transforming depression: mindfulness- based cognitive ... · transforming depression: mindfulness-...

Transforming Depression: Mindfulness-

Based Cognitive Therapy for TBI Results from a Randomized Controlled Trial

Melissa Felteau, MAdEd Lakehead University Rehab Research Team, Thunder Bay, Ontario Rolf B. Gainer, PhD The Neurologic Rehabilitation Institute, Brookhaven Hospital, Tulsa, Oklahoma Neurologic Rehabilitation Institute of Ontario Community NeuroRehab, Des Moines, Iowa Rehabilitation Institutes of America

Congress of Rehabilitation Medicine, October 2014

Disclosures • The research team received a research grant

from the Ontario Neurotrauma Foundation • Melissa Felteau has no conflicts to report • Dr Rolf Gainer has business relationships with

Brookhaven Hospital, the Neurologic Institute of Ontario, Community NeuroRehab & Rehabilitation Institutes of America

Learning Objectives

1.To define mindfulness in the clinical setting.

2.To recognize the efficacy of MBCT-TBI in reducing depression symptoms.

3. To recognize the 5 ways MBCT was adapted for the TBI population.

Presenter

Presentation Notes

Start by defining mindfulness, talk about the results of our study, how I adapted it for TBI, and how this work can be adapted for other populations.

• Michel Bedard, PhD, Lakehead University

• Melissa Felteau, MAdEd, Lakehead University

• Shawn Marshall, MD, The Ottawa Hospital

• Nora Cullen, MD, Toronto Rehab - UHN

• Sacha Dubois, MPH, St Joseph’s Care Group

• Carrie Gibbons, MPH, SJCG • Hilary Maxwell, MPH, SJCG

• Bruce Weaver, MSc, Northern Ontario School of Medicine

• Rolf Gainer, PhD, CEO, Neurologic Institute of Ontario & Brookhaven Hospital

• Dwight Mazmanian, PhD, Lakehead University

• Rupert Klein, PhD, Lakehead University

• Amy Moustgaard, PhD, University of Ottawa

• Laura Rees, PhD, The Ottawa Hospital

Research Team

Presenter

Presentation Notes

We wish to express deep gratitude to all the study participants, many of whom devoted themselves to the practice of MBCT-TBI, and the generous support of the ONF who funded the study. I would like to acknowledge Dr Rolf Gainer, CEO of the Neurologic Institute of Ontario who was one of our investigators and who is in the audience today.

Sites and Facilitators St. Joseph’s Care Group, Thunder Bay:

Mary Donaghy, PhD, Psychologist John Clack, MSc OT, Occupational Therapist Toronto Rehab - UHN: Sucheta Heble, MS, Speech Pathologist Martin Vera, MClSc, Speech Pathologist The Ottawa Hospital: Elly Endorp, MSW, Social Worker Jennifer Heron, BA, Rehabilitation Therapist Nancy McCormick, MSW, Social Worker Evelyn Tan, MA, Speech Pathologist * We thank all the participants of this research study

Inquiry oPersonal

experience? oTherapy

practice? oClient benefit?

Presenter

Presentation Notes

How many here have some experience with mindfulness practices personally? Does anybody use mindfulness in their therapy practice? Are any of you interested in exploring how mindfulness therapy could benefit your clients? (your boss, your partner or spouse?)

We have 60,000 – 80,000 thoughts per day

That’s one thought every 1.2 seconds!

Deepak Chopra, 2011

Presenter

Presentation Notes

And many of them are the same thoughts we had yesterday!

Mindfulness

• Witnessing constant flow of thoughts, judgments, daydreams, reminiscing, anticipations, emotions, sensations & letting go

• Emptiness training (Shunyata) watching mind phenomena arise & pass away through attention & concentration

Presenter

Presentation Notes

Most of those thoughts are reminisces, judgments, daydreams, & anticipations You will see the tendency of the mind to dwell in the past or skip to the future. It’s certainly not here… Can you feel you buttocks on the seat cushion, your belly rising and falling with each inhalation and exhalation? Being here means feeling your feet touching the ground, your legs holding you upright, your back against the chair. The breath flowing in and out, one after another. Pretty soon you realize your mind has jumped to another thought…and you’re no longer here…you’re there. Sometimes there daydreaming for quite some time. And then you take a breath and remember to come back. This is mindfulness.

Mindfulness is The awareness

that arises By paying attention

on purpose In the present

moment Non-judgmentally

Jon Kabat Zinn, 2013

Presenter

Presentation Notes

Letting go of judgments, reminisces, and coming back to the breath… Now that’s success in the practice. Coming back. No matter how many times the mind may wander. Coming back. Letting go of sticky thoughts no matter how enticing. Coming back to the breath.

“Simple but not so easy”

Presenter

Presentation Notes

It’s the energy or intention we bring to it. If we commit to sitting quietly for 3, 5, 25 minutes to see what our mind is up to… We might be surprised!

Mindfulness-Based Cognitive Therapy

Presenter

Presentation Notes

Since 2000, we have conducted 3 clinical trials in Mindfulness-Based Cognitive Therapy. Most recently, we tested our intervention in the conduction of a multi-site randomized controlled trial in Toronto, Ottawa and Thunder Bay.

Prevalence of Depression

Presenter

Presentation Notes

Post TBI-depression appears to be unrelated to gender, age, ethnic background, level of education & characteristics of injury such as severity of TBI & time since injury

Depression most common Axis 1 disorder following TBI 44 – 50% incidence post-TBI depression (Van Reekum, 1996, 2000)

Often co-morbid with anxiety Best predictor of psychosocial adjustment, even 10 yrs post injury (Owensworth & Fleming, 2005; Draper, Ponsford & Schonberger, 2007)

Psycho-social Correlates of Post-TBI Depression

• Poorer rehab outcomes • Greater functional disability • Less employment potential • Elevated divorce rates • Greater caregiver burden • Poorer subjective well-being • Poorer quality of life • Increased rates of suicidal ideation (brainline.org)

Presenter

Presentation Notes

Compared to those who are not depressed, individuals with post TBI depression experience:… It paints a bleak picture and underscores the need to address depression.

Can MBCT help people manage the symptoms of

depression?

The practice of meditation…

• Teaches us how to see thoughts with non-judgment & compassion

Teaching one to sit with &

relate differently

Decentering

• Helping to step away from unhelpful patterns of thinking associated with chronic sadness

& depression

Slowing down to see own thoughts

Befriending difficult moments…

Addresses apathy

Helps to cope with loss of self

Helping restore the self

Without the need to distract avoid

cover-up

Methodology

Mindfulness-Based Cognitive Therapy-TBI: 10 week psycho-

educational group

Intensive training in Mindfulness

meditation

To apply to challenges of their daily lives

Based on Segal, Williams, Teasdale, 2002

TBI Adaptation Felteau, 2010

Presenter

Presentation Notes

So let me tell you about our adapted Mindfulness-Based Cognitive Therapy program for TBI. The heart of the 10 week program invites participants to practice mindfulness as a way to experience And to develop a different relationship to negative thoughts and fluctuations of mood that occur in depression.

Participants learn to: Reduce reactivity

Decenter from ruminative thinking

‘Sit with’ + - +/-

thoughts, emotions, physical sensations

Prevent further depressive relapse

Presenter

Presentation Notes

Sessions focus on learning to reduce reactivity to sad moods by becoming more aware of present moment experience, and how negative affect can call forth unhelpful patterns of mind. Thru the instruction & practice of mindfulness activities such as formal meditation & gentle mindful movement, Participants are taught how to de-center from and ‘sit with’ positive, negative, and neutral content and to build recognition of depression relapse signatures. Participants are encouraged & supported to develop a daily home meditation practice & are supplied with a guided meditation CD.

Practices include:

body scans, sitting meditation,

walking meditation, 3-minute breathing spaces,

mindful movement, process of inquiry and dialogue

Brain on Meditation

Hippocampus learning & memory

Cingulate self-awareness, compassion & introspection

Amygdala anxiety & stress

Hoelzel et al., (2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging. 191;1:36-43. See also Davidson et al., 2003-2012

Presenter

Presentation Notes

So what happens to a brain during meditation? Studies like the 2011 one at the Massachusetts General Hospital are replicating findings with an 8-week mindfulness program similar to the one I am speaking about today. Their findings demonstrated increases in the hippocampus important for learning & memory, Increases in the cingulate associated with self-awareness, compassion & introspection, And decreases in the amygdala which plays an important role in regulating anxiety & stress.

Multi-site RCT of MBCT-TBI

3centers: Toronto, Ottawa, Thunder Bay Canada Blinded, block randomization, of 120 participants Controls were crossed-over 5 treatment waves Sept 2010 – June 2012

Presenter

Presentation Notes

Very briefly, we’ll turn to our RCT - we had 3 centers in Toronto, Ottawa & Thunder Bay. We used Block randomization to intervention or control of 120 participants The Blocking was according to Beck Depression Index scores, age & gender. Eventually the Controls were crossed over to treatment. 5 treatment waves occurred from Sept 2010 to June 2012.

Outcomes Attained

RCT of MBCT – TBI Results Our RCT found a

statistically significant

26% reduction

in overall depression

symptoms (BDI II)

Bedard, Felteau, Marshall, Cullen, Dubois et al., 2013, J Head Trauma Rehabil

Presenter

Presentation Notes

We don’t see as dramatic results – it tends to be more conservative because we have ruled out A lot of bias due to rigorous RCT methodology. Let’s take a look at the results more closely…

RCT Results - Mindfulness An improvement

in depression scores

showed a correlation

to increases in

mindfulness scores

Bedard, Felteau, Marshall, Cullen, Dubois et al., 2013, J Head Trauma Rehabil

Adaptations

Gibbons, Felteau, et al., Training Clinicians to Deliver a Mindfulness Intervention, Mindfulness, 2012;3(4)

MBCT –TBI has been modified by: - Time

- Program

Planning/Learning Conditions

- Learning Accommodations

- Use of Critical Reflection

Felteau, Marshall & Gainer. The role of clinician training in MBCT for TBI. Brain Injury, 2012(26)4-5.

Presenter

Presentation Notes

Sessions were modified from 2hrs to 1 and a half, but increased from 8 wks to 10. Meditations were shortened from 40 min to 30, and the home practice times were altered to 20-30 min. Sessions were redesigned to accommodate attention, concentration, memory & fatigue deficits. We also focused on making the learning more explicit by fostering critical reflection.

Time Accommodations

• Shorter classes • Shorter meditations i.e. 30 min • Shorter home practice

For attention, concentration, memory & fatigue:

MBCT-TBI Learning Conditions Trust

Non-judgment Compassion

Safety Confidentiality

Authenticity Acceptance

Support

Felteau, 2010. Understanding the Transformative Dimensions of Mindfulness Therapy. Unpublished manuscript.

Presenter

Presentation Notes

The findings mirrored the literature - fostering transformative dimensions is grounded in the learning conditions for learner-centered care. The participants told us trust, non-judgment, compassion, safety, confidentiality, authenticity, acceptance & support helped them transform.

Learning Accommodations

• Simplified language • Repetition • Visual aids • Flexible pacing • Experiential learning • Concrete examples • Use of symbol,

metaphor, poetry

Transfer of Learning is Key

• Fostering critical reflection is key

• Use of New Learning Forms every session

Presenter

Presentation Notes

Which is key in this population. We reinforced transfer of learning and critical reflection through the use of New Learning forms.

Fostering Reflection &

Insight

Self-reflective questions asked at end of each session Answers recorded to make learning explicit

Presenter

Presentation Notes

Self-reflective questions were asked at the end of each session to make learning explicit. Answers were recorded on these carbon-sided forms with one copy for the participants & one for facilitators. Reflective questions such as: What did you notice about eating a raisin mindfully? What are you learning about yourself? What application of the 7 attitudes of mindfulness might help you? Reflect on the reasons for maintaining a home meditation practice?

Embodiment, not Methodology

• The teacher embodies the heart of inquiry; the possibility of encountering, being with and befriending experiences with

• Loving kindness • Compassion • Sympathetic joy • Equanimity

Woods SL, 2011

Presenter

Presentation Notes

Teaching MBCT is not about methodology, but rather it is about embodiment. How compassion develops and operates in a MBCT program is important. It’s developed thru observation & being treated with compassion. The modeling of lovingkindness, acceptance & encouragement by the facilitator sets the tone for how members relate to each other. Gradually this style of interpersonal relating can become internalized as each member begins to relate compassionately to his or her personal struggles..

Compassion

• The capacity for self-empathy is critical to recovery, thus being able to cultivate compassion for oneself acts as an antidote to debilitating self-criticism and self-contempt.

• Bates, 2005

• Compassion invites us to soften our negative reactions & encourages a tolerance for

• imperfection and failure. Felteau, 2010

Transferability to Other Populations

• Military • Stroke • MS • Parkinson’s • Alzheimer’s • Cancer • Other

Transferability of MBCT • Consider unique characteristics of

disability • But avoid focus on disability • Foster learning conditions suitable for

population • Accommodate learning styles • Integrate disability through fostering self-

compassion

Presenter

Presentation Notes

To foster integration move towards self-concept beyond disability

Implementation

• Publish MBCT-TBI curriculum in 2015

• Webinar in Winter 2015 see www.onf.org

• Offer MBCT-TBI teacher training programs

• Ongoing clinical supervision & consultation

http://www.onf.org/�

Resources 1. Gibbons C, Felteau M, Mazmanian D, Cullen N, Marshall S, Maxwell H,

Dubois S, Weaver B, Bedard M. Results from a healthy group trial of a modified mindfulness-based cognitive therapy intervention. Mindfulness, 2014(5:3) 232-237.

2. Bedard M, Felteau M, Marshall S, Cullen N, Gibbon C, Dubois S, Maxwell H, Mazmanian D, Weaver B, Rees L, Gainer R, Klein R, Moustgaard A. Mindfulness-based cognitive therapy reduces depression symptoms in people with a traumatic brain injury: Results from a randomized control trial. Journal of Head Trauma and Rehabilitation, 2013;28(6).

3. Gibbons C, Felteau M, Cullen N, Marshall S, Dubois S, Maxwell H, Mazmanian D, Weaver B, Rees L, Gainer R, Klein R, Moustgaard A, Bedard M. Training Clinicians to Deliver a Mindfulness Intervention. Mindfulness, 2012;3(4).

Resources 4. Bedard M, Felteau M, Marshall S, Weaver B, Dubois S, Gibbons C,

Maxwell H, Klein R. Mindfulness-Based Cognitive Therapy: Benefits in reducing depression following a traumatic brain injury. Advances in Mind-Body Medicine, 2012;26(1):14-20.

5. Felteau M, Marshall S, Gainer R. The role of clinician training in mindfulness-based cognitive therapy for TBI. Brain Injury, 2012(26)4-5.

6. Felteau M, Bedard M, Marshall S, Dubois S, Weaver B, Gibbons C, et al., Mindfulness-based cognitive therapy reduces depression symptoms in people with traumatic brain injury: Results from a pilot study. Brain Injury, 22(1)67.

7. Moustgaard A, Bedard M, Felteau M. Mindfulness-Based Cognitive Therapy (MBCT) for individuals who had a stroke: Application of a novel intervention. Journal of Cognitive Rehabilitation, 2007(1)4-10.

Resources 8. Bedard M, Felteau M, Gibbons C, Klein R, Mazmanian D, Fedyk K, Mack G.

A mindfulness-based intervention to improve quality of life among individuals who sustained traumatic brain injuries: One-year follow-up. Journal of Cognitive Rehabilitation. 2005.

9. Bedard M, Felteau M, Mazmanian D, Fedyk K, Klein R, Richardson J, Parkinson W et al., Pilot evaluation of a mindfulness-based intervention to improve quality of life among individuals who sustained traumatic brain injuries. Disability Rehabilitation. 2003;25(13);722-31.

10. Felteau M. Know thyself, heal thyself: Novel research using holistic techniques. In S. Abbey (Ed.), Ways of knowing in and through the body: Diverse perspectives on embodiment. (pp.121-125). Welland:Soleil Publishing Inc.

Dissemination

• Manual and training program planned for 2015

For further information, please contact:

Melissa Felteau, MAdEd Lead Meditation Therapist & Clinical Educator Rehab Research Group Lakehead University [email protected] This presentation may be downloaded at: www.traumaticbraininjury.net Under “Resources” This presentation can not be copied, used, or distributed without the consent of the author.

mailto:[email protected]�

http://www.traumaticbraininjury.net/�

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