Mindfulness-Based Therapies

Mindfulness-Based Therapies:
Exploring potential benefits of mindfulness in
the post-stroke population
Steven Selchen, MD, MSt, FRCPC
•Head, Mindfulness-Based Interventions (MBI),
Department of Psychiatry, University of Toronto
•Head, Cognitive Behaviour Therapy & MBI,
Sunnybrook Health Sciences Centre
•Director, Sunnybrook Psychiatry Institute for
Continuing Education (SPICE)
www.sunnybrook.ca/mindfulness
Disclosures
• None.
Mindfulness-Based Therapies
• Typically involve eastern meditative practice in
a secular, clinical context
• Robust evidence supporting therapeutic value
in depression, anxiety, stress, chronic pain,
coping with physical illness, etc. (e.g. Teasdale et
al., 2000; Ma & Teasdale, 2004; Segal et al., 2010; Hofmann,
et al., 2010; Khoury et al., 2013)
Objectives
• Identify core principles of mindfulness
• Summarize the application of mindfulnessbased therapies to various clinical populations
• Discuss potential applications in the poststroke population
John was on his way to school.
He was worried about the math lesson.
He was not sure he could control the class again
today.
It was not part of a janitor’s duty.
– We actively ‘make meaning’ out of bare facts and
are barely conscious that we are doing so
(Segal et al, 2002)
John was on his way to school.
He was worried about the math lesson.
He was not sure he could control the class again
today.
It was not part of a janitor’s duty.
– We actively ‘make meaning’ out of bare facts and
are barely conscious that we are doing so
(Segal et al, 2002)
John was on his way to school.
He was worried about the math lesson.
He was not sure he could control the class again
today.
It was not part of a janitor’s duty.
– We actively ‘make meaning’ out of bare facts and
are barely conscious that we are doing so
(Segal et al, 2002)
John was on his way to school.
He was worried about the math lesson.
He was not sure he could control the class again
today.
It was not part of a janitor’s duty.
– We actively ‘make meaning’ out of bare facts and
are barely conscious that we are doing so
(Segal et al, 2002)
John was on his way to school.
He was worried about the math lesson.
He was not sure he could control the class again
today.
It was not part of a janitor’s duty.
– We actively ‘make meaning’ out of bare facts and
are barely conscious that we are doing so
(Segal et al, 2002)
Suffering…
http://www.etravelphotos.com/
Suffering…
http://www.win-with-women.com/
Suffering…
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Suffering…
blogs.scientificamerican.com/media/inline/blog/Image/scared_man.jpg
Two Arrows…
What is Mindfulness?
“Mindfulness is the awareness
that emerges from paying attention…
- on purpose
- in the present moment
- non-judgmentally
to things as they are.”
Themes: interest; curiosity; receptivity;
observation; openness; compassion …
Thought/image
emotion
urge/impulse
sensations
Cultivation…
• Through mindfulness meditative practice,
cultivate ‘new relationships’ to thoughts,
emotions, bodily sensations and behaviour
– Thoughts are thoughts; not facts
– Emotions are emotions; tolerable
– Urges are urges; need not be acted upon
• Bring interest, curiosity and compassion to our
exploration of ourselves and our patterns of
mind and experience
Metacognitive Awareness
• Instead of viewing thoughts as absolutely
true or as descriptive of important selfattributes, patients learn to see negative
thoughts and feelings as passing mental
events that are not necessarily valid
reflections of reality or central aspects of
the self (Segal, et al.)
Learn to…
• Unhook ourselves from automatic
maladapitve patterns of mind and behaviour
(e.g. rumination & avoidance)
• Increase freedom and choice
• Make more adaptive choices
‘Strategic’ Maintenance Processes
• Rumination
– Patients believe rumination will help uncover the
causes of depression and its solutions
– However, the main effect of going over and over
losses, past mistakes, judgments and comparisons
is often to perpetuate and amplify negative affect
‘Strategic’ Maintenance Processes
• Avoidance
– Similarly, patients often believe avoidance will
protect them from further harm
– However, avoidance and withdrawal can keep
people stuck, and confirm (or at least fail to
disconfirm) negative predictions
Approach vs. Withdrawal
• When difficult thoughts, emotions or urges
arise, can learn to turn toward them
(“approach”) and explore them experientially
in the present moment, rather than engaging
in the kind of rumination or avoidance that
would exacerbate and perpetuate them
• These ‘mental events’ are then able to
dissipate as the transient phenomenon they
were ‘designed’ to be
Responding vs. Reacting
• Mindfulness does not eliminate ‘cognitive
reactivity’, but it can restrain us from
getting carried away by it and spiraling
down
• Instead, we can learn to respond more
wisely and adaptively to our experiences
and situations
Engagement in Life
• Mindfulness training can shift negative
filters; directs attention also to positive
aspects of experience and encourages
deeper engagement in life
Mindfulness-Based Interventions
• MBSR (Mindfulness-Based Stress Reduction)
– Secularized adaptation of Eastern meditative
practices to a western medical context
– Developed by Kabat-Zinn at UMass
• MBCT (Mindfulness-Based Cognitive Therapy)
– integration of MBSR and CBT
– Developed by Segal, Williams & Teasdale
Mindfulness-Based Interventions
•
•
•
•
•
•
Group-based
Structured; e.g. 8 weekly “classes”
Psychoeducational, experiential
Focus: mental process > content
Teach a variety of meditations
MBCT also weaves in a variety of cognitivebehavioural exercises
• Up to an hour of daily home practice
MBCT
• Mindfulness of routine activities (e.g. eating)
• Body Scan
• awareness of sensations in the body; learning to direct attention
to different parts of the body
• Mindfulness of the breath
• (concentration on a single focus), then moving to mindfulness of:
sounds, the whole body, and thoughts
• Mindful movement
• ‘Breathing Spaces’
• scheduled regularly in working day, and additionally when under
stress
• CBT components
Relapse Prevention in Depression
(3 or more previous episodes)
Teasdale et al., 2000 in JCCP
And replicated: Ma & Teasdale, 2004 in JCCP
1.00
MBCT: 37%
0.5
TAU: 66%
10
20
30
40
50
60
Recurrence Across 18 Months – Intention to Treat
Analysis - Unstable Remitters
27%
28%
71%
Log-rank test = 8.24, df =2, p = 0.016
Segal et al., 2010, Arch Gen Psychiatry
Hofmann et al., 2010 (JCCP): The Effect of MBT on
Anxiety and Depression: A Meta-Analytic Review
• Effect size analysis of MBSR and MBCT for anxiety
and mood symptoms in clinical samples
• 39 studies totaling 1,140 participants
• Range of conditions, incl. cancer, GAD, depression,
chronic fatigue syndrome, panic disorder,
fibromyalgia, chronic pain, social phobia, ADHD,
arthritis, binge eating disorder, bipolar disorder,
diabetes, heart disease, hypothyroidism, insomnia,
organ transplant, stroke, and traumatic brain injury
• Updated and supported further in Khoury et al.,
2013
The Effect of Mindfulness-Based Therapy on
Anxiety and Depression: A Meta-Analytic Review
• Results: MBI were moderately effective for improving anxiety
(Hedges’s g 0.63) and mood symptoms (Hedges’s g 0.59)
from pre- to post-treatment in the overall sample
• In patients with anxiety and mood disorders – effect sizes
(Hedges’s g) of 0.97 and 0.95 for improving anxiety and mood
symptoms, respectively
• Effect sizes were robust and were maintained over follow-up
• Conclusions: “These results suggest that mindfulness-based
therapy is a promising intervention for treating anxiety and
mood problems in clinical populations.”
Mindfulness training increases ‘viscero-somatic’ processing and
uncouples ‘narrative-based’ processing (Farb et al, 2007, 2012)
Farb, N., Segal, Z.V., Mayberg, H., Bean, J., McKeon, D., Fatima, Z., & Anderson, A. (2007).
Attending to the present: Mindfulness meditation reveals distinct neural modes of self-reference.
Soc Cog Aff Neurosci., 2, 313-322.
Kuyken et al., 2010
Kuyken et al., 2010
Possibilities Post-Stroke…
Possibilities Post-Stroke…
• Moustgaard, A. (2005). Mindfulness-based
cognitive therapy (MBCT) for stroke survivors:
An application of a novel intervention.
Unpublished Dissertation.
• n=23; no comparison condition
• Statistically significant improvement in
depressive (BDI-II) and anxious (BAI)
symptoms
Possibilities Post-Stroke…
• Johansson, B., Bjuhr, H., & Rönnbäck, L. (2012).
Mindfulness-based stress reduction (MBSR) improves
long-term mental fatigue after stroke or traumatic
brain injury. Brain Injury, 26(13-14), 1621-1628.
• Primary endpoint: Mental Fatigue – reduced
capacity for work and participation in social activities
• n=18 (stroke); 11 (TBI); randomized
• Statistically significant improvement on selfassessment for mental fatigue; also: neuropsych tests
(Digit Symbol-Coding and Trail Making Test)
Possibilities Post-Stroke…
• H. Hofer, M. G. Holtforth, F. Luthy, E. Frischknecht, H.
Znoj, and R. M. Muri (2012). The potential of a
mindfulness-enhanced, integrative neuropsychotherapy program for treating fatigue following
stroke: a preliminary study. Mindfulness.
• combination of neuropsychological interventions,
psychoeducation, cognitive-behavioral therapy, and
mindfulness techniques.
• n=8; significant improvement in mental fatigue (pre
vs. post)
Possibilities Post-Stroke…
• ? Decreasing risk of recurrence…
– E.g. diabetes management, blood pressure
management, etc.
• Clinicians, caregivers…
Summary
• Mindfulness-Based Interventions (MBIs) help
cultivate ‘new relationships’ with our
experiences
• MBIs have led to improved coping with
psychological distress and increased wellbeing
across a number of populations
• Early studies show promise for positive impact
of MBIs on the post-stroke population, but
much more research is needed

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