The mindful way through depression | Zindel Segal | TEDxUTSC

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Zindel V. Segal is a cognitive psychologist, a specialist on depression and one of the founders of Mindfulness-based Cognitive Therapy. Over a decade ago, he, along with his colleagues Mark Williams, and John Teasdale developed the Mindfulness-Based Cognitive Therapy (MBCT) for helping people not relapse into depression.
In this talk Zindel Segal explains how Mindfulness-based Cognitive Therapy works.

Zindel Segal, PhD, is a Distinguished Professor of Psychology in Mood Disorders at the University of Toronto Scarborough and a Senior Scientist in the Campbell Family Mental Health Research Institute at the Centre for Addiction and Mental Health. He has advocated for mindfulness-based clinical care in psychiatry and mental health for over two decades.

Thank you.

It's a pleasure to be here.

I've worked in the field
of mood disorders for over 30 years

and I've witnessed a number
of advances in treatments.

I've witnessed new generations

of antidepressant medications
being developed.

The use of magnetic coils
to stimulate the skull

and affect different brain regions.

The implantation of electrodes
into the brain

in regions that are thought
to promote recovery from depression,

and even the customization
of talk therapies

to address certain subtypes of depression.

But let's face it,

the concept of meditation
was never high on that list.

And there's a good reason for that:

the reason is that these are treatments
that were developed

to alleviate depression,
to alleviate the suffering of patients

who are trying to get
their lives back on track

and also to reduce
the capacity for self-harm

that is often carried by untreated
and undiagnosed depression.

But the complex challenge
that depression provides us with

is to do more than allow people
to let go of symptoms

and returning to their lives.

The complex challenge involves
helping people recover from depression

and to stay well.

What we now understand about depression

is that it is an episodic
and recurrent disorder.

Getting well is half of the problem,
staying well is the other half.

And this is really where
my work in the area started,

I was tasked with addressing
the problem of relapse and its prevention.

And I was a card-carrying member
of a cognitive therapy group

working in an outpatient clinic
at a hospital.

My work was quite distant from meditation
and other contemplative practices.

I received a small grant
from the MacArthur Foundation

to try to modify an existing
treatment for depression

so that it could prevent relapse.

And what I did with that money was
to bring together two colleagues of mine,

Mark Williams, who is at Oxford,
John Teasdale, who is now at Cambridge,

and we sat together and thought about
how would we go ahead and do this,

modify this treatment,
provide something to people

who are in recovery
to help them stay well.

We kind of hit the pause button,

because we didn't want to take
a treatment that was designed

to help people come out of depression

and just continue to sort of spool
it forward to people in recovery.

We wanted to understand
if there were specific risk factors,

specific triggers, that helped people
who were in recovery get depressed

and maybe see whether we could design
a treatment around those specific triggers

to try to undo
their sort of pathological influence.

The really cool thing
about working with Mark and John

is that they had done seminal work
in the area of mood dependent memory.

The way in which moods and thoughts
come together and influence each other,

bringing moods that are negative
to mind much more easily

if one is thinking in a depressive way,

and depressive thoughts bringing moods
together that are depressed more easily.

One of the things that we found
was that when people are depressed

and they're feeling sad,
this is a symptom.

But when they are
no longer feeling depressed,

sadness can function
as an important context

to bring to mind judgmental, critical,
and harsh ways of viewing the self

that can sometimes tip people over
into a new episode of depression

and cause relapse.

And so we stood back
and thought to ourselves:

what if we could, first of all,
test out this model,

what if we could find a way to modify

this effect that sadness
has on mood and memory?

And then what if we could
teach this to people?

Wouldn't it be possible that this would be
a more efficient and a more direct way

of helping people stay well?

And it happened
that our theory led to a model

and very supportive data
for our conjectures.

People who were well, had recovered
from depression, had been treated,

but were experimentally induced
into a brief state of sadness

found that they could very easily start
to recall experiences from depression

and that the folks who did that the most

were the ones that had
the highest rates of relapse

when we followed them for 18 months.

We had some very important evidence here
that suggested that our model had legs.

That the ability to work with sadness,

in people that had recovered
from depression,

may determine whether
they are able to go on

and sustain the benefits of treatment

or whether they are going to relapse.

But how do you work with a trigger
of relapse like sadness,

when sadness is also a feature
of our universal human experience?

We weren't interested
in trying to eliminate sadness,

we weren't interested in trying
to get people not to feel sad.

What we really needed to do

was to help people develop
a different relationship to their sadness.

And what does that mean in terms
of trying to teach people certain skills?

This is really the point in which
mindfulness comes into the picture.

Mindfulness is really the awareness
that comes to mind,

the awareness that arises
when we pay attention in a particular way.

We're bringing our attention
into the present moment

and we're not judging.

What do we notice?

So, purposely attending
to the present moment, without judgment.

Turn out this is
a very useful skill to have,

because it can reveal
aspects of our experience

that have already been
and are continuing to be present for us,

but we are just not able to access them,
we're not focusing on them.

Let me just stop for a second,

because words have
a sort of limited utility

when you're talking about mindfulness.

And let's see whether we can have
a chance to experience this directly.

If you're willing,
maybe just pause for a sec.

Make yourselves comfortable
in your chairs,

and start by thinking about your feet.

See if you can just do that,

just let your mind
start thinking about your feet.

How your feet have carried you
a fair distance today.

Where they've taken you,

walking, driving, sitting?

Maybe comparing one foot to the other.

Noticing any judgments or evaluations.

Seeing whether you like one foot --

or the other foot.

Seeing whether there are
any worries about your feet,

any things that are medically
oriented, or undescribed,

sensations.

Whether you have any future oriented
things relating to your feet,

like maybe you've got
a pedicure that's scheduled,

or you need to redo your toe nail polish.

Continuing to think about your feet

and just letting whatever
comes up in your mind --

be there.

Just thinking about your feet.

And then stopping.

And now redirecting your attention,

and taking your attention
back to the feet,

but this time just becoming aware

of whatever sensations are present
in this part of your body.

So maybe feeling the way the feet
are pressing down against the floor,

through the soles of your shoes.

Perhaps feeling the points
of contact for the big toe,

the little toe,

the heel,

the ball of the foot.

Noticing any sensations
between the toes, any moisture,

any heat,

even the foot itself encased in the shoe.

Any sense of tightness,

pressure, throbbing.

And just allowing whatever
sensations come to mind

as you're experiencing
your feet in this way.

And then stopping, pausing...

and looking for a moment

Thinking about your feet,
directly experiencing your feet.

at these two different ways
of having an experience of your feet.

The practice of mindfulness allows you

to take all of this information
into account.

Allows you to be focused on directly
feeling what you're going through,

as well as having, or noticing,
thoughts about the experience as well.

And this, we felt at the time,
was an answer to the question

of how can people work with sadness,
not by eliminating it,

but by being able to have
a different relationship to it.

We've use a fairly
mundane example of feet,

but what happens if we try to tune
this into sadness when it is present,

negative emotions when they are present.

And thankfully, at the same time
we were doing this,

we were aware of Jon Kabat-Zinn's
pioneering work

with mindfulness meditation

with patients that had chronic pain.

He was doing this very thing.

People who had chronic pain
training themselves

to attend to the sensations
of physical discomfort.

Not pushing pain away, but finding
a way into their physical discomfort,

that allowed them to see more room
and more space inside it,

than simply thinking about it,
than trying to worry about it,

trying to eliminate it,
trying to distract themselves from it;

being present with it.

And he was showing remarkable outcomes,

more and more of these people's lives
could be reclaimed,

and that the chronic pain features
of their lives became less and less

of a primary concern.

And so what we tried to do
was to develop the same training program

for people who had recovered
from depression,

based on his seminal eight-week program,
which he developed,

much of which featured extensive training
in mindfulness meditation,

mindful movement,

and we also added in bits and pieces

that were relevant to living
with a depressive disorder.

And we called it
mindfulness-based cognitive therapy.

It became manualized,
it became evaluated,

and it had very little of the baggage

associated with contemplative
meditative practices.

You didn't have to enter
the world of meditation.

I dressed like this, I didn't wear robes
when I came into a class.

And opened the door as wide as possible

for people to see this as a very
pragmatic health practice --

for regulating emotions.

So it wasn't about finding God,
it wasn't about transcending reality,

this is about learning
how to harness attention

in the agenda of self-care.

Now, mindfulness-based cognitive
therapy essentially tries to work

starting with concrete examples
of how to pay attention

and how to be mindful.

We did this with the feet,

we start in our course with raisins,
with eating, with breathing,

with other kinds of activities,

and eventually we work our way up
to dealing with negative emotions.

What we're trying to get people to do is
to anchor themselves in their experience,

so that when a negative emotion comes up
in the mind it can wash over them,

it doesn't totally destabilize them,

neither does it necessarily bring to mind
all of the negative associations

that for some people can happen
very automatically.

Instead they can find a different place

for standing and working
with this feelings

and as a result have much more
of an option for selecting a response

and influencing what happens next.

Mindfulness-based cognitive therapy
has performed very well

in clinical randomized trials.

About a thousand patients
have been evaluated using this approach

across seven studies world wide.

And what we are finding is
that, compared to usual care,

mindfulness-based cognitive therapy
reduces relapse by about 43 percent.

And compared to antidepressant medication

it provides equal protection against
relapse as continuing on an antidepressant

for long periods of time.

The other positive thing
about this treatment

is that it enhances
people's ability to feel reward,

and to feel positive affect,
positive emotions,

in the course of their everyday lives.

Which is vital because
this is a tough sell for many patients,

for many people with depression

who are feeling well and feeling
as if their depression is behind them,

they don't need to continue to engage
in ways of looking after themselves,

why should they invest the time, space,
and often very busy lives for doing this?

The capacity to reward and to feel
reinforced for practicing mindfulness

allows these health benefits to continue.

And another way in which we know
these heath benefits can get locked in

is the fact that mindfulness
also changes the brain.

It changes the brain
in very meaningful ways

by allowing people to access
what's been called

the present moment pathway.

Now, on the face of it, it makes sense,

we are training people to pay attention
to the present moment,

maybe there're some parts of the brain
that get tuned up to be able to do this.

But we've got some fairly good data

to suggest that part
of this present moment pathway,

the region that is very active
in training in mindfulness is the insula.

And the insula is a part
of the brain on a network

that allows signals from the body
to be more carefully attuned.

Signals of present moment, sensations,

what's happening in the body,
in this moment,

not thinking about the body,
but right now, sensations.

And people are better able to tune into
the state of the body by doing this.

And what we're finding is

that as the present moment
pathway gets activated

people that have been
trained in mindfulness

are able to really increase
the activation in the insula,

more than people who haven't been trained.

So, mindfulness trains awareness
in this present moment pathway,

and, it turns out,
this is vitally important

for working with sad mood states.

So what happens if you put
someone into an fMRI scanner

and induce a mild state of sadness,

and they haven't had
training in mindfulness,

they will activate a part of the brain
called the executive control network,

which is sort of like the thinking
about your feet network, if you want,

a network of brain regions
that are involved with evaluating:

What do I need to do about this sadness?
Is this sadness relevant to me?

Is this a threat? How can I problem
solve it? How can I eliminate it?

So you're thinking
and thinking about sadness,

and what happens is,

as that network is stronger,
the present moment pathway gets weaker.

So, one is stronger, one is weaker,

and you're getting very little signal
from what's happening in your body,

how this emotion is actually
impacting you in this moment,

and you're getting a lot more about
the conceptual workings of the mind

around what is sadness,
what do I need to do about it,

what else is it also calling to mind.

Now, after people
have been trained in mindfulness

you're getting this rebalancing
between both networks coming online.

Executive control network
gets inhibited a little bit,

the present moment pathway
increases its activation a little bit,

and now the person feeling sad
has access to two channels of information.

A channel of information
about the meaning of sadness,

but also a channel about the present
moment state of the body

that is working
with sensations of sadness,

and both of these channels of information
can lead to more effective responses

and selections of activities
in terms of dealing with sadness.

This is a movement away from
a kind of automatic activation

of the previous contents that would be
brought to mind when sadness was present,

and widening into a much more
spacious view of sadness,

and the choicefulness
that comes with that.

And what we find in our work

is that our treatment
is eight-weeks in length

and yet we're asking people
to take this on board

as a way of continuing
to look after themselves.

About 75 to 80% of our patients --

continue some form of mindfulness practice

for about a year, two,
to three years afterwards.

And what happens is that although
the portal that brought them in to us

in the first place

had to do with a disorder, depression,
had to do with getting treatment,

more and more people recognize
that through the practice of mindfulness

they are able to connect
with an inner resource

that allows them to take care
of themselves in a way

that touches greater moments
of wholeness in their days,

and allows us to permeate more moments
of their lives as they go forward.

It becomes less about a treatment,
it becomes more about a way of life

and looking after themselves.

And this has really been the pinnacle
of the work that we've conducted,

to move from a juxtaposition
of two approaches for depression,

that seemed seemingly unconnected,

into developing a coherent,
and empirically supported way,

of delivering this type of care,

and allowing people to take over
once the course is over.

Thanks very much for your time!

(Applause)