Is MBCT effective?

Within the NHS, MBCT is recommended as a relapse prevention training for recurrent depression. ¹⁶ Several controlled studies have shown that the addition of MBCT to treatment as usual (TAU) can reduce the chance of relapse by about 40-50% in participants who have experienced three or more episodes. ^{Reference Ma and Teasdale17-Reference Godfrin and van Heeringen19} The efficacy of MBCT appears at least comparable with maintenance antidepressant medication, ^{Reference Piet and Hougaard7,Reference Kuyken, Hayes, Barrett, Byng, Dalgleish and Kessler20} making MBCT a viable alternative for those wishing to explore psychosocial ways to manage depressive illness. Early studies excluded individuals with a history of suicidal ideation, although recent work has explored the possibility that mindfulness training may also be helpful in these circumstances. ^{Reference Williams, Duggan, Crane and Fennell21,Reference Williams, Alatiq, Crane, Barnhofer, Fennell and Duggan22} For individuals with fewer than two episodes, or those whose depressive episodes are exogenously triggered (e.g. by stressful life events), the evidence is less compelling. ^{Reference Piet and Hougaard7,Reference Ma and Teasdale17} An early onset of depressive illness and experience of childhood trauma or adversity appear to be factors that increase the efficacy of MBCT. ^{Reference Ma and Teasdale17,Reference Williams, Crane, Barnhofer, Brennan, Duggan and Fennell23}

From these studies, it is clear that the picture as it relates to clinical efficacy (specifically, preventing depressive relapse) is more complex than first thought and warrants caution in the indiscriminate application of mindfulness training as a ‘treatment’ for depression per se. Screening prior to group entry is a key part of the process of mindfulness training. ²⁴

Is MBCT more effective than other approaches for depression?

One meta-analysis ^{Reference Khoury, Lecomte, Fortin, Masse, Therien and Bouchard5} indicates the superiority of MBIs over relaxation, psychoeducation, supportive therapy and imagery-based approaches, but no additional benefit when compared with cognitive-behavioural therapy (CBT). The findings were broadly similar at up to 3 months' follow-up. In a well-controlled randomised controlled trial (RCT), ^{Reference Williams, Crane, Barnhofer, Brennan, Duggan and Fennell23} where MBCT for depression was compared with a matched, active control condition (cognitive psychoeducation; CPE), there was no significant impact on the main outcome variable (relapse). However, for a sub-population of individuals in the study who had recurrent depression and childhood adversity, MBCT was superior in preventing relapse. ^{Reference Williams, Crane, Barnhofer, Brennan, Duggan and Fennell23}

Within the current literature, MBCT is indicated as an alternative offering to complement psychological (e.g. CBT) and pharmacological (antidepressant treatment) options, rather than necessarily being superior. ^{Reference Williams and Kuyken25} It may be particularly useful for those with a more chronic presentation, whose early experiences perhaps did not include the modelling needed to develop healthy emotional awareness and management. Providing a choice for clients is also important, and particularly so for those who have received CBT and found it ineffective or those who do not easily fit into the CBT model. This might also include those whose mental health difficulties prevent an active, motivated engagement with a process aimed at challenging thought content (as in CBT), so-called ‘traditional psychiatric insight’. ^{Reference Chadwick2} Working with thought processes rather than thought content makes it less necessary to have full insight. For example, in the work with psychosis, it may be possible to reduce the distress of auditory hallucinations by learning how to respond mindfully to a voice, while still maintaining a belief that the voice belongs to another entity.

Is MBCT effective in other categories of mental illness?

Although large-scale, independently replicated RCTs are few and far between in other areas of mental health, one of the larger randomised studies comparing MBCT for bipolar disorder and TAU ^{Reference Perich, Manicavasagar, Mitchell, Ball and Hadzi-Pavlovic26} showed no significant difference between interventions with respect to relapse, mood symptoms or total number of episodes. However, there was a significant reduction in state anxiety in the MBCT group, also reported in Williams' work. ^{Reference Williams, Alatiq, Crane, Barnhofer, Fennell and Duggan22} Given that inter-episode anxiety is a crippling, often neglected feature of bipolar illness, ^{Reference Simon, Otto, Wisniewski, Fossey, Sagduyu and Frank27,Reference Keller28} ameliorating it could make a big difference in quality of life and social/occupational functioning. In this case, it is clear that MBCT is having an ‘effect’ per se, but the mechanism of action may be different in bipolar illness than in major (recurrent) depression. Two meta-analyses indicate that MBIs are helpful in the management of clinical anxiety ^{Reference Khoury, Lecomte, Fortin, Masse, Therien and Bouchard5,Reference Hofmann, Sawyer, Witt and Oh29} and reductions in anxiety are also seen in non- or subclinical populations. ^{Reference Khoury, Sharma, Rush and Fournier9,Reference Cavanagh, Strauss, Forder and Jones13} A recent RCT showed no short-term advantage for MBCT over psychoeducation for generalised anxiety disorder (GAD). ^{Reference Wong, Mak, Cheung, Ling, Lui and Tang30}

In the field of psychosis research, there has been a growing number of studies looking at MBIs, including the more broadly defined third-wave therapies that contain components of mindfulness such as ACT. ^{Reference Khoury, Lecomte, Gaudiano and Paquin31,Reference Cramer, Lauche, Haller, Langhorst and Dobos32} Two meta-analyses have demonstrated that mindfulness training shows moderate short- and long-term benefits for positive symptoms and hospital admissions when compared with TAU, ^{Reference Cramer, Lauche, Haller, Langhorst and Dobos32} that effects are similar to other active interventions (such as CBT), and that there is lower attrition. ^{Reference Khoury, Lecomte, Gaudiano and Paquin31} This may be linked to the mindfulness stance which does not challenge the veracity of abnormal thinking and perceptions, but works with the process of how these emerge and are managed. ^{Reference Chadwick2}

A number of pilot feasibility studies report results from standardised (or modified) MBIs administered to different target populations, or MBIs with novel protocols. ^{Reference Kristeller and Wolever1-Reference Russell3} These approaches target specific features of a mental illness (e.g. auditory hallucinations or the impulse to binge eat) or postulate alternative methods such as mindful movement as an entry point to mindfulness. ^{Reference Russell and Arcuri33}

With these adaptations emerging, there is ongoing discussion in the field about more cognitively formulated mindfulness training (e.g. targeting specific mental processes such as rumination) v. more generic mindfulness training that teaches ‘techniques’. ^{Reference Teasdale34} The latter may have a different type of clinical value – developing the ability to manage ‘stress’ or anxiety is likely to have a positive effect on almost any physical or mental health condition.

Unexpected consequences

The range of outcome measures described in the cited studies points to the multiple routes through which mindfulness training may have its effects. In MBIs, symptom reduction is rarely the target. Instead, the training is about changing the relationship to symptoms and, specifically, becoming more curious (in a compassionate way) about mental habits. ^{Reference Kuyken, Watkins, Holden, White, Taylor and Byford35} If the previous relationship to symptoms was one of avoidance, then it is quite likely that mindfulness will make the symptoms appear ‘worse’ as the individual is more aware of them, relating to them in an engaged but relaxed manner. However, it is likely that even those who experience ‘more’ symptoms will be less distressed by them following mindfulness training.

There is ongoing discussion in the field and the popular press about whether mindfulness training may be harmful for some people. ^{Reference Ma and Teasdale17,Reference Dobkin, Irving and Amar36} There are concerns that individuals with certain difficulties (such as depersonalisation and dissociative disorders, trauma, psychosis and severe eating disorders) may struggle with standard MBI protocols. However, Chadwick's ^{Reference Chadwick2} elegant work with people with psychosis indicates that with careful formulation, adaptations and a high degree of compassion and skill, it is possible for clinicians to work mindfully with these populations. In the case of delusional beliefs and auditory hallucinations, it is not necessary to change the belief about the voice in order to create a different relationship to it through mindfulness. Working directly with the body as a starting point may not be appropriate for certain of the eating disorders (e.g. anorexia) and trauma. However, adaptations (e.g. using movement) may be an entry point.

As this field progresses, it will be vital that those teaching and training others in mindfulness are themselves open, non-reactive and non-judgemental about instances where mindfulness ‘has not worked’. Part of best practice is sharing what went wrong in order for us to learn more about cases where mindfulness training may need further adaptation or may not be useful. Creating a culture of acceptance around unexpected outcomes would be a good starting point for teams or clinics considering any form of mindfulness training. Among professionals in the field, modelling the principle of gentle, kind, open curiosity to whatever happens (even if it is an ‘unexpected effect’ in a participant) is vital. The stability of this stance is directly related to the personal experience of the professional.

The experience of the facilitator

The facilitator's own experience of mindfulness is a central factor to help work through (mindfully) any unusual or unexpected effects arising from mindfulness practice. Less experienced facilitators may be working on the edge of awareness of their own, more deeply embedded, habits or emotional reactivity and thus may not yet have the requisite steadfastness, non-reactivity and non-judgement when they meet this in their clients. The ability to hold a curious, open and accepting stance, even when things are not as we wish them to be, are qualities a mindfulness practitioner and teacher develops over time. This eventually leads to a position whereby it is possible to have a strong emotion or experience a strong (usually ‘negative’) mental habit without getting drawn into it or trying to make it be different or ‘go away’. This skill, developed through repeated practice, allows one to trust that it is possible to not react or judge, even when we see we are being unskilful in our actions or communications.

There may be moments when the client needs to see and trust that they can maintain the observer position in such instances. Conversely, there may be times when it is necessary to stop practising mindfulness. If there are dramatic changes in either internal (mental) or external (life) contexts that make the endeavour uncompassionate, forced or with a sense of too much expectation, this may be time to pause and reconsider intentions.

While personal experience of mindfulness is essential for those who wish to deliver MBIs in the clinical setting, the ability to teach mindfulness in a group setting requires further skills and training. How mindfulness is taught seems to be as important as what is taught. ^{Reference Teasdale34} The impact of the facilitator's own mindfulness experience and what is referred to as the ‘embodiment of mindfulness’ in the teacher appears critical to the observed clinical/therapeutic effects. ^{Reference Khoury, Lecomte, Fortin, Masse, Therien and Bouchard5,Reference Crane, Kuyken, Williams, Hastings, Cooper and Fennell37} The MBI-Teacher Assessment of Competency (MBI-TAC) ^{Reference Crane, Kuyken, Williams, Hastings, Cooper and Fennell37} has been proposed as a way to maximise the effectiveness of MBIs, and to ensure the quality of teaching in these clinical settings. It considers six domains of competence to teach MBIs: (1) coverage, pacing and organisation of session curriculum; (2) relational skills; (3) embodiment of mindfulness; (4) guiding mindfulness practices; (5) enquiry; and (6) holding a group. Box 1 outlines the key recommendations from the UK Network for Mindfulness-Based Teacher Training Organisations and all healthcare workers considering using mindfulness as a therapeutic intervention are advised to be familiar with these. ^{24,Reference Crane, Kuyken, Williams, Hastings, Cooper and Fennell37}

The reader is alerted to the therapeutic potential of therapist mindfulness alone, which is an essential starting point for those who wish to use mindfulness clinically but have yet to complete a formal teacher training. Studies indicate that mindfulness training for therapists enhances core therapeutic skills, ^{Reference Boudette38-Reference Keane40} and has a positive impact on patient experience ^{Reference Horst, Newsom and Stith41} and on clinical outcomes. ^{Reference Grepmair, Mitterlehner, Loew, Bachler, Rother and Nickel42} All this before you have even ‘done’ any mindfulness to the client!

Therefore, standard MBIs appear effective for certain conditions and at certain times. A number of outstanding challenges remain, including the provision for wider implementation of MBCT in the NHS, the training of therapists to deliver MBCT, ongoing discussion about the measurement of mindfulness as a construct, ^{Reference Grossman and Van Dam43} and the exact mechanism of change. ^{Reference Kuyken, Watkins, Holden, White, Taylor and Byford35,Reference Teasdale and Chaskalson (Kulananda)44-Reference Shapiro, Carlson, Astin and Freedman46} There are unexpected effects that have to be (mindfully) attended to, and the experience of the facilitator seems to be a critical component. However, alternative MBIs – targeting different populations and using different methods – appear promising, and a huge variety of resources are now widely available in the public domain. We will now explore a number of suggestions for those considering working outside the evidence base.

The real-world clinical context

Models of ‘stepped’ approaches, including ‘low-dose’ mindfulness, have been suggested. ^{Reference Demarzo, Cebolla and Garcia-Campayo47} These modified forms of MBI, which might be considered more lifestyle oriented, informal, practice-based approaches, ^{Reference Demarzo, Cebolla and Garcia-Campayo47} appear beneficial for working adults, ^{Reference Klatt, Buckworth and Malarkey48,Reference Creswell, Pacilio, Lindsay and Brown49} healthcare workers ^{Reference Mackenzie, Poulin and Seidman-Carlson50} and general practitioners. ^{Reference Manocha, Gordon, Black, Malhi and Seidler51} In one meta-analysis, mindfulness and acceptance-based self-help (including books and online courses, but not apps) reduced depression and anxiety with small to moderate effect sizes, across a range of clinical and non-clinical adult populations. ^{Reference Cavanagh, Strauss, Forder and Jones13} Evaluation of mindfulness apps is ongoing, with promising early results, ^{Reference Howells, Ivtzan and Eiroa-Orosa52} but still in the early stages. ^{Reference Plaza, Demarzo, Herrera-Mercadal and García-Campayo53}

Given the ever-widening opportunities to access various types of mindfulness training, and the currently quite specific and limited access to MBCT in the NHS setting, might clients benefit from more generic mindfulness training skills? If so, what competencies are needed to help support this endeavour? The intention will be necessarily distinct from that of a closed, group MBCT for recurrent depression. But what are the possible benefits and risks? An increasingly wide range of mental health professionals (medical, allied health, third sector, peer supporters, experts by experience) are sharing mindfulness in a variety of ways and with varying levels of supervision. ^{Reference Crane and Kuyken54} One of the main challenges is to understand who needs what training to deliver (what type) of mindfulness intervention, and with what intent. Box 2 shows some scenarios that may be familiar to the reader. While these may provide initial ‘touch points’ with mindfulness, they are also instances where a lack of clear intention and poor expectation management may lead to disappointment and/or confusion.

It is necessary to manage the tension between allowing clients access to methods of psychological development that may be helpful (and are readily available to the general public), and upholding the professional ethics of ‘do no harm’ and operating within professional competencies. ⁵⁵ Having, and communicating, a clear and specific intention is vital. Related to this, clarity around the language and a deeper exploration of what is meant by ‘mindfulness training’ may be helpful. If you are offering an informal-based mindfulness training (drop-in sessions, apps, books etc.) the intentions, level of practice and depth of work is likely to be different than during a closed, 8-week training programme with regular 45 min practice sessions. Working systemically with mindfulness will necessarily have a different type of impact than working with the individual.

A proposed framework

This article proposes a three-part framework (Fig. 1) to guide thinking in this emerging area. The overarching intention is to help those delivering new variants of mindfulness training in the mental health setting to do so as mindfully as possible. On this basis some preliminary recommendations are made below. Clinicians might consider rating the evidence, experience or client characteristics on a scale of 0-10. This will help guide decisions and also indicate where it is necessary for more evidence, supervision/training or thought to be given to a decision to implement mindfulness in each case.

Fig. 1 Three areas to consider if you are working with mindfulness outside the standard protocols: (a) the evidence base and intention of the work; (b) the characteristics of the client group and context; and (c) the facilitator's experience.

Recommendation 1: understand the evidence (or lack thereof)

Recommendation 2: client characteristics

Mindfulness requires the ability to become aware of mental and physical sensations, as they unfold moment by moment. Necessarily, this requires: (a) some form of paying attention; (b) an ability to engage with, yet not react to, physical (including emotional) and mental experiences; and (c) a mind oriented towards non-judging, acceptance and nurturing. Clients in the clinical setting will have a range of capacities in these attentional, emotion regulation and attachment domains. Low scores in all three domains may indicate something other than mindfulness as more appropriate. Some screening questions provided by Dobkin et al ^{Reference Dobkin, Irving and Amar36} indicate groups where caution and adequate preparation for the group would be helpful.

Adaptations to take into account reduced attentional capacities can be found in the work exploring mindfulness with people who have attention-deficit hyperactivity disorder (ADHD), ^{Reference van der Oord, Bögels and Peijnenburg58} whereas Chadwick ^{Reference Chadwick2} describes modifications to support those experiencing the symptoms of psychosis. Use of external objects or mindful movements ^{Reference Russell3} might initially help individuals who struggle to sit still and look inwards. Mindfulness skills for distress tolerance, as outlined in the DBT model, ^{Reference Linehan59} may be more appropriate for those experiencing intense affect.

Recommendation 3: facilitator experience

An emerging theme from the literature is that the embodiment of mindfulness in the person facilitating the training is vital. We are each at our own unique place in the development of our personal mindfulness skills, but if we wish to teach or share mindfulness with others, there needs to be an active commitment to self-reflection and ongoing professional development. An initial reflection might be around your own interest in, and path to, mindfulness. Was it through yoga practice, a secular or a Buddhist group? How does this training affect what you offer in the clinical setting? What might need modification or dropping altogether? As a general rule, teach what you have personal experience of, and do not ask anyone to do a practice you have not done yourself, under a variety of conditions (ranging from calm to under duress). What barriers do you come across? How can this learning be appropriately shared or modelled in your work?