Cogn Ther Res DOI 10.1007/s10608-013-9586-4 ORIGINAL ARTICLE Mindfulness Practice, Rumination and Clinical Outcome in Mindfulness-Based Treatment Lance L. Hawley • Danielle Schwartz • Peter J. Bieling • Julie Irving • Kathleen Corcoran • Norman A. S. Farb • Adam K. Anderson • Zindel V. Segal Ó Springer Science+Business Media New York 2013 Abstract Mindfulness-based cognitive therapy (MBCT) was associated with decreased rumination, which was and mindfulness-based stress reduction (MBSR) are par- associated with symptom alleviation. ticularly effective treatment approaches in terms of alle- viating depressive symptoms and preventing relapse once Keywords MBCT Á MBSR Á Mindfulness practice Á remission has been achieved. Although engaging in Depression Á Rumination Á Distraction mindfulness practice is an essential element of both treat- ments; it is unclear whether informal or formal practices differentially impact on symptom alleviation. The current Introduction study utilizes a correlational design to examine data pro- vided by thirty-two previously depressed, remitted outpa- An increasing awareness exists among healthcare profes- tients who received either MBCT or MBSR treatment. sionals that mindfulness-based approaches are particularly Outpatients in the MBCT group received treatment as part effective in terms of alleviating depressive symptoms and of a previously published randomized efficacy trial (Segal preventing relapse once remission has been achieved. et al. in Arch Gen Psychiatry 67:1256–1264, 2010), while Interventions such as mindfulness-based cognitive therapy those in the MBSR group received treatment as part of a (MBCT; Segal et al. 2002) and mindfulness-based stress separate, unpublished randomized clinical trial. Through- reduction (MBSR; Kabat-Zinn 1982, 1990) have demon- out treatment, clients reported on their use of formal and strated significant clinical efficacy in the treatment of informal mindfulness practices. Results indicate that various clinical presentations, including mood disorders engaging in formal (but not informal) mindfulness practice (e.g., Segal et al. 2010), treatment resistant depression (Eisendrath et al. 2008; Kenny and Williams 2007), and anxiety disorders (Hofmann et al. 2010; Evans et al. 2008; Kim et al. 2009), leading to significant improve- L. L. Hawley (&) Á D. Schwartz Á J. Irving Á Z. V. Segal ments in psychological functioning. Meta-analyses indi- Centre for Addiction and Mental Health, 100 Stokes Street, cate that successful MBCT treatment is associated with Toronto, ON M6J 1H4, Canada symptom reduction and up to 50 % reduction in depres- e-mail: [email protected] sive relapse risk (Hofmann et al. 2010; Piet and Hougaard L. L. Hawley Á N. A. S. Farb Á A. K. Anderson Á Z. V. Segal 2011). Similarly, researchers who have examined the University of Toronto, Toronto, ON, Canada efficacy of MBSR treatment have demonstrated that MBSR treatment leads to reduced depressive symptoms P. J. Bieling St. Joseph’s Healthcare, Hamilton, ON, Canada (Sephton et al. 2007; Shapiro et al. 1998) and improve- ments in various indicators of psychological well-being K. Corcoran (Grossman et al. 2004). Stanford University, Palo Alto, CA, USA Although the clinical efficacy of mindfulness-based A. K. Anderson interventions have been well established, the mechanism Rotman Research Institute, Baycrest, Toronto, ON, Canada by which mindfulness practice leads to symptom 123 Cogn Ther Res alleviation is not entirely clear. When clinicians discuss One possibility is that mindfulness practice is only one mindfulness concepts with their patients, they emphasize element of a complex process that leads to symptom alle- that engaging in regular mindfulness practice is essential in viation. It may be that there has been a failure to model the order to promote lasting clinical change. This view is mediating steps between practice and outcome, which may supported by information-processing models which pro- account for the mixed findings described above. Several pose that mindfulness practice allows for the development mechanisms have been proposed in order to clarify this of enhanced capacities for regulating emotion, cognition, relationship. According to information processing models and behavior (Segal et al. 2002; Shapiro et al. 2006). Both of depression, vulnerable individuals who experience dys- MBSR and MBCT emphasize the importance of daily phoric affect may experience depressive relapse when mindfulness practice throughout treatment—prescribing problematic forms of thinking and feeling are reinstated between 45 and 60 min of daily practice over the course of (Segal et al. 2002). Two relevant forms of problematic 8 weeks (Kabat-Zinn 1990; Segal et al. 2002). In both thinking are termed rumination and distraction (Nolen- treatments, participants engage in mindfulness exercises Hoeksema 1991). According to the Response Styles The- that are either formally or informally structured. In a for- ory of Depression, individuals who are vulnerable to mal practice, guidance is provided involving the nature and experiencing depressive episodes typically respond to content of the practice (e.g., suggestions are made depressive affect by either engaging in rumination (defined regarding posture, attitude, and how one directs their as a problematic cognitive process in which individuals attention) for a specific period of time. During informal repetitively focus on symptoms of distress, and on their practices, individuals bring mindful awareness to routine possible causes and consequences) or distraction (in which experiences that occur throughout the day; these practices individuals divert their attention away from depressive are less structured, and do not require a set length of time. experiences in order to change them into neutral or pleasant In MBCT and MBSR, the assigned mindfulness prac- thoughts and actions). Although it is believed that dis- tices are identical; however, there are treatment elements traction may temporarily alleviate feelings of dysphoria, which are unique to each intervention; the psychoeduca- engaging in rumination often prolongs and intensifies epi- tional material presented differs, the therapists’ guided sodes of depression. These problematic modes of thinking inquiry process differs, and discussions involving symptom are considered to be well established cognitive vulnera- management approaches differ regarding how mindfulness bility factors for the onset, relapse and recurrence of practice plays a role in assisting individuals to maintain depressive episodes (Robinson and Alloy 2003; Nolen- remission from depression. Despite these differences, both Hoeksema 2000). Several studies have provided evidence approaches emphasize the fundamental importance of suggesting that individuals who experience symptom alle- engaging in daily mindfulness practice in order to viation demonstrated decreased ruminative thinking fol- encourage present moment experiential awareness. lowing mindfulness training (e.g., Ramel et al. 2004). Considering the level of commitment that is involved Decreased rumination has been associated with symptom with mindfulness-based interventions, one could assume alleviation (Kingston et al. 2007), and reduction of that there is a well-established association between the depression symptoms were mediated by decreased rumi- amount of time an individual engages in mindfulness nation following MBCT (Van Aalderen et al. 2012). practices and subsequent symptom alleviation. Unfortu- Overall, these results suggest that mindfulness practice nately, this relationship remains somewhat unclear. For an reduces mood symptoms only to the extent that it reduces a extensive review of the mixed findings involving the rel- mediating cognitive pattern such as rumination or distrac- ative impact of mindfulness practice in MBCT and MBSR, tion. It may be that individuals who utilize mindfulness see Vettese et al. (2009). In brief, only eight of the twenty- practices on a regular basis become better able to engage in four studies that the authors reviewed demonstrated support effective attention regulation strategies when they experi- for the relationship between mindfulness home practice ence dysphoric affect. and clinical outcome. For example, Carmody and Baer The purpose of the current study was to examine the (2008) reported that formal meditation practice during possible mediating effects of rumination and distraction in MBSR treatment was significantly related to improvement the relationship between mindfulness practice (total, formal in depressive symptoms, well-being, and characteristics of and informal) and depression symptom change. Data from mindfulness. In contrast, Bondolfi et al. (2010) demon- two studies were combined; the first dataset involved data strated that the frequency of mindfulness practice (formal resulting from an 8 week MBSR program offered by St. or informal) following MBCT treatment did not differ Joseph’s Healthcare, Toronto (the details of the study based on relapse status. Taken together, there remains design are discussed below). The second dataset involved some degree of uncertainty regarding how forms of med- data provided by individuals receiving an 8 week MBCT itation practice may influence treatment outcome. intervention as part of a randomized clinical trial; an 123 Cogn Ther Res overview of the study design for this second dataset has Participants and Study Flow been reported in Segal et al. 2010. A brief description of each study is provided below. The present study