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Acceptance and Change: The Integration of Mindfulness-Based Cognitive Therapy
Into Ongoing Dialectical Behavior Therapy in a Case of Borderline Personality
Disorder With Depression
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Clinical Case Studies
Clinical Case Studies
Acceptance and Change
The Integration of Mindfulness-Based
Cognitive Therapy Into Ongoing Dialectical
Behavior Therapy in a Case of Borderline
Personality Disorder With Depression
Debra B. HussRuth A. BaerUniversity of Kentucky, Lexington
Both dialectical behavior therapy (DBT) and mindfulness-based cognitive therapy (MBCT)include training in mindfulness skills and address the synthesis of acceptance and change.
DBT is a comprehensive treatment for borderline personality disorder (BPD). MBCT wasdeveloped for prevention of relapse in individuals with a history of depressive episodes. Bothhave considerable empirical support for their efficacy. Many individuals with BPD also sufferfrom depressive episodes, which can interfere with motivation to participate in DBT. In suchcases, it may be helpful to integrate strategies designed to prevent recurrence of depressiveepisodes. This case study describes integration of MBCT into ongoing DBT in the treatmentof an individual with BPD and a history of depressive episodes. Findings suggest that MBCTcan be successfully integrated into ongoing DBT in cases in which prevention of depressiveepisodes is an important goal. Findings also suggest that mindfulness skills may be very help-ful in enhancing the efficacy of traditional cognitive-behavioral treatment approaches.
mindfulness-based cognitive therapy; dialectical behavior therapy; mindfulness;acceptance and change
1 Theoretical and Research Basis
Dialectical behavior therapy (DBT; Linehan, 1993a, 1993b) and mindfulness-based cog-
nitive therapy (MBCT; Segal, Williams, & Teasdale, 2002) both belong to the recentlydescribed expansion of the cognitive-behavioral tradition known as the third wave (Hayes,2004; Hayes, Follette, & Linehan, 2004), after traditional behavior therapy and cognitivetherapy. Third wave treatments generally include concepts such as mindfulness, accep-tance, and dialectics and address the relationship between acceptance and change, oftenthrough training in mindfulness skills. Mindfulness can be described as the self-regulationof attention to nonjudgmentally focus on particular stimuli, including bodily sensations,perceptions (sights, sounds), cognitions, and emotions (Kabat-Zinn, 1990). Participantslearn to observe these phenomena without evaluating their truth, importance, or value andwithout trying to escape, avoid, or change them. Development of mindfulness skills is
believed to lead to increased self-awareness and self-acceptance, reduced reactivity tothoughts and emotions, and improved ability to cope with problematic situations (Linehan,1993a, 1993b).
DBT was developed for the treatment of borderline personality disorder (BPD) and
emphasizes the synthesis of acceptance and change. It includes a wide range of behavioraland cognitive strategies designed to help individuals change their behaviors, emotions, andthoughts. To encourage acceptance of one’s history and current experiences, including dis-comfort associated with change, DBT also incorporates training in mindfulness skills,including observation, description, and acceptance of current experiences (e.g., sensations,cognitions, and emotions) without evaluation or self-criticism and participation in currentactivities with undivided attention. DBT has strong empirical support for its efficacy(Robins & Chapman, 2004).
MBCT is an 8-week, manualized group program based largely on the mindfulness-based
stress reduction program (MBSR) developed by Kabat-Zinn (1982, 1990). MBCT wasdeveloped for the prevention of depressive relapse and has been shown in randomized tri-als to be effective for individuals with a history of three or more major depressive episodes(Ma & Teasdale, 2004; Teasdale et al., 2000). MBCT includes mindfulness practicesdesigned to cultivate nonjudgmental observation and acceptance of bodily sensations, cog-nitions, and emotions. Participants learn to engage in sustained observation of these phe-nomena, with an attitude of interest and curiosity, and to accept them as they are, withouttrying to change or escape them. MBCT also includes elements of cognitive therapy thatare consistent with nonjudgmental acceptance of current experience. A decentered view ofthoughts is emphasized, in which participants are encouraged to view their thoughts as tran-sient mental events rather than as aspects of themselves or as necessarily accurate reflec-tions of reality or truth.
Several mechanisms by which mindfulness may lead to symptom reduction and
improved functioning have been suggested (Kabat-Zinn, 1982; Linehan, 1993a, 1993b;Segal et al., 2002). Sustained observation of aversive thoughts and feelings may functionas exposure to these phenomena and lead to reduced emotional reactivity and fewer mal-adaptive escape and avoidance behaviors. Mindfulness also may encourage a particular per-spective on internal events: that thoughts are just thoughts, are numerous and transient, maynot be true or important, and do not necessitate specific behaviors. Mindfulness also maylead to improved self-observation, which may promote better recognition of internal statesand ability to use adaptive coping skills. Thus, mindfulness skills may be applicable to awide range of disorders.
Although DBT and MBCT share an emphasis on mindfulness, important differences can
be noted. Linehan’s (1993a) biosocial theory of BPD assumes that many individuals withBPD have grown up in severely dysfunctional environments in which they could not learnimportant skills. For this reason, DBT includes explicit instruction in a wide range of skills,including emotion regulation, interpersonal effectiveness, distress tolerance, problem solv-ing, and behavioral analysis strategies. MBCT, in contrast, assumes that bringing mindful-ness awareness to current experience will enable individuals to cope adaptively withdifficulties by using skills already in their repertoires. Thus, MBCT places much lessemphasis on teaching skills for behavior change. In addition, MBCT is an 8-week protocol
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with a clear agenda for each session and a focused goal: to teach mindfulness skills necessaryto prevent relapse of depressive episodes. Standard outpatient DBT, in contrast, generallyinvolves a 1-year commitment to treatment involving both group and individual sessionsand encompasses a much broader array of goals tailored to the needs of the client. Finally,MBCT teaches mindfulness skills primarily through the practice of lengthy meditationexercises, in which participants spend up to 45 minutes sitting or lying quietly and direct-ing their attention in specific ways. Linehan (1994) argues that many individuals withsevere BPD are unable or unwilling to meditate this extensively. For this reason, DBT doesnot use extended meditation practices but rather provides a wide range of much shorterexercises for the practice of specific mindfulness skills, such as nonjudgmentally observ-ing and describing.
Many individuals with BPD also suffer from depressive episodes (Diagnostic and
Statistical Manual of Mental Disorders
; American Psychiatric Association, 2000). Althoughdepressive episodes can be treated effectively, the risk of relapse is high and increases witheach episode. Prevention of relapse is a central challenge in the treatment of depression(Segal, Teasdale, & Williams, 2004). Depression is likely to interfere with motivation toparticipate in DBT, a rigorous and demanding treatment. Thus, for individuals with bothBPD and a history of depressive episodes, it may be useful to include treatment strategiesdesigned to prevent depressive relapse. MBCT has been shown to be effective for this pur-pose and may be beneficial for those clients willing and able to engage in the necessarymeditation exercises.
The following case study describes the integration of MBCT into ongoing DBT in the
treatment of an individual with BPD and a history of depressive episodes and other symp-toms. When the client presented for treatment, her symptoms and skills deficits made heran excellent candidate for DBT. After she had learned a number of DBT skills and gainedparticular benefits from the mindfulness skills, it became clear that MBCT was consistentwith her goals to become more aware of her emotions and to prevent additional depressiveepisodes. We hypothesized that MBCT could be integrated into the structure of ongoingDBT and would provide the client with tools helpful in maintaining her mental health overthe long term. As described in the following sections, however, we also found that themindfulness skills learned in MBCT showed more immediate benefits in facilitating theclient’s progress in DBT.
2 Case Presentation
Ann was a Caucasian female in her mid-50s with one grown child living outside the
home. She had been married for 10 years but had separated from her husband just beforebeginning the therapy described herein. She held a bachelor’s degree in early childhoodeducation but had been unemployed for 10 years because of poor mental health. She reliedon financial support from her husband despite their marital difficulties. Ann spent her dayssleeping, tending to her house, engaging in arts and crafts, and taking care of her pregnantdaughter who was on bed rest. Although Ann was not living with her husband, she fre-quently visited him to cook and clean the house, despite feelings of sadness and anger whenshe spent time around him.
3 Presenting Complaints
Ann presented for treatment with many of the symptoms of BPD (see assessment section
below for more information). She was particularly troubled by symptoms of depression andanxiety and reported severe insomnia. She also reported that she sometimes felt “numb”and wanted to become more in touch with her emotions. She stated that her social networkwas limited to individuals who also suffered from mental illness and that she provided moresupport to them than they provided to her. She wanted to improve her relationships bylearning interpersonal skills that would enable her to give support to others while assertingher own needs and preferences. Ann had frequent interactions with her parents but desiredless contact with them, as they often triggered memories of sexual abuse, particularly herfather (see history section below). However, she was unable to communicate her wishes tothem. Finally, Ann wanted to reduce her financial dependence on her husband by attainingemployment, and she was interested in returning to school.
Ann had a significant psychiatric history and a family history of mental illness. All of
her immediate family members (parents and 7 siblings) had histories of mood disorders andall had attempted suicide. Ann’s brothers and her father were alcoholics. Between the agesof 6 and 12, Ann had been sexually abused by her father, a brother, and her uncle. Whenthe current therapy began, she had no ongoing relationships with any of her siblings.
Ann reported a history of frequent depressive episodes beginning in childhood. She had
been participating intermittently in outpatient psychotherapy, primarily cognitive-behavioraltherapy (CBT), since the age of 32. She reported two 1-week hospitalizations during the pre-ceding 3 years for depression and suicidal ideation with a plan. She had participated brieflyin our clinic’s DBT program 1 year before the treatment described here, but shortly after start-ing, she missed four consecutive sessions because of circumstances including her husband’shospitalization for anxiety, her own hospitalization for depression, and her daughter’s wed-ding. In accordance with standard DBT procedures, which had been carefully explained toher, these four consecutive absences resulted in her termination from the DBT program, andshe was referred to other sources of treatment. Several months later, Ann completed a volun-tary, intensive, 10-week treatment at a psychiatric hospital, where she received some expo-sure to DBT skills along with treatment for posttraumatic stress disorder (PTSD), depression,anxiety, and insomnia. Throughout her psychiatric treatment history, Ann had been prescribednumerous psychotropic medications. When she began the current treatment, she was takingTrazadone, Buspar, and Lexapro.
Ann requested readmittance to the clinic’s DBT program 1 year after her previous ter-
mination and following completion of inpatient treatment. She stated that she was now ableto attend sessions regularly and motivated to participate actively in DBT. In accordance
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Minnesota Multiphasic Personality Inventory-2 Pretreatment
and Posttreatment Results
MMPI-2 Pre and Post Results
with the clinic’s standard procedures, she attended an intake session focusing on her pre-senting complaints, her social and psychological history, the nature of DBT, and her goalsfor therapy. The BPD section of the Structured Clinical Interview for DSM-IV
(First,Spitzer, Williams, & Gibbon, 1997) was administered. Ann met 5 of the 9 diagnostic crite-ria for BPD, including an unstable sense of self, impulsive binge eating and reckless spend-ing, chronic feelings of emptiness, affective instability, and dissociation in responseto stress. Ann also was questioned about her other reported symptoms, and met criteriafor chronic major depressive disorder (MDD), PTSD, and primary insomnia. Ann alsocompleted the standard intake packet, which included the Beck Depression Inventory-II(BDI-II; Beck, 1996) and the Beck Anxiety Inventory (BAI; Beck & Steer, 1993). Her pre-treatment scores on these measures were 13 and 24, respectively, indicating mild levels ofdepression and moderate levels of anxiety symptoms. Her BDI score was surprisingly lowgiven that she had endorsed all the symptoms of MDD during the clinical interview andpresented with flat affect and psychomotor retardation. However, it may be consistent withlack of awareness of her emotions and behavior sometimes observed early in treatment.
All clients at our clinic are asked to complete the Minnesota Multiphasic Personality
Inventory-2 (MMPI-2; Hathaway & McKinley, 1989) and the Revised NEO PersonalityInventory (NEO PI-R; Costa & McCrae, 1992) within 4 weeks of beginning therapy. Onthe MMPI-2, Ann’s validity scales were within normal limits, but she had significant eleva-tions on 6 of the clinical scales (Scales 1, 2, 3, 4, 7, and 8; see Figure 1). Elevations onScales 1, 2, and 3 were consistent with her reported symptoms of anxiety, depression, and sleep
Beck Depression Inventory-II Scores
Beck Anxiety Inventory Scores
disturbance (Graham, 2000). The high score on Scale 3 also suggested lack of insight intohow her bodily sensations, emotions, and environmental stresses are related. Elevation ofScale 8 suggested that she felt socially and emotionally isolated and had very little confi-dence in her abilities. On the NEO PI-R, Ann’s neuroticism score fell in the very highrange. Her openness to experience score fell in the high range, agreeableness in the averagerange, and extraversion and conscientiousness in the low range. Although Ann endorsedhigh levels of depression, anxiety, self-consciousness, and vulnerability, her scores sug-gested willingness to try new experiences and consider new ideas. Ann completed the BDI-II and BAI several times during her therapy. These scores can be seen in Figures 2 and 3and are discussed in later sections.
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6 Case Conceptualization
As Ann met diagnostic criteria for BPD, she was an excellent candidate for DBT. Ann’s
symptoms and history were clearly consistent with the biosocial theory of BPD, whichstates that BPD is a dysfunction of the emotion-regulation system brought on by the trans-action over time of an emotionally vulnerable temperament and an invalidating environ-ment (see Linehan, 1993a, for more detail). DBT views sexual abuse, which Ann hadexperienced for several years, as an extreme case of invalidation. Ann’s history of invali-dation was seen as a major factor in her pattern of ignoring or suppressing her emotionalstates and her tendency to be guarded in relationships, to worry about others perceptions ofher, and to be overly accommodating to others’ wishes without asserting her own needs andpreferences. These tendencies appeared to be important factors in her depressed mood, aswas sleep deprivation because of sleep apnea and insomnia.
Within DBT, case conceptualization is strongly guided by the hierarchy of targets, which
prioritizes treatment goals (Koerner & Linehan, 1997). Several general principles arereflected in this hierarchy. Life-threatening and self-harming behaviors are the first targetsof treatment, as the patient’s death or serious injury will prevent progress in life improve-ment. Behavioral problems that interfere with participation in treatment, such as skippingsessions or failing to complete homework, are addressed next, as progress requires activeparticipation in treatment. As Ann did not present with life-threatening or therapy-interfer-ing behavior, she was able to progress immediately to the third step in the hierarchy, whichinvolves learning skills for improving quality of life and managing emotional states. Thehierarchy dictates that posttraumatic stress is not addressed until the patient has developedmore stability in her life and mastered emotion-regulation and distress tolerance skills.
These skills are seen as essential for managing the negative affect that inevitably will beelicited when childhood traumas are discussed. In Ann’s case, this principle appeared espe-cially important, as she had a significant trauma history and severe deficits in skills formanaging negative affect. As case conceptualization is an ongoing process in DBT, evolv-ing as targets are addressed and progress is made, additional material about our conceptu-alization of Ann’s case is integrated into the following treatment section.
7 Course of Treatment and Assessment of Progress
Treatment was conducted at an outpatient training clinic operated by the doctoral pro-
gram in clinical psychology at the University of Kentucky. Therapy is provided by doctoralstudents who are supervised by licensed clinical psychologists. Ann was admitted to theDBT program and began attending weekly skills group and individual therapy sessions.
The skills group is co-led by two doctoral students, whereas individual therapy is con-ducted by one doctoral student. For the first 6 months of Ann’s participation in DBT, herindividual therapist was also one of the skills group leaders. All DBT therapists meetweekly with the faculty supervisor to discuss clients’ progress, facilitating continuitybetween individual and group components of the program.
Skills group meetings last 2.5 hours and include review of homework and didactic
presentation and discussion of new skills. Four modules are covered: core mindfulness,
interpersonal effectiveness, emotion regulation, and distress tolerance. The mindfulnessmodule, which requires two or three sessions, is reviewed after each of the other modules.
Completion of all four modules requires about 6 months, at which point the entire sequenceis repeated. As most clients commit to participating in DBT for a minimum of 1 year, theywill experience each module twice, with several additional reviews of the mindfulnessmodule. The group is continuously ongoing, and new members are allowed to join whenevera new module is beginning. Ann joined just as the core mindfulness module was beginning.
The initial sessions of individual therapy focus on orientation to DBT, commitment, and
goal setting. Ann expressed strong commitment to participation in DBT. The hierarchy oftargets was reviewed. As Ann was not engaging in self-harming, life-threatening, or therapy-interfering behaviors, work began with problems interfering with her quality of life. InDBT, this category of targets is potentially very broad and can include problems related tohealth, finances, school or work, relationships, substance use, or other Axis I disorders.
When appropriate, empirically supported and manualized treatment approaches for specificproblems or disorders can be incorporated into this phase of treatment. For several reasons,Ann and her therapist agreed to address her insomnia as the first target of treatment. Sleepdeprivation can have a substantial negative impact on mood, cognitions, and motivation andcan interfere with concentration and energy levels. Thus, we hoped that improvementin Ann’s sleep might have wide-ranging positive effects. In addition, CBT for insomniahas been shown to be effective (Jacobs, Pace-Schott, Stickgold, & Otto, 2004; Smith &Neubauer, 2003) and can often be accomplished in a few sessions, potentially providing aninitial experience of success and mastery for the client.
An important element of DBT is development of a diary card, on which patients monitor
target behaviors daily. The diary card is brought to each individual session and used for orga-nizing the session and monitoring progress. As Ann’s initial goal was to reduce insomnia,she and her therapist developed a sleep diary, on which she recorded the time she went tobed, latency to falling asleep, number of awakenings, hours slept, naps taken during the day,and type and dosage of sleeping medications used. She also rated the quality of her sleep andhow refreshed she felt in the morning. Ann and her therapist also developed a more generaldiary card on which to monitor behaviors related to her other treatment goals. On this diarycard, Ann recorded her meals, exercise, social activities, other enjoyable activities, andmoods. Ann was very conscientious about completing both of these monitoring devices eachday and often included additional detailed information she felt was important, such as neg-ative thoughts or feelings or insights she had regarding her treatment goals.
Treatment of Insomnia
CBT for insomnia generally includes educating the client about physiological, cognitive,
and affective factors that may lead to insomnia, teaching the client to recognize maladaptivethoughts that may exacerbate sleep problems and developing and engaging in a sleephygiene routine to reduce physiological arousal at bedtime and environmental reinforcers forwakefulness (e.g., food and caffeine consumption before bedtime, reading or watching TVin bed, etc.). We used an unpublished manual developed for an unrelated project (Beacham,Carlson, & Philips, 2001), which was based on similar approaches described in the literatureand provided comprehensive treatment during three sessions (Jacobs et al., 2004).
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To promote continuity between individual and group components of DBT, individual
sessions generally include monitoring of progress in group. Although not part of the insom-nia manual, the mindfulness skills that Ann was learning in group appeared very useful duringthis phase of treatment. These skills include nonjudgmentally observing and describingexperiences and allowing them to be as they are and to come and go as they will. Ann reportedusing these skills at bedtime and noticing several factors related to her difficulties in fallingasleep, including muscle tension, worries about stressors (e.g., marital difficulties, rela-tionships with family members), and PTSD symptoms (e.g., flashbacks, bodily sensationsrelated to abuse, and physiological arousal that made it difficult to relax) she experienced whilelying in bed that were preventing her from falling asleep. Ann reported that her anxietydecreased if she observed and labeled these experiences without self-judgment or criticismand allowed them to come and go.
Outcome of Insomnia Treatment
Prior to treatment, Ann’s average latency to sleep onset was at least 2 hours. After three
sessions, she was able to fall asleep within 15 to 20 minutes, on average. Ann’s bedtime andwake time became more consistent, as did her structured bedtime routine. The benefits ofthis routine appeared to inspire her to increase the structure of her daytime routine as well,as she began planning her meals and activities in advance. During subsequent months, astreatment shifted to other goals, Ann continued to use a sleep diary and maintained her abil-ity to fall asleep quickly at night, with only occasional, brief lapses.
Ann’s improvements in insomnia appeared primarily related to her changed sleep
hygiene behaviors and her application of mindfulness skills before falling asleep. Althoughthe mindfulness skills reduced her anxiety at bedtime, they also increased her awareness ofdepressed mood and negative thinking, and her BDI-II score increased to 24. Unfortunately,it became apparent that Ann lacked skills for modifying maladaptive thoughts, in spite ofher history of cognitive therapy. Ann and her therapist agreed that strengthening these skillswould be beneficial in helping to reduce her depressive symptoms and began work on theMind Over Mood workbook (MOM; Greenburger & Padesky, 1995), a structured manualbased on the principles of cognitive therapy.
Implementation of MOM
The MOM workbook focuses on recognizing automatic thoughts, identifying evidence
for and against the thoughts, developing more balanced, rational thoughts, and recognizingcore beliefs that lead to maladaptive thoughts. During the next 2 months, Ann worked dili-gently on these skills, completing thought records each week and bringing them to indi-vidual sessions for discussion. During this process, Ann identified several core beliefs thatshe had developed early in life that contributed to her depressive thinking. She recognizedthat she had grown up believing that she had to take care of others to survive and be lovedand therefore evaluated herself according to how others viewed her. In addition, she recog-nized that her core belief that she did not deserve happiness was at the center of her guiltfeelings, her tendency to prioritize others over herself, and her inability to assertively andeffectively communicate her wants and needs to her family and friends.
Although not part of the MOM workbook, the mindfulness skills learned in skills group
again appeared very helpful in facilitating this work. Whenever Ann experienced a moodchange during a session, she and the therapist practiced a brief mindfulness exercise togetherin which they observed their thoughts for several minutes. Ann was also encouraged to usemindfulness skills to increase awareness of her internal experiences between sessions.
These skills appeared to help Ann to identify the thoughts related to her emotions and phys-ical sensations.
Outcomes of MOM Workbook
At the conclusion of working with MOM, Ann’s BDI-II and BAI scores had declined to
12 and 14, respectively, indicating mild to minimal symptoms. Ann demonstrated substan-tially increased ability to recognize and modify maladaptive thoughts and had reduced herhigh rates of catastrophizing and of negative overgeneralizations about herself. At this pointin treatment, Ann stated that her most important goals were to become more aware and lessavoidant of her emotions and to learn skills for preventing the relapse of depression. MBCThas been shown effective for this purpose in a group format and seemed likely to increaseher ability to experience and accept her emotions. Moreover, Ann had already shown ben-efit from and enjoyment of the mindfulness exercises taught in DBT. Ann was not referredto MBCT group treatment for several reasons. At the time, no MBCT groups were avail-able in the area. Moreover, Ann was already committed to 1 year of the DBT program,which required her to attend weekly individual and group sessions. Attendance at anotherweekly group would have been unrealistic for Ann. As a result, the therapist consideredadapting MBCT for individual therapy and incorporating it into the DBT program.
Although clinical trials have established the efficacy of MCBT in group format, a recentcase study with an individual with binge eating disorder suggests the feasibility of adapta-tion to individual therapy (Baer, Fischer, & Huss, in press). For these reasons, Ann and hertherapist agreed to work on the MBCT protocol as the next phase of treatment.
Implementation of MBCT
MBCT is designed as an 8-week group intervention with 2-hour sessions. Initial adap-
tations for Ann’s case included lengthening the duration of this phase of therapy from 8 to10 sessions and expanding individual sessions from 50 to 90 minutes to allow sufficienttime for reviewing the diary card, addressing any other treatment issues that might arise,and then working on the MBCT material. The MBCT portion of each session began with a20- to 30-minute mindfulness meditation that the therapist led and in which both partici-pated. At the conclusion of this exercise, Ann and the therapist discussed the meditationexperience, addressing themes from the MBCT manual. Ann’s experience of homeworkpractice during the preceding week also was discussed, as was application of mindfulnessskills to issues Ann was facing during the upcoming week. New material then was dis-cussed, and homework for the following week was assigned.
Sessions 1 to 5 of MBCT included a wide variety of meditation exercises. During mind-
ful eating (Session 1), Ann and the therapist slowly ate a few raisins, focusing attention onthe sensations and movements associated with eating and on thoughts and emotions that
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arise while eating. In the body scan (Sessions 1 and 2), attention is focused sequentially onnumerous parts of the body, and sensations are nonjudgmentally observed. When thoughtsand emotions arise, these are noted briefly, and then attention is returned to the body.
Mindful stretching (Session 3) and walking (Session 5) encourage awareness of internalexperiences during slow, gentle movements. In sitting meditation (Sessions 3-5), awarenessis focused sequentially on the sensations and movements of breathing, sensations in thebody, sounds in the environment, thoughts, and emotions that may arise. Generalization ofmindfulness to daily life was encouraged with the 3-minute breathing space (taught inSession 3), which involves practicing mindful awareness of internal experience for shortperiods during the day.
Cognitive therapy elements of MBCT include a discussion of how thoughts about situa-
tions influence our feelings about them and the crucial concept that thoughts are not facts(Session 2). In Session 4, symptoms of depression were reviewed, and automatic thoughtsrelated to depression (e.g., “I’m no good.”; “I’m a failure.”) were discussed. Ann was encour-aged to notice these thoughts and allow them to come and go rather than becoming absorbedin them, believing them, or acting in accordance with them. The primary goals of these ses-sions were to increase nonjudgmental awareness of present moment experience and to rec-ognize how often our minds are on automatic pilot and how this lack of awareness can leadto negative thinking and rumination, which in turn may lead to a relapse of depression.
The remaining sessions of MBCT focused on cultivating a different relationship to
unpleasant experiences, accepting all internal experiences (pleasant or unpleasant), usingthe breathing space to bring mindful awareness to mood shifts, and developing a relapseprevention plan. Beginning in Session 6, the sitting meditation encouraged Ann intention-ally to bring to mind a problem or difficulty she experienced and to observe the resultingsensations, emotions, and thoughts without trying to change or eliminate them. GivenAnn’s longstanding tendency to shut out all aversive thoughts and emotions, two additionalsessions were added to the program at this point (bringing the total number of sessions forthe MBCT protocol to 12) to allow Ann more opportunities to practice awareness andacceptance of unpleasant internal experiences. During this phase of treatment, the 3-minutebreathing space was expanded to include practicing it during times of stress by focusing onunpleasant internal experiences with openness, willingness, and acceptance. This mindfulstance allowed Ann to make more adaptive choices about how to respond to stressful situ-ations. In later sessions, Ann identified and increased her participation in activities that ledto feelings of pleasure and mastery (e.g., babysitting and crafts) while decreasing partici-pation in activities associated with negative thoughts and moods (e.g., interactions with herparents and husband). In the final two sessions, Ann developed a relapse prevention planthat included identifying her depressive triggers, using a breathing space to observe themwithout maladaptive, impulsive attempts to avoid or escape them, and then choosing whatto do next. Ann generated a list of DBT skills and cognitive change skills from which shecould choose to help cope with her triggers.
Although the mindfulness approach to thoughts (nonjudgmentally observing them with-
out changing them) appears to differ from the cognitive therapy approach to thoughts(changing distorted thoughts to more rational thoughts), integrating these two approacheswas not difficult in Ann’s case. Bringing nonjudgmental awareness to internal experiencewas described as the initial step in coping with mood changes. Once Ann became aware and
accepting of her current experience, she could decide if additional steps were needed tocope with her current state. If Ann determined that change was necessary, one of her optionswas to use the cognitive restructuring skills learned from the MOM workbook to changeher thoughts, thereby changing her behavior and mood. However, another option was toallow thoughts to come and go as they are while practicing other DBT skills (e.g., emotionregulation, distress tolerance) to address her current state. Ann readily understood these twooptions and found them useful in her step-by-step approach to coping with mood changes.
Outcomes of MBCT
As MBCT progressed, Ann reported increased awareness of how her bodily sensations,
thoughts, and emotions are related to each other and to environmental stressors. Increasedself-awareness allowed Ann to recognize triggers that change her mood and to take neces-sary steps to prevent a negative mood from escalating. By the conclusion of 12 weeks ofMBCT, Ann reported increased ability to notice changes in her current internal experience(moods, sensations, or thoughts) and to engage in a 3-minute breathing space to nonjudg-mentally observe the experience. The therapist also observed that Ann was more readilyaware of her thoughts, moods, and sensations and how they were related. Bringing mind-ful awareness to her experience enabled Ann to decide effectively how to cope with thechange. At times, recognition and acceptance of the experience was sufficient. That is, onthese occasions, Ann decided that an adaptive response was to allow the experience as itwas, even if this meant accepting some inevitable unpleasantness. On other occasions, Annwas able to make adaptive decisions about which DBT skills to utilize to cope with theexperience. This appeared to be a significant change. Prior to completing MBCT, Ann’schoice of DBT skills to use in times of stress often appeared haphazard, as she generallydescribed using the first skill that came to mind or the one most recently discussed in skillsgroup, regardless of its applicability to the situation. However, after completing MBCT,Ann regularly described using a breathing space or practicing a short sitting meditation andthen choosing a DBT skill well suited to the situation. For example, when Ann received aphone call from her father that resulted in an increase in anxiety, using a breathing spaceallowed Ann to identify the anxiety and accept it without becoming more alarmed.
Although she noted that mindful observation alone significantly reduced her anxiety, shealso identified the need to engage in relaxation and self-statements that she was safe.
By the conclusion of MBCT, Ann’s BDI-II and BAI scores had declined from 12 to 1
and from 14 to 9, respectively, indicating no significant depressive or anxiety symptoms,and her MDD was in remission. In addition, Ann consistently reported experiencing a rangeof positive and negative emotions, rather than recognizing only intense, extreme emotion.
It should be noted that Ann experienced an increase in anxiety symptoms (BAI = 33) earlyin her work on the MBCT protocol. This appeared related to an increase in awareness inbodily sensations and emotions and an increase in environmental stressors. As MBCT pro-gressed, her symptoms steadily decreased. The MMPI-2 was readministered after comple-tion of MBCT, and significant declines in previously elevated scales were noted. Althoughinterpersonal interactions are not addressed by the MBCT protocol, Ann continued toattend the DBT skills group, which includes interpersonal effectiveness skills. During thisperiod, Ann began engaging in more effective communication with her parents and friends
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and began taking steps to improve her social network. She was also engaging much moreconsistently in behaviors that promote a positive mood while reducing her vulnerability toemotional instability, such as eating, sleeping, and exercising regularly.
8 Complicating Factors
Ann had previously been diagnosed with several medical conditions, including
fibromyalgia, hypertension, asthma, hypothyroidism, and sleep apnea. When she begantreatment, she reported that most of these conditions were reasonably well controlled butthat sleep apnea was causing significant fatigue. Although her primary insomnia was sub-stantially improved during treatment, Ann continued to have frequent nighttime awakeningsbecause of sleep apnea. During the subsequent months of therapy, Ann worked closely withher physician to request that her insurance company pay for surgery for sleep apnea. On sev-eral occasions, she used the interpersonal effectiveness skills taught in DBT to talk with herphysician and insurance company and also wrote several appropriate letters regarding thematter. At the present time, the surgery has been approved and scheduled. Ann uses distresstolerance skills to cope with fatigue and maintains good sleep hygiene behaviors.
9 Managed Care Considerations
Managed care considerations are not an issue at our clinic. Like many doctoral training
clinics, we use a sliding fee scale and require payment at each session. However, Comtois,Levensky, and Linehan (1999) note that since the publication of controlled trials showingDBT’s efficacy (see Robins & Chapman, 2004, for a recent update), many behavioral healthmaintenance organizations, and some state departments of mental health, have become will-ing to fund DBT, in spite of the expense associated with its length and complexity.
Ann has completed about 8 months of her 1-year commitment to DBT. She remains in
therapy and is working on additional treatment goals. Although she no longer meets crite-ria for MDD or primary insomnia, she continues to suffer from fatigue related to her sleepapnea and perhaps her fibromyalgia. However, she has increased her physical activity, hersocial interactions, and her ability to concentrate despite her level of fatigue. In addition,although Ann continues to endorse symptoms of BPD, their frequency and severity havedecreased. Perhaps her most significant presenting complaint that has not resolved is herPTSD. She reports flashbacks, nightmares, and anxiety resulting from trauma-related trig-gers at least once per month. However, Ann notes that the symptoms are less intense andless distressing as a result of her increased awareness, acceptance, and understanding of themand her increased repertoire of mindfulness, distress tolerance, and emotion-regulationskills. As noted earlier, DBT does not address PTSD until clients are consistently and suc-cessfully using the many skills taught in group to ensure that they will be able to manage
the distress likely to arise when early traumas are discussed. Ann is currently working onincreasing her social support network, increasing her participation in mastery-related andpleasant activities, and finding employment while continuing to practice her skills. Whenshe is ready to address PTSD, she and her therapist will discuss a new commitment to thisphase of therapy, which very likely will extend her participation in DBT beyond her initial1-year commitment.
Strong conclusions about the efficacy of MBCT for preventing a relapse of depression in
Ann’s case cannot be drawn for quite a few months. However, Ann’s improved ability to rec-ognize mood changes and engage in healthy coping strategies suggests that she now has theskills necessary for preventing the escalation of negative moods into depressive relapse.
Moreover, Ann’s DBT and mindfulness skills also enable her to engage in adaptive behav-iors that increase positive emotions while decreasing negative emotions. As randomizedclinical trials cited earlier indicate that the likelihood of a depressive relapse within the yearfollowing MBCT is reduced by 50%, Ann’s prognosis for relapse prevention is encouraging.
11 Treatment Implications of the Case
This case study illustrates that MBCT can be integrated into ongoing DBT for BPD
clients who have incorporated DBT skills into their repertoires and are willing to engage inmeditation exercises. Although the intense negative affect common in many BPD clientsmay reduce their willingness to meditate, in Ann’s case these exercises proved tolerable anduseful. Their length was reduced from 45 minutes (typical in MBCT) to 20 to 30 minutes.
In addition, Ann reported that she found the 3-minute breathing space at least as helpful asthe lengthier meditations and regularly practiced this skill in her daily life.
This case also suggests the potential utility of mindfulness skills in increasing the effec-
tiveness of CBT for a range of problems. Ann presented with a complex symptom picture.
Despite her extensive history of mental health treatment, Ann was still disconnected fromher thoughts, emotions, and bodily sensations. CBT generally includes monitoring of suchexperiences, and Ann realized that she needed to become more aware of them but lackedthe skills to do so. Teaching mindfulness skills provided her with the tools she needed toobserve and recognize her sensations, thoughts, and emotions, to understand how these arerelated to each other and to environmental stimuli, and to become more accepting of hermoment-to-moment experiences, regardless of how pleasant or unpleasant it was.
This case also highlights the utility of integrating acceptance and change. During Ann’s
initial months of DBT, she was so averse to negative affect that she habitually searched fora “quick fix” to change how she was feeling. This often resulted in haphazard choice ofDBT skills to use, which led to disappointment in their effectiveness, a sense of failure, andself-invalidation of her emotions. The longer mindfulness practices (20-30 minutes) thatoccurred during MBCT sessions facilitated the development of acceptance of emotions.
Exposure to negative affect during these practices reduced her fear of these experiences asshe realized that negative affect did not lead to catastrophic outcomes. During discussionsof mindfulness practices, the therapist had opportunities to validate Ann’s feelings and toemphasize that all emotions, thoughts, and sensations are a natural part of life and can help
Huss, Baer / Mindfulness-Based Cognitive Therapy
us develop insight if we attend to them carefully. Such validation appeared more meaningfulto Ann when she had just spent 20 to 30 minutes closely observing her internal experiences.
The meditation practices also helped Ann to learn that change is not always required, evenin unpleasant circumstances, and that acceptance may sometimes be more adaptive thanimmediate attempts to change things. Finally, the highly experiential nature of the mind-fulness meditations taught in MBCT appeared helpful in facilitating acceptance. When Anncame to a session in a distressed mood and then completed a 20- to 30-minute meditation,she consistently reported that she now understood her distress, was less upset about it, andknew what (if anything) to do about it. The insights she gained from this practice appearedmore powerful to her than the understandings gleaned from thought records or from dis-cussions with the therapist about her emotional states.
MBCT and DBT differ substantially in the number of behavior-change skills taught. As
noted earlier, DBT assumes that clients may have significant skills deficits and thereforeincludes training in a broad array of skills. MBCT, in contrast, focuses primarily on mind-fulness meditation practices designed to teach acceptance of experience as it is and assumesthat “staying present with what is unpleasant in our experience . . . allows the processto unfold, lets the inherent ‘wisdom’ of the mind deal with the difficulty, and allows moreeffective solutions to suggest themselves” (Segal et al., 2002, p. 190). Thus, MBCT does notteach interpersonal interaction, emotion regulation, or problem-solving skills. The courseof therapy with Ann suggests the potential utility of both approaches. When she presentedfor the therapy described here, Ann had significant skills deficits and was an excellent can-didate for DBT skills training. However, after she had spent several months learning theseskills, the value of the MBCT approach became very clear. That is, bringing mindful aware-ness to difficult situations allowed Ann to choose wisely from skills within her repertoire.
Several limitations of this case study should be noted. One limitation of adapting the
MBCT manual for individual therapy is the loss of group support, which is likely an impor-tant factor in the success of MBCT (Segal et al., 2002). Although the therapist practicedall the meditation exercises both during the sessions and during the week and discussed herexperiences of the practice at every session, Ann did not have the opportunity to receive thesupport and feedback from other clients regarding MBCT practices that group formatwould have provided. Although she was participating in group mindfulness practice andreceiving group support from the DBT skills group, it is not clear whether the DBT groupwas an adequate substitute for the group support in MBCT, especially given the muchlonger duration of meditation practices in MBCT. More research is needed to investigatethe importance of the group experience in the outcome of MBCT.
Because Ann was simultaneously learning mindfulness skills in DBT skills group and
from MBCT in individual therapy, another limitation of this case study is that the influenceof these two programs on Ann’s outcomes cannot be separately evaluated. However, as notedearlier, it appeared that the lengthier meditation practices of MBCT had beneficial effectsthat had not been observed during Ann’s initial months in DBT. Research investigating theeffects of different types of mindfulness exercises might clarify this question. Although con-clusions cannot be drawn regarding which aspects of the two treatments had the greatestimpact on the clinical outcomes, the integration of these two treatments, with their differingemphases on acceptance and change-based strategies, appeared very useful in this case.
12 Recommendations to Clinicians and Students
This case study suggests that, in appropriate cases, MBCT can be integrated into ongoing
DBT and that mindfulness skills can contribute substantially to the efficacy of cognitive-behavioral approaches. Development of mindfulness appears to enable clients to becomemore aware of their internal experiences, less distressed by them, and more accepting ofthem. This state of nonjudgmental awareness appears to facilitate making adaptive choicesabout skills and strategies to use in coping with problematic situations. More rigorousresearch is needed to clarify the effects of incorporating both acceptance and change-basedstrategies in the treatment of presenting problems and the prevention of relapses.
Clinicians and students interested in these treatment approaches may wish to pursue pro-
fessional training that is available through a variety of workshops nationwide. Informationabout DBT workshops is available at www.behavioraltech.com. MBCT training is occa-sionally offered at the Omega Institute (www.eomega.org). In addition, MBCT stipulatesthat therapists have their own regular mindfulness practice. Thus, interested professionalsmay wish to learn about beginning a mindfulness meditation practice. Suggestions for pur-suing this option can be found in Segal et al. (2002).
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Debra B. Huss
, MA, is a 5th-year clinical psychology graduate student at the University of Kentucky. She is
interested in clinical outcome research, health psychology, pediatric psychology, and mindfulness and acceptance-
Ruth A. Baer
, PhD, is a faculty member in the Department of Psychology at the University of Kentucky. She
is interested in mindfulness and acceptance-based interventions and the assessment and conceptualization of
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