Mindfulness-Based Cognitive Therapy 1
Mindfulness-Based Cognitive Therapy: Past, Present & Future
Mark A. Lau 1,2 & Amanda R. Yu 1
Abstract
This paper provides an overview of the past, present and future of Mindfulnessbased Cognitive Therapy (MBCT), a relatively new psychosocial group based intervention which integrates mindfulness meditation and cognitive therapy techniques.
MBCT was specifically developed to reduce the risk of relapse or recurrence of Major
Depressive Disorder. The short history of MBCT includes a description of the theoretical rationale underlying the development of MBCT and the empirical support of its efficacy in reducing depressive relapse risk for individuals with three or more previous episodes. Currently, there is accumulating evidence from MBCT outcome research supporting the efficacy of MBCT in reducing depressive symptomatology as well. Future foci of MBCT related work will include dissemination related issues such as determining the underlying mechanisms of action of MBCT, the contribution of teacher training to MBCT outcomes and the development and evaluation of treatment delivery models in addition to group.
Key words: Mindfulness-based Cognitive Therapy, meditation, depression, relapse prevention

Mindfulness-Based Cognitive Therapy 2
When we take the time to bring awareness to where our mind is focussed in a given moment, it is not uncommon to find that it has wandered from the task at hand to past or future events. As will be discussed in more detail later in this article, where one’s mind wanders to is strongly associated with how one subsequently thinks, feels and behaves (e.g., Beck et al., 1979) and is implicated as a risk factor for relapse in individuals at-risk for depression. However, as William James wrote over 100 years ago, it is difficult to define practical instructions for “…voluntarily bringing back a wandering attention, over and over again…” (James, 1890, p. 401). Yet, this is precisely the challenge faced by Segal, Williams, & Teasdale (2002) in developing a new psychosocial intervention to prevent depressive relapse. Specifically, they were looking for a way to educate atrisk individuals to voluntarily bring back a ‘wandering attention’ from ruminative thought patterns implicated in depressive relapse. Their solution to this problem led to the development of Mindfulness-based Cognitive Therapy
(MBCT) to reduce the risk of depressive relapse.
Past
The World Health Organization has established that unipolar depression represents the fourth greatest burden of illness and projects that by 2020 it will be second only to ischemic heart disease as the greatest burden of ill health worldwide
(Murray & Lopez, 1997). The projected increase in the burden of Major Depressive
Disorder (MDD) can be attributed, in part, to the fact that MDD is a chronic illness with a significant risk for relapse and/or recurrence (Berti Ceroni et al.
, 1984; Judd, 1997;
Keller et al.
, 1983). For example, for those who have recovered from an initial episode of MDD there is a 50% chance they will experience a second episode and for those with a history of two or more episodes the risk of relapse increases to 70-80%. These statistics support the development of a more comprehensive approach to the management of MDD to include not only treatment of the acute episode but also a focus on prevention and a better understanding of the risk factors contributing to relapse/recurrence.

Mindfulness-Based Cognitive Therapy 3
While antidepressant medication is the mainstay approach to prevent depressive relapse, many individuals experience side effects, low adherence rates and, in particular, many prefer psychosocial interventions (Cooper et al.
, 2007). Clearly, there is a need for psychosocial interventions as an alternative to pharmacotherapy to prevent depressive relapse. In fact, over the past twenty years, there has been a growing interest in developing such psychosocial interventions. In particular, interest in developing a maintenance version of cognitive therapy began in the early 1990’s. This interest was prompted by the seminal work of Frank and colleagues (1990) who first demonstrated that a maintenance version of Interpersonal Therapy was effective in preventing depressive relapse. The interest in developing a maintenance version of cognitive therapy also stemmed from several studies demonstrating that using cognitive therapy to treat acute MDD could reduce subsequent relapse rates by about 50% compared to discontinuation pharmacotherapy (Blackburn, Eunson, & Bishop, 1986;
Evans et al ., 1992; Shea et al ., 1992; Simons, Murphy, Levine, & Wetzel, 1986).
Based on these findings, Zindel Segal, and subsequently John Teasdale and
Mark Williams, initially intended to develop a maintenance version of CT. However, because acute cognitive therapy had been demonstrated to reduce relapse rates so effectively, they were pessimistic that a maintenance version would provide significant improvement over and above the reduction in relapse rates provided by acute cognitive therapy. In addition, they viewed increasing the demand for cognitive therapists, which were already in short supply, as a potentially limited solution to the growing problem of depressive relapse. Thus, rather than adapting cognitive therapy to develop a maintenance version, the team chose to develop a novel maintenance therapy guided by answering two central questions: (1) what are the psychological mechanisms underlying cognitive vulnerability to relapse? And (2) how might cognitive therapy reduce depressive relapse/recurrence?
Cognitive vulnerability model of depressive relapse
Cognitive models of depression, which emphasize the role of negative thinking patterns in the development and maintenance of MDD ( e.g.
, Beck, 1967; Beck et al .,
1979; Nolen-Hoeksema, 1991), have led to a theoretical model of mood-dependent

Mindfulness-Based Cognitive Therapy 4 processing designed to explain vulnerability to onset, relapse and recurrence in depression (Ingram, 1984; Teasdale & Barnard, 1993). Briefly, this theoretical model, the differential activation hypothesis (DAH) , holds that “vulnerability to severe and persistent depression is powerfully related to differences in patterns of thinking that are activated in the depressed state
” (Teasdale, 1988; p. 251). In other words, the interpretation of an individual’s experience in particular negative ways contributes to the maintenance or exacerbation of depressive symptoms . The DAH also assumes that during early episodes of depression, an association between negative thinking patterns and depressed mood are established (Teasdale & Barnard, 1993; Segal, Williams,
Teasdale, & Gemar, 1996) such that subsequent depressed mood, however caused, will re-activate the negative thinking patterns. In addition, depressed mood is hypothesized to activate negative biases in information processing (Gotlib & Macleod,
1997; J.M.G. Williams et al.
, 1997) which further contribute to negative interpretations of experience by influencing the information attended to, either external or from memory.
In summary, depressed mood and cognitive processing incrementally interact in a way that increases the chances that mild dysphoric states are amplified through further ruminative processing, eventuating in a downward spiral of depression (Nolen-
Hoeksema, 1991; Teasdale, 1983, 1988).
In addition to differential activation of thought patterns there appears to be a difference in the way those vulnerable to depressive relapse deal with their depressive mood states. Individuals with ruminative response styles tend to focus their attention on their depressive experience attempting to solve their mood by analysing it which serves to intensify the depressed mood and thereby prolong their experience of depression.
On the other hand, for those who respond to their low mood by distracting themselves, depressed feelings tend to be short-lived. (Lyubomirsky & Nolen-Hoeksema, 1995;
Nolen-Hoeksema, 1991; Nolen-Hoeksema & Morrow, 1991).
Taken together, this suggests a cognitive vulnerability model for depressive relapse risk where ingrained depressive thinking patterns and negative self schemas are activated automatically whenever an individual experiences a lower mood. In addition, individuals at risk tend to ruminate on their depressive thoughts further amplifying the situation turning mild, fleeting mood states into severe depressed states.

Mindfulness-Based Cognitive Therapy 5
Thus, relapse risk may be reduced by raising one’s awareness of mood-activated negative thinking and changing one’s response style in such a way that facilitates an
‘unhooking’ or ‘decentering’ from the depressive thoughts. In short, the goal of a relapse prevention treatment should be to normalize the thinking patterns of at-risk individuals so that transient sad moods do not spiral out into a depressive episode.
How cognitive therapy reduces depressive relapse/recurrence
To develop depressive relapse prevention treatment, Segal et al. also had to understand the mechanisms underlying the effectiveness of cognitive therapy as an acute treatment in reducing subsequent relapse risk. At the time they were working on this project, the consensus was that cognitive therapy reduced relapse risk by teaching individuals new skills to modify the content of depressive thinking. However, an alternative explanation was that cognitive therapy taught an individual skills to
“decenter” or “distance” themselves from their negative thoughts thereby facilitating a change in one’s relationship to negative thoughts such that they are viewed simply as events in the mind rather than being viewed as reflections of reality. Many had viewed
“decentering” simply as a by-product of thought content change but others including
Segal, Teasdale & Williams had suggested that it was the essential mechanism underlying the prophylactic properties of cognitive therapy.
This fundamental shift in the importance of ‘decentering’ as a skill in preventing depressive relapse led Segal and colleagues to consider methods other than cognitive therapy to teach individuals to decenter from their depressing beliefs and opinions.
Mindfulness-based Stress Reduction (MBSR), developed by John Kabat-Zinn (1990), was ultimately the approach they selected. MBSR was originally designed to improve the quality of life of individuals suffering from intractable chronic pain by facilitating their ability, in part, to decenter from their thoughts and feelings. Mindfulness, defined as a non-judgemental, present-centered awareness, is a meditative practice where thoughts, feelings and sensations that occur within one’s attention field are acknowledged and accepted as they are. Instead of ruminating about one’s experiences and focussing on the source and consequence of those experiences, mindfulness involves observing thoughts and emotions directly in a non-judgemental way. It is referred to as a

Mindfulness-Based Cognitive Therapy 6 metacognitive state involving non-elaborative attention to internal experiences of physical sensations, emotions and thoughts. It also is seen as a strategy for selfregulation, detaching one from thinking modes that serve to heighten stress or perpetuate psychopathology. Teasdale et al . (1995) evaluated the benefits of mindfulness training and concluded that it could foster the ability to decenter or unhook from ruminative, depressive thinking induced by sad mood states in the service of preventing depressive relapse.
Segal et al . (2002) subsequently developed a group-based intervention integrating mindfulness meditation training, derived from the MBSR program, with the elements of cognitive therapy thought to reduce relapse risk. Specifically, their goal was to offer at-risk individuals a series of mindfulness and cognitive therapy exercises to help them develop a non-judgmental awareness of their present moment experience
(i.e., mindfulness) to facilitate their detection of depression related thinking patterns and, to develop more flexible, deliberate responses at times of potential relapse. In this way, an at-risk individual experiencing dysphoric mood would avoid a potential relapse as they would be less likely to be influenced by mood-activated depressive thinking posited to contribute to a downward spiral of depression. The resultant MBCT program is now briefly described.
What is MBCT?
MBCT is a novel psychosocial intervention originally developed to help individuals who have recovered from depression to stay well. MBCT, as used in the first two research outcome trials (Ma & Teasdale, 2004; Teasdale et al ., 2000), was originally offered to groups with up to 12 recovered depressed patients in eight-weekly two hour sessions followed by four booster sessions over a one year follow-up period.
Since these two trials, however, MBCT has undergone a few minor modifications. First, group size has increased to as high as 15 individuals per group, both in clinical and research settings. Second, in clinical settings where there are no research related constraints, session length typically ranges from 2-2.5 hours. Third, instead of four follow-up sessions, a full weekend meditation day is offered around session six of the program where graduates of previous MBCT programs are also invited to attend.

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As described earlier, MBCT integrates mindfulness meditation exercises from
MBSR with traditional cognitive therapy techniques (Beck et al ., 1979). MBSR meditation exercises used in MBCT include the body scan, mindful stretching, mindful walking and mindfulness of breath/body/sounds/thoughts. Cognitive therapy techniques include psychoeducation about depression symptoms and automatic thoughts; exercises designed to demonstrate how the nature of one’s thoughts change with one’s mood; questioning of automatic thoughts; and creating a relapse prevention plan.
Unique to MBCT is the three-minute breathing space which Segal et al . (2002) designed to facilitate mindful awareness in everyday upsetting situations.
The first of the eight MBCT sessions begins with a brief discussion of the purpose of the group and the group rules (e.g., confidentiality), and participant introductions. Then group members participate in an introduction to meditation via eating a raisin mindfully followed by doing the body scan, a short breathing meditation and the opportunity to discuss one’s experience of these meditations. The seven remaining MBCT sessions follow a slightly different structure. Sessions begin with a 30-
40 minute meditation (e.g., body scan) to help group members transition from a mode of doing to a mode of non-doing, of simply being present in the moment. The MBCT teacher then guides the participants in a discussion of their experiences of the justcompleted meditation as well as the homework from the previous week. This discussion, known as the ‘inquiry’ is designed to facilitate participants’ growing awareness of their present moment experience. New concepts or techniques are then introduced by having participants learn from experiential exercises whether they are meditations or cognitive therapy exercises. Finally, the session closes with the assignment of between session exercises where the participants are asked to practice approximately one hour of formal and informal daily meditation directed at integrating mindful awareness into everyday life.
Broadly speaking, the course can be divided into two parts. The first half of the course is devoted, in large part, to developing participants’ non-judgmental awareness of their moment-by-moment experience through various meditation and cognitive therapy exercises. The second half of the course is designed to teach more flexible,

Mindfulness-Based Cognitive Therapy 8 conscious responses at times of potential relapse including practicing acceptance, choosing how to respond to thoughts and/or taking pre-planned action.
Empirical Support
A recent systematic review of the MBCT outcome literature concluded that MBCT has an additive benefit to usual care for individuals with three or more previous depressive episodes (Coelho et al ., 2007). This review was based in large part on two randomized controlled trials of MBCT versus a wait-list control, the first of which was a multicentre trial (Teasdale et al ., 2000) followed by a single site replication (Ma &
Teasdale, 2004). MBCT is now recommended by the United Kingdom’s National
Institute for Clinical Excellence (NICE) Clinical Practice Guidelines for Depression
(2004) for the prevention of recurrent depression. Since then, MBCT was shown to be as effective in preventing relapse among patients with a history of three or more depressive episodes when compared to maintenance antidepressant treatment (Kuyken et al ., 2008). Importantly, MBCT was shown to be more effective than maintenance pharmacotherapy in reducing residual depressive symptoms and improving quality of life, with no difference in the costs between these two treatments.
Present
Currently, the focus of MBCT outcome research has been to evaluate the efficacy of MBCT in treating depressive symptoms themselves. This research stemmed from the view that the cognitive vulnerability model of relapse could potentially also be applied to depressive symptoms themselves. Specifically, some have postulated that teaching patients mindfulness skills to help distance themselves from ruminative, depressive thought patterns may also be effective in reducing depressive symptoms.
MBCT to treat depressive symptoms
Those with recurrent depression experience residual symptoms months after the resolution of an acute episode (Judd et al ., 1998; Paykel et al ., 1995). Several studies have demonstrated that MBCT is effective at reducing residual depressive symptoms in patients with a history of three or more episodes who have recovered from an acute episode of depression (Kingston et al ., 2007; Kuyken et al ., 2008; Williams, Russell &

Mindfulness-Based Cognitive Therapy 9
Russell, 2008). In addition, MBCT has been shown to reduce depressive symptoms in individuals diagnosed with unipolar depression or bipolar disorder, in remission with a history of suicidal ideation or behaviour (Williams et al., 2007).
MBCT has been shown to be acceptable and effective in reducing depressive symptoms in individuals with current depression in four uncontrolled studies (Eisendrath et al., 2008; Finucane & Mercer, 2006; Kenny & Williams, 2007; Ree & Craigie, 2007).
In two of these studies (Eisentdrath et al ., 2008; Kenny & Williams, 2007), patients were treatment resistant which is defined as those depressed patients who fail to improve in response to adequate treatments of at least two antidepressant medications (Wijeratne
& Sachdev, 2008). In the remaining two studies, the patients were recruited from primary care settings and included those with active symptoms of depression and anxiety (Finucane & Mercer, 2006; Ree & Cragie, 2007). Interestingly, these results contradict Teasdale et al.’s (2000) concern that problems with concentration and energy would impair depressed patients’ ability to engage with the meditation practices.
Finally, these results must be considered preliminary as they lacked appropriate comparison groups leaving open the possibility of a selection bias of a sample of motivated patients who had not responded to initial treatment.
Future
An important focus of future MBCT related work will be issues related to MBCT dissemination including identifying the mechanisms underlying the efficacy of MBCT; the training requirements to develop as an effective MBCT instructor; and, the development and evaluation of new treatment delivery models in addition to group.
Potentially the most important of these is to determine whether teaching mindfulness meditation techniques significantly contribute to MBCT treatment outcomes. Although results from previous randomized controlled trials are consistent with the theoretical rationale underlying the development of MBCT, none of these studies were designed in a way to permit attributing the findings to MBCT-specific effects. Furthermore, there are currently no studies evaluating to what extent the effects of MBCT can be attributed to mindfulness meditation training versus standard cognitive therapy techniques.

Mindfulness-Based Cognitive Therapy 10
Consistent with recommendations of Coelho et al . (2007), future MBCT research should directly investigate potential mechanisms underlying the efficacy of MBCT in order to rule out non-specific factors such as group participation and/or therapeutic attention and to explicitly evaluate the assumptions of the theoretical rational underlying the development of MBCT. In response to these comments, Williams et al . (2008) recommended the use of a ‘dismantling’ paradigm whereby MBCT is compared to a group-based control treatment that includes just the psychoeducational component of
MBCT but no meditation training. Until studies like this are done, it remains possible that similar relapse prevention outcomes could be obtained from group cognitive therapy treatment alone or from other types of group therapy such as those focused on relaxation or psychoeducation. Thus, large scale MBCT dissemination programs remain to be supported by research demonstrating MBCT’s specific effects.
Second, effective MBCT dissemination will depend on training many clinicians in this modality. Before teaching MBCT to others, Lau and Segal (2007) recommend a five component MBCT training program: (1) participation in a five-day MBCT teacher development intensive workshop; (2) be a participant-observer in an MBCT group; (3) provide MBCT under supervision; (4) attendance at a one week-long residential insight meditation retreat; and, (5) develop and/or maintain a consistent personal mindfulness practice. In addition to this specific MBCT training, Segal et al . (2002) recommend that clinicians have recognized training in counseling, psychotherapy, or as a mental health professional, as well as training in cognitive therapy and conducting group therapy.
Very few potential MBCT practitioners, however, have experience in all of these recommended areas. Completion of the recommended requirements involves a significant investment of time, effort and financial resources on the part of the clinician.
So much so that it may represent a significant barrier for many clinicians to become competent in the delivery of MBCT. Moreover, there are unique challenges for the potential practitioners in integrating change-based CT techniques with acceptancebased mindfulness skills (Lau & McMain, 2005).
It is important to note, however, that the above recommendations derive from the widely held assumption among mindfulness instructors that one needs to teach from

Mindfulness-Based Cognitive Therapy 11 one’s own meditation experience. To date, we are not aware of any studies evaluating the impact of instructor experience on MBCT outcomes. There is indirect evidence supporting this assumption from a recent study where psychotherapists in training
(PiTs) who were randomly assigned to practice meditation had greater symptom reductions in their patients as compared to PiTs who did not engage in meditation
(Grepmair et al ., 2007). Nevertheless, the importance of teacher training to MBCT outcomes will be an important area for future research.
Third, dissemination of MBCT will potentially be facilitated by the development of additional delivery formats. MBCT was originally designed to be provided as a group treatment. However, not everyone is interested in participating in group MBCT; Kuyken et al. (2008) reported that approximately 5% of potentially eligible patients declined participation in the study due to the group aspect of MBCT. Furthermore, group treatment may not lend itself to certain settings such as the workplace where employees may have concerns about participating in a group with their co-workers. Participating in a group with co-workers may also have a negative impact on group cohesion and ultimately group effectiveness. Finally, access to MBCT remains a potential barrier in many rural centers where demand for MBCT may be insufficient or geographic barriers may limit the ability to conduct/attend MBCT groups.
One potential solution is to develop and evaluate other delivery formats. In particular, offering MBCT in an individual format would facilitate participation of those with concerns about participating in group treatment. In addition, there have been recent promising technological developments which may facilitate additional MBCT delivery formats. For example, offering group MBCT via the internet would provide individuals the benefits of group MBCT, convenient access, and in some cases not having to participate in a group with co-workers. Individual MBCT via the telephone or web would offer the confidentiality of individual treatment along with more convenient access, particularly for individuals in rural areas. However, the efficacy of MBCT as delivered in group format via the internet or as delivered to individuals, in person, via the telephone or web remains to be demonstrated.

Mindfulness-Based Cognitive Therapy 12
In conclusion, MBCT is a novel, relatively new psychosocial intervention with much still to be learned about its effectiveness. Nevertheless, MBCT has become widely accepted and adopted as a treatment for the prevention of depressive relapse.
For example, North America, Europe and Australia all have research and training programs. As research in the field expands, our understanding of how and for which presentations MBCT is effective will too. In a world filled with distractions and worries, learning to bring one’s awareness to the present moment has become an ever more important skill. For people with recurrent depression MBCT offers one more tool to help them in better managing this disorder.
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1 BC Mental Health and Addiction Services
2 Department of Psychiatry, University of British Columbia