In recent years therapists from various clinical orientations have been utilizing mindfulness-based procedures to help depressed patients challenge their depressive stance. Mindfulness is a very simple way of relating to experience. It is based on the teaching of Buddha and Buddhist psychology. Buddha attributed human suffering to the tendency to cling to thoughts, feelings, and ingrained perceptions of reality and habitual ways of acting in the world (Lynn, Das, Hallquist, & Williams, 2006). In contrast, mindfulness directs one’s attention to the task at hand. When mindful, one’s attention is not entangled in the past or the future, and one is not judging or rejecting what is occurring at the moment. One becomes the present; this kind of attention can generate energy, clear-headedness, and joy (Germer, 2005). Most people with psychological disorders are preoccupied with past or future events. Particularly, the depressed person has a tendency to become preoccupied with feelings of guilt, regret, and sadness related to past events, or to constantly ruminate on future suffering. In such a scenario, the person strays from the present moment and becomes absorbed in past or future suffering, resulting in the exacerbation of depression. The person thus becomes the depression. As described in Chapter 4 this process is not dissimilar to negative self-hypnosis (NSH). Germer (2005, p. 5) provides a very lucid description of this:

As our attention gets absorbed in mental activity and we begin to daydream, unaware that we are indeed daydreaming, our daily lives can become a nightmare. Some of our patients feel as if they are stuck in a movie theatre, watching the same upsetting movie their whole lives, unable to leave. Mindfulness can help us to step out of our conditioning and see things freshly–to see the rose as it is.

Mindfulness helps us to be less reactive to what is happening now. As a result, our overall level of suffering is reduced and our sense of well-being increases. However, it is important to note that when a mindfulness approach is utilized in therapy, the therapist is not invalidating the patient’s past history and is not unrecognizant of the fact that depression is a biopsychosocial-spiritual disorder. The narrative history of a person struggling with depression can be critically important: What happened in the past can bear on the present pain. For these reasons, mindfulness and acceptance are introduced during therapy or after acute-phase treatment. It is important to have already worked with triggering or maintenance factors and to have addressed issues related to the past or the future before taking a mindfulness approach in therapy. It is also important to have established a strong positive alliance so that the patient does not feel that her past history and the complexity of her depression is undermined.

Although mindfulness occurs naturally, its maintenance requires practice. There are two types of mindfulness training: formal and informal. Formal mindfulness training involves mindful mediation, allowing practitioners the opportunity to experience mindfulness at its deepest levels. Informal mindfulness training refers to the application of mindfulness skills in day-to-day living. Any exercise such as paying attention to one’s breathing or listening to ambient sounds in the environment can alert us to the present moment; with acceptance, this cultivates mindfulness. In the therapeutic context, informal mindfulness is usually taught with the goal of helping patients disengage from their disruptive patterns of thinking, feeling, and behavior, and experience the relief of moment-to-moment awareness. For example, Teasdale, Segal, and Williams (1995) developed a mindfulness-based cognitive therapy (MBCT), utilizing acceptance and meditation, to help patients distance themselves from depressive ruminations. MBCT combines aspects of CBT with some components of the mindfulness-based stress reduction (MBSR) program developed by Kabat-Zinn (1990) and his colleagues. Unlike MBCT, which is a generic program applicable to a variety of problems, MBCT is specifically designed by Teasdale and his colleagues to treat unipolar depressed patients who are in remission. Unlike CBT, in MBCT little emphasis is placed on changing the content of thoughts; rather, the emphasis is on changing awareness of and relationship to thoughts, feelings, and physical sensations (Segal, Teasdale, & Williams, 2004). MBCT is an 8-week relapse prevention group treatment for depressed patients who are successfully treated with CBT or medication, or a combination of both. Patients are trained to defocus away from the content of their thinking and to direct their attention to the thinking process. They are coached in becoming aware of the occurrence of their thoughts without responding to them emotionally and without examining the accuracy of their beliefs. This approach teaches depressed patients to learn to separate themselves from feelings and thoughts and not to consider them as objective facts. An emotion or a thought is regarded as simply a behavior, a part of the person, and not the whole person. This ability to distance or decenter away from a cognition or affect aids patients in maintaining
control over their thoughts (prevents catastrophizing) and feelings (mutates negative affect).

MBCT was empirically evaluated in a three-center study (Teasdale, Segal, Williams, Ridgeway, Soulsby, & Lau, 2000) involving 145 patients, with at least two previous episodes of major depression (77% had experienced three or more episodes), in remission or recovery, randomly assigned to treatment as usual (TAU) or MBCT. All the patients who participated in the study were previously treated with antidepressant medication but had been symptom-free and off medication for at least 3 months before entering the trial. Compared to the TAU group, MBCT reduced relapse rate by 44% in the group of depressed patients with three or more episodes of depression at 60 weeks follow-up, after the end of the 8-week program. In contrast, the relapse rate in the TAU group increased over the study period in a statistically significant linear relationship with number of previous episodes of depression: two episodes, 31% relapse/recurrence; three episodes, 56% relapse/recurrence; and four or more episodes, 72% relapse/ recurrence. Similar results were found in a replicated study of depression (Ma & Teasdale, 2004). The investigators attribute the success of MBCT with depressed patients to decreased overgeneralized memories and ruminative thinking.

Mindfulness can be easily integrated with hypnotherapy in the management of depression. Lynn, Das, Hallquist, and Williams (2006, p. 145) suggest that “hypnosis and mindfulness-based approaches can be used in tandem to create adaptive response sets and ameliorate maladaptive response sets.” They recommend using hypnosis to catalyze mindfulness-based approaches. Since meta-analytic studies, qualitative reviews, and controlled trials have shown hypnosis to enhance the effectiveness of both psychodynamic and cognitive behavioral psychotherapies (Kirsch, 1990; Kirsch, Montgomery, & Sapirstein, 1995; Bryant, Moulds, & Nixon, 2005; Alladin, 2005; Alladin & Alibhai, 2007), it is reasonable to expect that hypnosis will also enhance the effectiveness of mindfulness training.