomplished than by increasing achievement levels. In depression, expectations are often set so high, that no matter what is achieved, an individual does not feel good. Helping Jean understand reasonable expectations for herself (a marriage, children, and a successful career) helped her begin to feel better about herself. Accepting the expectation that she might have future episodes of depression did not mean she would have to dampen her view of herself as a competent and adequate person.