Prof. Mark Williams is the Director of the Oxford Mindfulness Centre. He helped in the development of Mindfulness Based Cognitive Therapy as one alternative in the prevention of relapse and recurrence in depression.
All of us will encounter depression and stress related issues from time to time throughout our lives. Thankfully for a lot of us, these bouts with depression are temporary from which we rebound quickly with no lasting damage. Unfortunately, far too many people in modern society suffer from deeper, longer, and crippling recurrent episodes of depression that cause serious damage to the sufferer.
We need first to understand what depression is and, second, how to alleviate the crippling effects of depression, especially for those who suffer recurrent episodes of depression. Buddhistdoor International discussed these issues with Prof. Mark Williams from the Oxford Mindfulness Centre.
How should we define depression? According to Prof. Mark Williams, depression goes beyond simply feeling low or irritable or grouchy which we all feel sporadically for short periods of time. To be designated a fully blown episode of depression a few of the following symptoms should occur together which impair the person's mental and physical functions: low mood, lack of interest, cannot eat, have feelings of guilt, being fatigued and having no energy. These symptoms should happen everyday over a period from more than two weeks up to eight to ten months. Serious cases involve patients experiencing unrelenting depression for 4 months out of 12.
For the treatment of depression, the traditional approach has been one of medication in conjunction with various therapies, one of which is cognitive therapy. Another approach was how Buddhist studies and scientific disciplines could converge to address issues of depression. More than 30 years ago Jon Kabat-Zin's Stress Reduction Programme brought together the Four Foundations of Mindfulness from the Buddhist tradition into an 8 week programme. By focusing on one aspect of Buddhist practice, meditation, and calling it Mindfulness, Kabat-Zin was able to introduce Buddhist practice to ordinary people in the West who had no knowledge of Buddhism as a complementary therapy to help people cope with various health problems.
Mark Williams was interested to discover if Jon Kabat-Zin's 8 week programme could be effectively adapted with some aspects of cognitive therapy into an effective alternative to medication in the treatment of people with periodic or chronic depression. More importantly for Williams, could Mindfulness Based Cognitive Therapy (MBCT) provide some help to prevent or reduce a relapse or recurrent depression?
Mark Williams stresses the importance of Kabat-Zin's focus on training mental attention. 'First, people's attention gets hijacked all the time; second, a way of focusing on the body rather than the ruminations of the mind was really helpful for depressed people. Also, it is a way to break out of habits of mind that have been around a long time. In depression, classically, you go around the same thing again and again. How to break out of that? You can observe this, even with people not in an episode of depression.'
One of the main aims of MBCT is to sharpen awareness in the patient of small shifts towards negative moods. How can mindfulness training help to shape new positive thought patterns for patients with traumatic histories? Mark Williams is well aware that this is not easy and requires dedicated practice. Williams said that according to research, the use of MBCT as a treatment method has reduced risk of depression by 50% and is as effective as taking anti-depressants. A similar result has been found for patients with long traumatic histories
We need to awaken our awareness to the small changes in our mood, which may lead to an episode of depression. But many of us find mental training in awareness to be laborious, painful and something we want to avoid.
'Many people say they are too aware! They want to stop thinking about it. Yes, often we are aware because we are overthinking, it's an immediate thinking awareness but we are not really very aware of our body for example, not aware in a non-judgemental way. We tend to be aware in a judgemental way: our awareness is filled with thoughts, with judgements, with wishes about the past and future, with taking our thoughts personally and seriously, with avoiding what we don't want, with ruminating about what we do want.'
According to Williams, most of us have an unwise form of awareness because we may not necessarily realise when our mood has shifted in small ways and how we should react. 'Often our mood has shifted; rather than holding it gently and compassionately, we start blaming ourselves. What is going to happen to me? This is terrible! I am going to get depressed again. And, before long, you are down. So, by bringing the lens of non-judgemental, really openhearted awareness to the little, tiny mood shifts, it enables people to see clearly what's happening without becoming drawn into the force of the mood.'
During the 8 week MBCT programme, patients go to class 2 hours a week and the class size is 12 to 15 on average. In addition to class activities, they are given meditations of 40 to 45 minutes on CD or for download to take home. They need to find this time for meditation on a daily basis, which requires a certain amount of self-discipline and the ability to reconstruct their day to fit this activity into. 'What is amazing is to see that people do, and can, turn their lives around because it only takes a flash of a second to suddenly see that there is a different way to be.' Williams is aware of and appreciates the enormous commitment involved to finish the 8 week long programme.
What follow up care activities are provided in case a course participant fears a relapse? Initially, they are given a book with short and long meditations as well as meditations of 3 minutes’duration and exercises on how to incorporate them into their daily routines. According to Williams, '…they've got ways of spotting their moods going down, ways of standing back and observing their moods with compassion and ways in which they can begin to see how they might fit this into their life, like brushing teeth, washing hands….' Additionally, people who feel down can opt for over a week or more of intensive meditation as well as attending day classes or refreshing their practices at Thursday evening sessions.
What is the extent of chronic depression and how to treat it? Williams stated that 20% of patients diagnosed with depression remain depressed. Some patients find medication is a lifesaver but it is not suitable for everyone. It is satisfying to know that MBCT can be a good alternative to medication. In early studies, Williams and his colleagues determined that between two trial groups, one on medication and the other not, the beneficial effects of doing MBCT for treating depression were found to be equivalent.
Mark Williams has this to say on the use of medication for depression: 'One of the things we know about medication is that it works as long as you keep taking it but when you come off medication, your risk of relapse goes back to what it was before you started taking it. So, medication often gets you well and nothing has been found to be better than medication but when you stop taking it, you tend to relapse within a year. For some people, they don't want to take medication, they want something that would prevent a new episode.'
MBCT addresses and alleviates the debilitating effects of depression which has a pattern of early onset and recurrent bouts over a lifetime. 'Of the people, [seen by Williams and his team], who were depressed at least 3 times, 50% become depressed before 18, a childhood onset. Indeed, when you look at the shape of the curve of the onset, the most common age to first get depression is between 13 and 15 years old. We know that 20% of people are going to become depressed during their lifetime. 10% of the population are depressed before they become adults and often they are not treated then, so that's a long time where they suffer depression without getting proper treatment.'
Mark Williams and his team are carrying out valuable work in the fight against depression. Reception of MBCT has been positive and seen as non-threatening to non-Buddhhists/non-believers although it originally comes from Buddhist teaching. It will be interesting to see how MBCT develops in the future.
From a Buddhist perspective, it is intriguing to see how within a secular context, a central component of the Buddhist path, Mindfulness, can be transformed into an effective tool for combatting mental illness. Much work remains to be done to monitor this transformation and its implications.
Watch Prof. Williams' further discussion with Buddhistdoor International
Watch Prof. Williams' further discussion with Buddhistdoor International
Oxford Mindfulnfess Centre: http://oxfordmindfulness.org/