Mindfulness for Anxiety and Depression

Thank you.

It’s a pleasure to be here.

I’ve worked in the field of mood disorders for over 30 years and I’ve witnessed a number of advances in treatments.

I’ve witnessed new generations of antidepressant medications being developed.

The use of magnetic coils to stimulate the skull and affect different brain regions.

The implantation of electrodes into the brain in regions that are thought to promote recovery from depression, and even the customisation of talk therapies to address certain sub types of depression.

But let’s face it, the concept of meditation was never high on that list.

And there’s a good reason for that: the reason is that these are treatments that were developed to alleviate depression, to alleviate the suffering of patients who are trying to get their lives back on track and also to reduce the capacity for self-harm that is often carried by untreated and diagnosed depression.

But the complex challenge that depression provides us with is to do more than allow people to let go of symptoms and returning to their lives.

The complex challenge involves helping people recover from depression and to stay well.

What we now understand about depression is that it is an episodic and recurrent disorder.

Getting well is half of the problem, staying well is the other half. And this is really where my work in the area started, I was tasked with addressing the problem of relapse and its prevention. And I was a card-carrying member of a cognitive therapy group working in an outpatient clinic at a hospital.

My work was quite distant from meditation and other contemplative practices.

I received a small grant from the MacArthur Foundation to try to modify an existing treatment for depression so that it could prevent relapse.

And what I did with that money was to bring together two colleagues of mine, Mark Williams, who is at Oxford, John Teasdale, who is now at Cambridge, and we sat together and thought about how would we go ahead and do this, modify this treatment, provide something to people who are in recovery to help them stay well.

We kind of hit the pause button, because we didn’t want to take a treatment that was designed to help people come out of depression and just continue to sort of spool it forward to people in recovery. We wanted to understand if there were specific risk factors, specific triggers, that helped people who were in recovery get depressed and maybe see whether we could design a treatment around those specific triggers to try to undo their sort of pathological influence.

The really cool thing about working with Mark and John is that they had done seminal work in the area of mood dependent memory.

The way in which moods and thoughts come together and influence each other, bringing moods that are negative to mind much more easily if one is thinking in a depressive way, and depressive thoughts bringing moods together that are depressed more easily.

One of the things that we found was that when people are depressed and they’re feeling sad, this is a symptom.

But when they are no longer feeling depressed, sadness can function as an important context to bring to mind judgemental, critical, and harsh ways of viewing the self that can sometimes tip people over into a new episode of depression and cause relapse.

And so we stood back and thought to ourselves: what if we could, first of all, test out this model, what if we could find a way to modify this effect that sadness has on mood and memory?

And then what if we could teach this to people?

Wouldn’t it be possible that this would be a more efficient and a more direct way of helping people stay well?

And it happened that our theory led to a model and very supportive data for our conjectures.

People who were well, had recovered from depression, had been treated, but were experimentally induced into a brief state of sadness found that they could very easily start to recall experiences from depression and that the folks who did that the most were the ones that had the highest rates of relapse when we followed them for 18 months.

We had some very important evidence here that suggested that our model had legs.

That the ability to work with sadness, in people that had recovered from depression, may determine whether they are able to go on and sustain the benefits of treatment or whether they are going to relapse. But how do you work with a trigger of relapse like sadness, when sadness is also a feature of our universal human experience?

We weren’t interested in trying to eliminate sadness, we weren’t interested in trying to get people not to feel sad.

What we really needed to do was to help people develop a different relationship to their sadness. And what does that mean in terms of trying to teach people certain skills?

This is really the point in which mindfulness comes into the picture.

Mindfulness is really the awareness that comes to mind, the awareness that arises when we pay attention in a particular way.

We’re bringing our attention into the present moment and we’re not judging.

What do we notice?

So, purposely attending to the present moment, without judgement.

Turn out this is a very useful skill to have, because it can reveal aspects of our experience that have already been and are continuing to be present for us, but we are just not able to access them, we’re not focusing on them.

Let me just stop for a second, because words have a sort of limited utility when you’re talking about mindfulness.

And let’s see whether we can have a chance to experience this directly.

If you’re willing, maybe just pause for a sec.

Make yourselves comfortable in your chairs, and start by thinking about your feet.

See if you can just do that, just let your mind start thinking about your feet.

How your feet have carried you a fair distance today.

Where they’ve taken you, walking, driving, sitting?

Maybe comparing one foot to the other.

Noticing any judgements or evaluations.

Seeing whether you like one foot — or the other foot.

Seeing whether there are any worries about your feet, any things that are medically oriented, or unsubscribed, sensations.

Whether you have any future oriented things relating to your feet, like maybe you’ve got a pedicure that’s scheduled, or you need to redo your toe nail polish.

Continuing to think about your feet and just letting whatever comes up in your mind — be there. Just thinking about your feet.

And then stopping.

And now redirecting your attention, and taking your attention back to the feet, but this time just becoming aware of whatever sensations are present in this part of your body.

So maybe feeling the way the feet are pressing down against the floor, through the soles of your shoes.

Perhaps feeling the points of contact for the big toe, the little toe, the heel, the ball of the foot.

Noticing any sensations between the toes, any moisture, any heat, even the foot itself encased in the shoe.

Any sense of tightness, pressure, throbbing.

And just allowing whatever sensations come to mind as you’re experiencing your feet in this way.

And then stopping, pausing… and looking for a moment Thinking about your feet, directly experiencing your feet. at these two different ways of having an experience of your feet.

The practice of mindfulness allows you to take all of this information into account.

Allows you to be focused on directly feeling what you’re going through, as well as having, or noticing, thoughts about the experience as well. And this, we felt at the time, was an answer to the question of how can people work with sadness, not by eliminating it, but by being able to have a different relationship to it. We’ve use a fairly mundane example of feet, but what happens if we try to tune this into sadness when it is present, negative emotions when they are present.

And thankfully, at the same time we were doing this, we were aware of Jon Kabat-Zinn’s pioneering work with mindfulness meditation with patients that had chronic pain.

He was doing this very thing.

People who had chronic pain training themselves to attend to the sensations of physical discomfort.

Not pushing pain away, but finding a way into their physical discomfort, that allowed them to see more room and more space inside it, than simply thinking about it, than trying to worry about it, trying to eliminate it, trying to distract themselves from it; being present with it.

And he was showing remarkable outcomes, more and more of these people’s lives could be reclaimed, and that the chronic pain features of their lives became less and less of a primary concern. And so what we tried to do was to develop the same training program for people who had recovered from depression, based on his seminal eight-week program, which he developed, much of which featured extensive training in mindfulness meditation, mindful movement, and we also added in bits and pieces that were relevant to living with a depressive disorder.

And we called it mindfulness-based cognitive therapy.

It became manualized, it became evaluated, and it had very little of the baggage associated with contemplative meditative practices.

You didn’t have to enter the world of meditation.

I dressed like this, I didn’t wear robes when I came into a class.

And opened the door as wide as possible for people to see this as a very pragmatic health practice — for regulating emotions.

So it wasn’t about finding God, it wasn’t about transcending reality, this is about learning how to harness attention in the agenda of self-care.

Now, mindfulness-based cognitive therapy essentially tries to work starting with concrete examples of how to pay attention and how to be mindful.

We did this with the feet, we start in our course with raisins, with eating, with breathing, with other kinds of activities, and eventually we work our way up to dealing with negative emotions.

What we’re trying to get people to do is to anchor themselves in their experience, so that when a negative emotion comes up in the mind it can wash over them, it doesn’t totally destabilise them, neither does it necessarily bring to mind all of the negative associations that for some people can happen very automatically.

Instead they can find a different place for standing and working with this feelings and as a result have much more of an option for selecting a response and influencing what happens next. Mindfulness-based cognitive therapy has performed very well in clinical randomized trials.

About a thousand patients have been evaluated using this approach across seven studies world wide.

And what we are finding is that, compared to usual care, mindfulness-based cognitive therapy reduces relapse by about 43 percent.

And compared to antidepressant medication it provides equal protection against relapse as continuing on an antidepressant for long periods of time.

The other positive thing about this treatment is that it enhances people’s ability to feel reward, and to feel positive affect, positive emotions, in the course of their everyday lives. Which is vital because this is a tough sell for many patients, for many people with depression who are feeling well and feeling as if their depression is behind them, they don’t need to continue to engage in ways of looking after themselves, why should they invest the time, space, and often very busy lives for doing this?

The capacity to reward and to feel reinforced for practising mindfulness allows these health benefits to continue.

And another way in which we know these heath benefits can get locked in is the fact that mindfulness also changes the brain.

It changes the brain in very meaningful ways by allowing people to access what’s been called the present moment pathway.

Now, on the face of it, it makes sense, we are training people to pay attention to the present moment, maybe there’re some parts of the brain that get tuned up to be able to do this.

But we’ve got some fairly good data to suggest that part of this present moment pathway, the region that is very active in training in mindfulness is the insula.

And the insula is a part of the brain on a network that allows signals from the body to be more carefully attuned.

Signals of present moment, sensations, what’s happening in the body, in this moment, not thinking about the body, but right now, sensations.

And people are better able to tune into the state of the body by doing this. And what we’re finding is that as the present moment pathway gets activated people that have been trained in mindfulness are able to really increase the activation in the insular, more than people who haven’t been trained.

So, mindfulness trains awareness in this present moment pathway, and, it turns out, this is vitally important for working with sad mood states.

So what happens if you put someone into an fMRI scanner and induce a mild state of sadness, and they haven’t had training in mindfulness, they will activate a part of the brain called the executive control network, which is sort of like the thinking about your feet network, if you want, a network of brain regions that are involved with evaluating: What do I need to do about this sadness?

Is this sadness relevant to me?

Is this a threat?

How can I problem solve it?

How can I eliminate it?

So you’re thinking and thinking about sadness, and what happens is, as that network is stronger, the present moment pathway gets weaker.

So, one is stronger, one is weaker, and you’re getting very little signal from what’s happening in your body, how this emotion is actually impacting you in this moment, and you’re getting a lot more about the conceptual workings of the mind around what is sadness, what do I need to do about it, what else is it also calling to mind.

Now, after people have been trained in mindfulness you’re getting this re balancing between both networks coming online.

Executive control network gets inhibited a little bit, the present moment pathway increases its activation a little bit, and now the person feeling sad has access to two channels of information.

A channel of information about the meaning of sadness, but also a channel about the present moment state of the body that is working with sensations of sadness, and both of these channels of information can lead to more effective responses and selections of activities in terms of dealing with sadness.

This is a movement away from a kind of automatic activation of the previous contents that would be brought to mind when sadness was present, and widening into a much more spacious view of sadness, and the hopefulness that comes with that. And what we find in our work is that our treatment is eight-weeks in length and yet we’re asking people to take this on board as a way of continuing to look after themselves.

About 75 to 80% of our patients — continue some form of mindfulness practice for about a year, two, to three years afterwards.

And what happens is that although the portal that brought them in to us in the first place had to do with a disorder, depression, had to do with getting treatment, more and more people recognise that through the practice of mindfulness they are able to connect with an inner resource that allows them to take care of themselves in a way that touches greater moments of wholeness in their days, and allows us to permeate more moments of their lives as they go forward.

It becomes less about a treatment, it becomes more about a way of life and looking after themselves.

And this has really been the pinnacle of the work that we’ve conducted, to move from a juxtaposition of two approaches for depression, that seemed seemingly unconnected, into developing a coherent, and empirically supported way, of delivering this type of care, and allowing people to take over once the course is over.

Thanks very much for your time!

(Applause) .