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Adapting Ancient Wisdom for the Treatment of Depression


									Adapting Ancient Wisdom for the Treatmentof Depression:
Mindfulness-Based  Cognitive TherapyGroup Training
  Maggie Chartier, Robin Bitner, Tracy Peng,
  NicoleCofelt, Maura McLane, and
  Stuart Eisendrath
'lhe National Group Psvchotherapv                                  |5
A lllending of Two EducationalMethods                              z     v o r , u M E 4 .4
                                                                                     3                                                     DECEMBER 2O1O
  Michael I. Stiers                                                t
                                                                                                                     SPECI AL I SSUE:
'llre Systems-Centered
                     Training and Research
                                         Institute                                                           Training in Group Psychotherapy
( )rientation to Training                                                                                       GuestEdited by Walter Stone
  Yvonnne Agazarian
                                                                         fnl rrrrfrtt lir r n                                                      .........        277
                                                                             l \' ttl trrSlone
I'sychodrama: Training Program for Group Psychotherapists. . . .
               A                                         .
   I)avid A. Kipper
                                                                          llrr' | )r'vr'krplrrclrt the Universityof Rochester
                                                                         (,t()l l ) l i i r ir r ingPr ogr am                                           . . . . . 283
[.lsingan ObservationModel for Training Group Therapists
                                                                            .\l t' ' rtt St t t it lr
in a (lommunityMental Health Setting
   I)avid Ward and Carol Crosby
                                                                         A l ,rl rrrrrl<r rLear ningAppr oacht oTeachingG r oup
                                                                                                                             Psychot her apy. . . . .
                                                                                                                                          ..                        293
'l he liastern Group Psychotherapy
                                         One-Year                          /rrrr'/r/t/r.olto.s
'l'r 'i ri n i nProgr am .
  l'hyllis Wright,lim Ellis,and Marie Rothschild                                   (
                                                                         ll,ryhrr )ollcgc MedicineGroup PsychotherapyTraining
                                                                                                   of                                              . . .. . . ... 3o1
                                                                            l).1r.'ttltttlt Knight,PatriciaA. Barth, Aaron H. Fink,
'lilining in Group Analysisin the United Kingdom:                           Irtt I tI ri t tc ( )u n ningham Tervalon, Carol A.Vaughn,
'llrc lnstitr"rte Group Analysis
                of                                                           rtrtrllililtct'tIi. White
  Ihrrl Itopper,David Vincent,and Peter Wilson                     rll
                                                                   o     ( ; t or|| r' | |rt'rlPy' l'raining at Naropa Universityt Contemplative
                                                                         (nrrrrst' l rngl'syclr ologyPr ogr am                                          . . . . . 3o9
                               BOOK   REVII' ]WS
                                                                   |.n      ,\rrrrrr I I Nitttntonhcminda,                Abigail M. Lindemann,
                                                                                                              Robert Unger,
                                                                            rtttrl tt lllt t wO . I lollor un
ffool< Il,cvicw l0l Interventions Oroup'lhcrupy.
                                in                                 l\)

   llcvicwttl by Ounr Mcndclow
                                                                         t rtttl trttttrl ott l ntc k c ov (' r . . .

                                                                    fIl'|HR                                                                        IE
                                                                         lBiN (l             ,1 ( tr l                                                      Irh,,
ilfl                  N t M M A N i l tlM tNlr A,   ( ' N( ) iltt,   l,tNt) tlM ANN ,   A N l r l l (!Ll ,()R A N   (itt()uf', Vrl, t,f, No, 4, tlel"tulrcr'x'lo
Mltehell, & Aron, L, (rccc). Ilalatironal
          S,,                               psyclnanalysis: cnrcryctrcr tradition.
                                                          Ihc           o.l't
   l llllnclrrle, Antlytic l)rcss.
Mnnt€ro,ll, & Colman,A. D. (zooo).Collective      consciousness thc psychology
                                                                and               of
   hunrunInlcrconnectedness.       GROUB24, zo3-2rg.
Nlntntenhenrlnda, (zoo8).
                      S.        Groupasa mindfulness practice. F.Kaklauskas, Nim-
                                                             In               S.
   nenhefnlnda, L. Hoffman, & M. fack (Eds.),Brilliant sanity:Buddhistapproaches  to
   Ptycholhcrupy     (pp. r6r-ry1. ColoradoSprings,
                                                  CO: Universityof the RockiesPress.
Wellcee, ll. (rqgg). The
          A,                 four immeasurables:
                                               Cultivatinga boundlessheart. New Yo*:
   Srrow   [,lon,                                                                                                   Adapting Ancient Wisdom for the
Wegef K, K. (rgg6).How to bea helpinstead a nuisance.
       c,                                     of           Boston:Shambhala.
Young-lllnendrath, (zool). Transference transformationin Buddhismandpsycho-
                      P.                   and
                                                                                                                    Treatment of Depression:Mindfulness-
   enelysfn,n J. D. Safran(Ed.), Psychoanalysis Buddhism:An unfoldingdialogue
               f                                 and                                                                BasedCognitive Therapy Group Training
   (pp.lot-fr8). Boston,     MA: Wisdom.
                                                                                                                    Maggie Chartier,l Robin Bitner,2Tracy Peng,3
                                                                                                                    Nicole Coffelt,3Malrra Mclane,3 and Stuart Eisendrath3'a

                                                                                                                    Thisarticleoutlines discusses models trainingforgroupmindfulness-based
                                                                                                                                       and          two       of
                                                                                                                    cognitivetherapy (MBCT),whichwehavecalled                        MBCT train'
                                                                                                                                                                  inivo and intensive.
                                                                                                                    ing andpractice focuseson present momentexperience  versuscontent an efort to
                                                                                                                    gain a metacognitiveperspective one\ thoughts
                                                                                                                                                    on               and internalprocesses.
                                                                                                                    and trainerssharetheir reflections the trainingprocess well astheexperiential
                                                                                                                                                     on                    as
                                                                                                                    and acceptance-based frameworkof MBCT reJlected the trainingprocess
                                                                                                                                                                        in                  itself.
                                                                                                                    Suggestions optimizing
                                                                                                                               for           trainingacrossmultiple                       and
                                                                                                                                                                    mentalhealthdisciplines set-
                                                                                                                    KEYWORDS:    Grouptherapy                                  experiential;

                                                                                                                    This article is a reflective description of a mindfulness-based cognitive therapy
                                                                                                                    (MBCT) training program to treat depression at the University of California, San
                                                                                                                    Francisco (UCSF), Langley Porter Psychiatric Institute (LPPI). At LLPI, group
                                                                                                                    MBCT is offered to patients with depression several times a year. Trainees across
                                                                                                                    mental health disciplines have a variety of opportunities for training as group lead-
                                                                                                                    ers in this modality.

                                                                                                                        SanFranciscoVA Medical Center,Correspondence                           to
                                                                                                                                                                            should be addressed Maggie Chartier,
                                                                                                                        PsyD,MPH, SanFrancisco Medical Center,4t5o ClementStreet,SanFrancisco,
                                                                                                                                                  VA                                                   CA 94rzr.
                                                                                                                    )   Department of Psychiatry,University of California, SanFrancisco.
                                                                                                                    5   SanFranciscoVA Medical Center.
                                                                                                                    4   S.E.was supportedby grant RolAToo4572-orer     from the National Centerfor Complementary
                                                                                                                        and AlternativeMedicine/NationalInstitutesof Health.
                                                                                                                                                                   rssN 0362-4021 2o1o Eastern Group PsychotherapySociety

.t]o                  ( ;llAR' l' ll{ l{ , ltl' l' Nl{ R, I' ltN( i, ( :(}trFrt,'t', M(:l .A N n, l l l t{l tN l )l rA 't'l t                lfurrl ()tgtlllv('lhffttl'y(iroup'lfulrrltr*
                                                                                                                                Mltnllirlttrss                                                                    .t,

     Mllc'l' holds deccnlcring, gaining a certain lcvcrl objcelive disturrce,
                                or                                                                                              ancloulsicle  grorrptlrrough"hornework"tlrat includes      ttrcditativcpructices. as
                                                          ol                    frour
 thoughts and other internal experiences a cerrtralfbcus,'lhis is accornplished
                                            as                                                                                  patientslcarn thcsenew skills through experience, training required to learn to
 through the teaching and real-time practice of various mindfulness exercisesand                                                deliver this modality demandsno lessof the trainees.MBCT therapistsmust have
 discussionof experiential metaphors in the group setting. Mindfulness-defined as                                               well-developed,experiential knowledge that has been developedthrough their own
 paying attention in the presentmoment, on purpose,and without judgment (Kabat-                                                 practice of mindfulness and acceptance,      which is reflected in this training model.
 Zinn & University of Massachusetts    Medical Center, t99r)-is combined with the                                               The authors of this article, all trained in MBCT, representmental health profession-
presentation of a new way of relating to internal processes  that can profoundly shift                                          als at various levels in psychiatry psychology, and marriage and family therapy. All
the experienceof depressionand an individual's self-perception.There is increasing                                              have had a range of previous training in other psychotherapeuticmodalities aswell
 empirical support for MBCT and the treatment of depression (Eisendrath et al.,                                                 as experiencewith mindfulness in professional and personal contexts.
 zoo8; Finucane & Mercer, zoo6; Kenny & Williams, zooT) and prevention of relapse                                                   This article describes two primary models of training for the delivery of an
 (Kuyken et al., zoo8; Ma & Teasdale,zoo4; Teasdaleet al., zooz).                                                               eight-week group MBCT intervention. We have called them the in vivo model and
     Researchon the training ofgroup psychotherapistshas found that the teaching                                                the intensivemodel,which are described in detail later. We also reflect on the train-
most often naturally flows from the theoretical foundations in which the therapies                                              ing experiencesfrom the perspectivesof both trainees and trainers. We conclude
are rooted. For example, psychodynamic group psychotherapy training has been                                                    with summary thoughts on delivering this type of training in a university-based,
described as a developmental process in which a trainee goes through multiple                                                   medical school environment.
stagesthat meet operational goals based both on dynamic group theory and training
needs.Thesegoalsinclude (but arenot limited to) assessing selectingappropriate
                                                             and                                                                                          IN VIVO TRAINING MODEL
participants; learning fundamental psychotherapeutictechnique witl variations in
a group setting; developing appreciation and understanding of group phenomena;                                                  Traineesin the LPPI psychiatry residency program are given a choice of a number
and building skills for recognizing and understanding issuesrelated to transference,                                            of different time-limited groups to colead in the third year of training, including
countertransference,and termination in the group setting (Gallagher, rgg+).                                                     MBCT for depressionand CBT-basedgroups for treatment of depression,anxiety,
    In contrast, cognitive-behavioral therapy (CBT) group training has a different                                              eating disorders, and chronic pain. Some trainees are particularly interested in
set ofoperational goals based on theoretical foundations that emphasizethe rela-                                                learning MBCT because of a previously established interest or experience with
tionship between thought, feeling, and behavior. Therapistseducateand encourage                                                 meditation and/or mindfulness-based therapies, whereas other trainees may be
participants to learn specific skills such as the identification of thought distor-                                             assignedto colead an MBCT group without any previous interest, experience, or
tions and the use of thought records to influence maladaptive thought patterns.                                                 particular desire to learn MBCT as a therapeutic modality.
In comparison to psychodynamic group therapists, CBT group therapists have                                                          MBCT groups are principally run by two senior clinicians, a psychiatrist and a
been observed to use more cognitive, behavioral, and psychoeducational strate-                                                  master's-levelclinician, who have completed professional training in MBCT. The
gies; to foster self-efficacy;and to be more supportive and empathic compared to                                                trainee serves as an additional coleader to gain experience by engaging with the
psychodynamic group therapists, who use more interpretative and confrontative                                                   group as a leader and participant-observer. The trainee'slevel of participation may
interventions and focus on interactional and dynamic aspects(Watzke, Rueddel,                                                   vary depending on level ofinterest, comfort as a group leader,and previous experi-
Koch, Rudolph, & Schulz, zoo8).                                                                                                 ence with meditation and mindfrrlness-basedinterventions.
    As with CBT, the main focus of MBCT is on skill development rather than on                                                      Traineesattend all eight sessions  and are encouragedto develop a mindfulness
understanding unconscious interpersonal mental processes, in psychodynamic
                                                                as                                                              practice during the sessions  similar to what patients are askedto do, if they do not
group therapy. However, the skills taught in MBCT differ from the skills taught                                                 already havean establishedpractice of their own. Reading materials recommended
in traditional CBT by helping individuals develop a different relationship to their                                             to preparefor sessions  include an instructor's manual developedby the senior group
thoughts rather than changing specific thought content. Thoughts are dealt with                                                 leaders and Mindfulness-BasedCognitive Therapy Depression: New Approach
                                                                                                                                                                                   for             A
as impermanent mental eventsthat come and go. The patient is encouragednot to                                                    to Preventing Relapse(Segal,Williams, & Teasdale,zooz). Trainees are typically
view them as valid factual representationsof the world. In this way, MBCT repre-                                                given a portion ofeach sessionto lead, for which they prepare in advance,and they
sentsa more metacognitive therapeutic process,allowing patients to observetheir                                                 participate in exercises along with group members. The trainee'slevel of leadership
own thought processes.                                                                                                           may increaseas he or shebecomesmore familiar with the principles of MBCT and
    A key component of MBCT is the experiential processthat occurs during group                                                  accustomed to the particular group members and format. Trainees are asked to
                                     r llr\lrlll     [,   ilttNt     tr.   t't   f.](.,   i ()l   | | | t,   Al(   | ANI   I t,rt   NtrIAttl

 tl o l l t t ' s ilt l) ( " ' ll( ) t t l (' w ()tl l(" tt l ' !r' ()un)l (' n l l )r' rs o r ,vl ri l t' i rrl rr' ti rotrp, l ttl rrtl i rrl i
                                                   l li                 l                rl                   l               i                          Ittr oi l l r .r :, 1   l o o l l rr' t   l i t t l U l rl l t l ' r' 1 1 P y (' x l )r' l i (' i l ((' \ ,
                                                                                                                                                                                                                                                                       lttttttt't   t t i t l l l (' (' s (()l l l l )l (' l l l (' (l   llt

 45  r'r r ir r t lt c s r r r ir r rl l i rl l rc ls s c ti c c .g .,[ro tl ys c i ln,y()l ]i r, tti rrgrrrcrl i tl l i on)
                        ol                             )ra            (c                                    si                             at       tl rc l ol l ow ir r tw, r y:
 horncsix daysa week.
      Prior to the start of each group, the trainers meet with the traineesto cliscuss                                                                   .         "'lhis trainingwasflore focused a teaching
                                                                                                                                                                                                 on         modelthan on groupprocess.
 the MBCT group structure,rationale(including differences                                                from other modalities),                                   In many ways, it was simPleri'
 and expectations                 (basedon trainee's                 interest,experience,           and comfort in the group                             .         'I liked the manualized approach better. I knew what I was supposed to
 setting). The traineesare given avideo, MindJulness-Based                                           Stress      Reductio,x, orient
                                                                                                                                to                                 be doing."
 to the generalclassstructure,readingson mindfulness,and the MBCT instructort                                                                            .         "I dont like leading groups,but in the MBCT group, I felt more like a teacher.
 manual. Trainees                  also participatein a pregroup screeningprocess,                                      after which the                            That was better for mel'
 trainers meet with traineesfor one to two follow-up meetings to review patient
 interviews, answer any questions about the training process,and discusstrainees'                                                                       Sometraineesfound coleadingthe MBCT groupschallenging.Somefound the
 concerns about starting the group and how active to be in it.                                                                                      reading and/or mindfulness practicesdone at home too time consuming and did
      The MBCT group trainerstake the lead rolesin presentingMBCT to the group                                                                      not do them. Some found learning how to meditate difficult. One former trainee
 members such as rationale,attitudes,and mindfulness practices.This is tlpically                                                                    commented,"I didnt know anything about MBCT prior to the experience, I felt   so
 challenging for beginning trainees to explain effectively.This material should be                                                                  like I was winging it." This is consistentwith recent data that suggestthat new group
conveyedin an authentic manner by experiencedmeditators rather than by reciting                                                                     therapists often feel uneasy about leading groups, stemming from a fear of public
from a manual.Traineesare encouraged lead some of the experientialpracticesto                                                                       exposureabout revealinga lack of competence(Hahn, zoog)-
starting with simpler exercises,such as eating a raisin mindfully, and those most                                                                       There were also some challenges in titrating the right amount of clinical re-
familiar to them, such as the CBT exercises                                         (identifying thoughts, feelings,and                             sponsibilityto give eachtrainee.For example,one traineehad a good deal of prior
consequences behavior) or discussionof Diagnosticand StatisticalManual of
                            of                                                                                                                      meditation experienceand felt she was not given enough to do as a coleader in the
Mental Disorders, fourth edition, symptoms of depression (American Psychiatric                                                                      group. Someother trainees,especially    thosewithout any prior meditation experience,
Association,             r994).                                                                                                                     were anxiousabout assuminga leadershiprole and preferredmore of an observer
     Foilowing eachof the eight sessions MBCT groups,trainersand traineesdiscuss
                                                                      of                                                                            statusfor the mindfulnesscomponents.
group processand content for 3o-45 minutes. Trainersanswertrainees'questions                                                                            commenting on using the training in MBCT after the initial experience,trainees
and provide feedback about how different tasks and exerciseswere handled. The                                                                       reflected as follows:
leaders then distribute tasks for the following session,with an explanation of the
rationale.After completing the eight sessions, trainers give overall feedbackto      the                                                                  .         'Although I feel MBCT and mindfulness techniques are very useful, I have
the trainees in person and complete an electronic evaluation that is transmitted to                                                                                 found it difficult to find a way to bring the principles into my work with
the residency training program. Traineesare also offered a reciprocal opportunity                                                                                   individuals. I find it difficult to convey the paradox of not 'trying to get
to give feedbackto the trainers about the learning experience.                                                                                                      better'while a patient is in treatmentl'
     Someformer traineeswere askedto comment on their experiences coleaders                                                as                             .         "I feel much more able to make an appropriate referral to a mindfulness-
of MBCT groups in this training model. All felt that participation in the MBCT                                                                                      basedtherapyl
program was positive both personally and professionally.                                                 Former traineescom-                              .         "So many peoplein the SanFrancisco  Bay areahaveexperiencewith medi-
mented in the following way:                                                                                                                                        tation or yoga. Going through the experiencewith MBCT has given me a
                                                                                                                                                                    common languageto discussthesetopicswith patientsi'
      .      "I had a misunderstanding what mindfulnesswasbeforeparticipatingin
             the group. Now I know itt not about trying too hard to concentrate."                                                                                                                  INTENSIVE TRAINING MODEL
      .      "I still usesome of the techniquesmyself; especiallywhen I'm really stressed
             outl'                                                                                                                                  The trainers also offered intensive training in MBCT. Its primary purpose is to
      .      "l really enjoyed hearing the patients' experiencesand watching them make                                                              provide an in-depth training experiencefor therapists in preparation for coleading
             new discoveries   about their own mindsl'                                                                                              MBCT groups for an upcoming randomized clinical trial using MBCT for treatment-
     .       "I especially enjoyedthe focus on the body using yoga and the body scan."                                                              resistantdepressionbeing conducted at UCSF.The training was expandedto involve
.tr4                    ( :il A R' t' ililt, lil' t' N F ,R, tr ilN0 , ( :( ) trtrt{t,'t"M( :t,A N tl , ti i l i l {N l )R A 'l l l
                                                                                                                                      M Indlitlt 'l"tsllnrei ( hgnltlvc'I ln'rupy ( )roup'IlttlttIrrg                   tt5

other cliniciansinterested learningMBCIl incluclingpsychiatrists
                            in                                         anclpsycholo-                                                           lircusedon 0 spccilic casewas very different and f'eltnrore intimate than a
gistsat various levelsof training. This enriched the overall training experience  for                                                          conlbrence."
trainers and clinicians. This in-depth training was ideally to be paired with the in                                                      .    "l appreciatedthe opportunity to lead meditations with peers and receive
vivo experience described earlier before a therapist was considered competent to                                                               feedbackl'
conduct MBCT groups independently.                                                                                                        .    "This was a good introduction to MBCT, especially for clinicians already
    The trainingbegan with a detailedpresentationon MBCI includingthe develop-                                                                 familiar with mindfulness-based psychotherapiesand groups."
ment ofthe process,the theoretical and technical rationale, and a discussion ofthe
researchfindings supporting its applications.The format followed the eight-session                                                              COMBINATION              IN VIVO AND INTENSIVE TRAINING
model of MBCT, with 2.5-hour weekly sessions      devoted to reviewing and practicing
mindfulness exercises.The trainers and study therapist presented the meditation                                                       Sometrainees experiencedboth the in vivo and intensive models. Traineesfelt that
practices experientially, followed by group discussion ofthe practice. The trainees                                                   the first stepof in vivo training (reading the MBCT materialsand coleadinga group)
were then ableto practice delivering the classcontent to eachother with immediate                                                     provided immediate, active application of the MBCT exercisesand principles to
feedback from the instructors. Practice was followed by a review ofsession goals                                                      patients,in a supported context. Others felt there was lesstime and spaceto integrate
and discussionof the mindfulness skills taught that session,subsequentlyfollowed                                                      mindfulness principles personally before being askedto addresspatient issues.The
by a discussion ofthe techniques.                                                                                                     second step in the intensive model (participating in the group training in MBCT)
    Owing to the experiential nature of MBCT conceptswere presented and prac-                                                         provided supervision outside the setting ofpatient care and involved a peer group
tices delivered in much the sameway asto a patient population, but with additional                                                    of mental health professionalsdemonstrating interest in, and opennessto, mindful-
emphasis on the theoretical and empirical underpinnings for each exercise.This                                                        ness.The experience of participating in both ways of being trained in MBCT was
type of group MBCT training does not include coleading an MBCT group; clinical                                                        thought to be synergistic, offering both a supportive learning environment and a
applications were carried out in more heterogeneoussettings.Sometrainees,espe-                                                        practical senseof how MBCT might be offered in a group setting for patients with
ciallythose with previous mindfi.rlness training, startedto usethe MBCT techniques                                                    depressionwith real-time modeling by seasonedfaculty.
they had learned in the intensive training model with their patients struggling with
depressionin various settings:                                                                                                                                          THE MBCT TRAINERS

       .   'Although I was not leading an MBCT for depressiongroup at the time, I                                                     From the trainers' perspective,the combination of in vivo and intensive training
           would apply exercisesbrought up in the training with individual patients                                                   is an ideal way to fully prepare the trainees for being independent practitioners of
           addressingdepressionor self-critical thinkingJ'                                                                            MBCT. Owing to time constraints, most of the trainees choseonly one method of
       .   "The main difference between group MBCT training and group therapy                                                         training yet gained considerableskills. The challengefor many in learning MBCT is
           supervision, in my experience, was the emphasis on mindfulness-based                                                       similar to that ofthe patients: changing frorlaa doingto abeingmode. Many trainees
           experiential exercisesand the lack of emphasis on psychological content                                                    approachtroubledpatients bytryingto help them changedepressogenic          thoughts or
           of thoughts or emotions which might arisei'                                                                                alter cognitive distortions. MBCT shifts this type of doing to allow those thoughts
                                                                                                                                      but help the patient changethe relationship to them, allowing them to just be and
    Sometraineesthought the manuals were somewhat confusing and that practic-                                                         pass from consciousnesswith the next thought. This metacognitive shift can be
ing in a group with other mental health providers would not provide an adequate                                                       challenging but also-as trainees grasp this therapeutic stance-rewarding. Train-
reallife, patient experienceof potential barriers to theseideas.Others commented                                                      eesoften comment that they feel less in a debatemode with chronically depressed
on the training in the evaluation:                                                                                                    patients attached to negative cognitions.
                                                                                                                                          Similarly, helping patients shift their attitudes toward accepting dysphoric states
       .   "It was good to experience the whole sessionlike patients. It was really                                                   rather than trying to eliminate them differs from other therapeutic approaches.
           helpful to notice or imagine how a patient might feeli'                                                                    MBCT emphasizesthe role of acceptanceas laying the groundwork for skillful re-
       .   "Lots of hands-on practice in the sessions-forces you to jump in and do it!"                                               sponsesrather than reflexive reactions.This is also distinct from passivity or lack of
       .   "I have either been to large conferencesor have had one-on-one supervi-                                                    response,  which is often howthe stanceof acceptance misinterpreted. Someof the
           sion for my patients. This short-term, small group training that was not                                                   trainees have to make a paradigm shift to relinquish an attitude toward dysphoric
                                    ( ll/\lr   lll   lr,   lil   lNl   l(.   l'l.N{;,   ( r)lll   I I,   Nl(   Lr\N1..,   l,lsl   Nl)lrAltl   A l ttt,l l ttl tt,.   l l ,t.r tl t tt.r' ttrl tt' tl l t,' t,r1' yt ' rtttrl ' I trtttrrtt!"

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                                                        lo                l<      l.                                                                (()rfff:,('lrti l ' .((' nl (' t:..l ttl (' tttttl i ottti l l ottrtt,i l ol (i rorrp l ' s y tl nl l tttrtpt".l u(' t)'   5' l l 55' r'

is a cluirlitativcshili in unclcrstanding thc powcr ol'a nrinclfuhressapproach.                                                               hi rtri rt Zi rrrr, f.,& tJ rri v ets i ty ol       Mi ts s ac l l us c tts Mc tl i c a[(]c tttc r,w orc c s tc t,s trc s s l { c tl trc ti ott

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                                               SUMMARY THOUGHTS                                                                                            pain, and illness. New York: Dell.
                                                                                                                                              Kenny,M. A., & williams, J.M. (zooz).Treatment-resistant      patients
                                                                                                                                                                                                    depressed       showa
                                                                                                                                                goodresponse mindfulness-based
                                                                                                                                                              to                 cognitive              Research Therapy,
                                                                                                                                                                                          therapy.             and
We have discussedtwo primary modes of training in MBCT, one of which allows
for real-world patient experience and supervision (in vivo), whereas the other is                                                               + S b),612- 62s.
more experiential, in a group of professionalstraining together without the benefit                                                           Kuyken,W., Byford,S.,Taylor,R. S.,Watkins,E', Holden' E', White' K'' et al'
                                                                                                                                                Mindfulness-based    cognitivetherapyto preventrelapse  in recurrentdepression.
of real patient contact and closesupervision(intensive).Ideally thesetwo models
would be paired to provide the optimal group training experience.Most trainees                                                                  lournal   of Consulting Clinical
                                                                                                                                                                      and        Psychology,z6(6)' g66-gz8'
                                                                                                                                              Ma, s. H., & Teasdale, D. (zoo+).Mindfulness-based
                                                                                                                                                                   J.                            cognitivetherapy depression:
only completedone of the two models and reported exporting MBCT techniques
and strategiesto work with depressed   patients into their clinical practice. It is likely                                                       Replicationandexplorationof  differentialrelapseprevention      lournalof Con-

that the extent ofprevious and current exposureto mindfulness and group therapy                                                                 sultingand Clinical Psycholo 7z(t), 3r-4o'
                                                                                                                                                   z.,williams, I. M., & Teasdale, Qooz).Mindfulness-based
                                                                                                                                              segaI,                               J.                         cognitivetherapyfor
greatly affectsthis training experience.
    MBCT training and practicefocus on experiencein the moment, working toward                                                                   depression.New York Guilford.
greateracceptance   ofselfand internal processes. Thoughts come to be seenasevents                                                            Teasdale,D.,Hayhurst, Moore,R' G.,Pope, Seagal' V'' &Williams' S'
                                                                                                                                                      J.               H.,                   M',        Z'
                                                                                                                                                 Metacognitive awareness prevention
                                                                                                                                                                           and                    in
                                                                                                                                                                                        of relapse depression:  Empiricalevidence'
in the mind, independentof their content and emotional charge.       They need not be
disputed,fixed, or changedbut are held in a more spaciousawareness.        Depressive                                                            lournal of Consulting and ClinicalPsychology,7o(z)' 275-287'
thoughts can then be seenas transient mental events rather than as a core identity                                                            Watzke, Rueddel, Koch, U., Rudolph,M', & Schulz, (zoo8)'Comparison
                                                                                                                                                      B.,          H.,                                   H'
of the depressedindividual. Trainees may encounter multiple challengesas they                                                                    therapeuticaction, style,and contentin cognitive-behavioural psychodynamic
                                                                                                                                                 group therapy under clinically  representativeconditions' Clinical Psychologyand
begin to understand how their own minds operateand affect their experienceof the
world around them, just asgroup participants do. MBCT training differs from many                                                                                 t5$)'
                                                                                                                                                     PsychotheraPY, 4o4- 4r7.
group therapy training programs by emphasizing that the clinician develop his or
her own mindfulness practice and self-inquiry to bring authentic self-knowledge
to bear on helping clientsin emotional distress.


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Gallaghea E. (zoo4).Stages
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                                                     supervision: modelfor super-
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