MBCT and Suicide – how to extend MBCT and treat those at risk

Mark Williams and his co-authors show how to adapt Mindfulness-Based Cognitive Therapy (MBCT) for people who have struggled with suicidal thoughts and impulses, and were in remission from Major Depressive Disorder at least 8 weeks.
This is an important work, extending on the understanding that MBCT is helpful to those most at risk for depressive relapse.

The book is Mindfulness-Based Cognitive Therapy with People at Risk of Suicide. The authors are J. Mark G. Williams, Melanie Fennell, Thorsten Barnhofer, Rebecca Crane, Sarah Silverton. A previous edition was titled Mindfulness and the Transformation of Despair: Working with People at Risk of Suicide.

Mark Williams, lead author, in 2003 moved from Bangor University in Wales to Oxford University to begin a 10-year research program, putting together a team that would together be able to research psychological processes underlying mindfulness and how they could “apply to those who suffered depression so severely that they became suicidal.” P 4

He continues the research tradition of MBCT. While basing changes on research slows things down (the 3 creators of MBCT began work in 1993, and the first edition of their treatment manual came out in 2002) the result is a treatment that is well understood both in what it does and what is not yet researched.

This book will be most useful for active MBCT practitioners who want to extend their range, but also offers gems for others. As Williams puts it,”MBCT is particularly useful for those people who are at the greatest risk of relapse or recurrence [of depression].” (P 302)

This book takes that understanding a big step further.Here are a few examples:

• How the authors refined the intake process to reduce dropouts and increase the numbers of people helped
• How to address 5th session teacher doubts (a frequent phenomenon related to the delicate nature of inquiry, in which it’s easy for the teacher to feel “I haven’t taught anything”)
• How to adjust a session after one that had absences
• An essay on the role of the curriculum, balancing first the need to stay close to the content of each session, against, second, the nature of inquiry, which requires flexibility
• A short essay on a potential direction for future research: adding in measures of the positive effects of MBCT (e.g. Increasing well-being) rather that focusing solely on reducing suffering.

• Description of the international training path
• How to work with “at risk” people
• The story of ‘Jane’, one participant, described in detail from intake through the 8 th week and 2 follow-up sessions; a very helpful illustration of how transformation can happen in MBCT
• Guided meditations recorded by Mark Williams, Zindel Segal and John Teasdale
• The role of individualized mentorship in preparing new MBCT teachers around the world (full disclosure: Donald Fleck is a recognized MBCT mentor)
• Accessing the doing and being modes of mind in the teacher, while teaching: using self awareness to be fully present, and most effective, during inquiry

• Insights into clients with suicidal depression
• Review of the extensive research on MBCT, which is rich with information for therapists developing a mindfulness-based practice

The Experience of Being an MBCT Teacher is explored creatively in a chapter I haven’t seen elsewhere. Teachers present and future can gain from this exploration of the subject to teaching MBCT. In includes
*The teacher’s own doing and being state of mind in teaching
*The role of supervision
*What makes a skillful teacher
*Responding in moments of discovery
*Holding the curriculum loosely and firmly at the same time (an adaptation of the increased focus in inquiry, in which the moments of learning are less controlled)
*Teacher doubts
*How to effectively use recordings of yourself teaching, for self-evaluation

The book is available at Amazon and other places. It is pubished by Guilford.

When Sitting With Difficulty is Not Enough: Adding the Action Step

When sitting with difficulty is not enough,  we need to accept the situation, realizing we have done all we can to re-gain perspective.  Then we consider wise action.Without action we miss the power of mindfulness in psychotherapy. The process is explained in Working The Present.


by Donald Fleck, Diplomate in Clinical Social Work  –  Endorsed by Zindel Segal, Ph.D.

Available on Amazon:

Click here to preview the book on Amazon

The eBook price is  $6.99.     The print price is  $21.

Book Cover

 Zindel V. Segal, Ph.D., author of

Mindfulness-Based Cognitive Therapy for Depression,

has endorsed this book:

In Working the Present, Mindfully Based, Donald Fleck succeeds in staying true to the intentions of MBCT while adapting it for use in individual therapy.  The book can be used with clients who have serious mindfulness meditation practices as well as those just getting started, as Fleck has taken many of the core elements of MBCT — the 3-Minute Breathing Space, Kindness and Self-Compassion, Working with Difficulty, Allowing/Letting Be, Thoughts are not Facts, Kindness in Action — and found ways to use them effectively within the basic dyadic encounter.

Packed with clinical vignettes and a user friendly narrative structure, Working the Present, Mindfully Based, provides a clear path towards offering this novel delivery format for MBCT’s key concepts and practices.
Zindel V. Segal, Ph.D., Author of Mindfulness Based Cognitive Therapy for Depression 

Read the beginning of this book, or order it, on Amazon.

Pressed for time? Here’s the executive summary…

  1. Aware – We increase our awareness of the present. When we are present, we perceive more, we perceive differently. When our clients are aware, they have stepped out of automatic pilot.
  1. Allow – When we practice allowing our experience to continue, without chasing after it, or running away from it, we find we have more strength to work with it. Same thing for our clients.
  1. Accept – When we accept our experience as it is, just for now, or go a step further and accept ourselves, our energy can move from resistance to relief and finding solutions. Same for our clients.
  1. Act – When ready, we act. Our actions propel us forward in life. Getting the next action right is really important. This is how change starts. This is how change continues. With awareness, allowing, and acceptance we are grounded and better able to choose helpful actions. Clients, too.

© Donald Fleck

Why this book?

Mindfulness-Based therapies are getting a lot of attention these days, to say the least, and they are very effective in a group format. But clients meeting one-on-one expect sessions geared to their unique needs.

So, over the years I have sought out new ways to use the powerful elements of Mindfulness-Based Cognitive Therapy within the individual session. They are explained in this book.

Read the beginning of this book, or order it, on Amazon.

CD for Mindfulness-Based Cognitive Therapy (MBCT)

Guided Meditations for Mindfulness Based Cognitive Therapy, by Donald Fleck

You can buy and download a complete set of guided meditations for Mindfulness-Based Cognitive Therapy, tracks by Donald Fleck, from CD Baby.

Note: clicking on the graphic below takes you to CD Baby, my distributor. At their site you can see the listing of tracks and album description, and decide if you want to buy certain tracks, or the whole CD.

Donald Fleck: Mindfulness- Based Cognitive Therapy tracks by Donald

Great source for mindfulness news

The University of Vermont has a Mindfulness Center for students, run by Miv London, one of the people who trained me in MBCT. Miv does a great job of finding interesting thinking about mindfulness, such as a recent one documenting that sex and mindfulness are the same to your brain. If you want to stay in the loop of mindfulness news, especially news that would be of interest to younger folks, join the UVM Mindfulness Practice Center, and click to receive updates. And thanks, Miv.

Radical acceptance of the good, and the not so good

Tara Brach lays out a way to deal with painful feelings, and to live life more fully. Her book Radical Acceptance, Embracing Your Life with the Heart of A Buddha, lays out her thinking.

Tara Brach is a clinical psycholotist, meaning she practices psychotherapy. She’s also a student of Buddhism, including mindfulness meditation. She has a lot to contribute to mindful psychotherapy.

The idea here is to embrace all of life, the good, the bad, and the boring. Want to eliminate suffering in your life? Forget it. Want to only experience joy? Forget it.   The way of mindfulness is to be with all experience, not to chase it away, even if it is unpleasant.  It just takes too much energy to chase away experience.   Avoiding knowing experience is a little like living in delusion.

The book’s title, Radical Acceptance, comes from the idea that it’s radical to accept negative experience, radical because in this society we’re brought up to minimize the bad and maximize the good. It really is radical to say that when we’re experiencing something unpleasant, we should allow ourselves to ‘be’ fully in that experience.  This doesn’t mean going out looking for unpleasant experience; just being with it when it comes.  Why practice this radical acceptance?  Because it works.

The Buddha was raised in luxury, his father a King, yet he wasn’t happy. He wanted to find enlightenment, and like many Hindus of his day began by depriving himself of all comfort: nearly starving himself, living the life of a homeless person. That didn’t work either, he nearly died, not at all the better of having lived in suffering.  Living in luxury hadn’t worked; living in suffering hadn’t worked, either.   He struggled to make sense of life, finally resolving to sit under the Boddhi tree until he understood things more deeply.  He realized the idea of embracing whatever experience came to him, the pleasant, the unpleasant, and the neutral (boring).  Life always included elements of happiness and elements of sadness. Enlightment meant accepting all of experience,  even as a child does, without preference.

This is a rather large teaching moment in Buddhism, and also for Tara Brach. She sees how we lead so much of our lives trying to avoid pain and suffereing, seeking after comfort, to no avail. The difficulties just keep on coming.

The change she teaches involves accepting all of experience, as the Buddha did.

It plays out like this:  The prime dissatisfaction for many of us is the sense that we are unworthy. We aren’t enough, we don’t do enough, we don’t have enough.  We live in a trance of unworthiness. It’s a trance because the pain of KNOWING the unworthy feelings is rather deep. So we keep really busy, so there’s no time to sit and feel. We embark on self-improvement projects to try to be good enough. We avoid risks to avoid more pain. We withdraw from knowing our current experience.  We become self-critics. And like most self critics, we also become critical of others.  Doing all this activity just to live in the delusion that everything should be pleasant. And to avoid knowing what’s life is really like.

Being caught in the trance  means losing sight of the self who’s connected, whole, in the ‘fullness of being.’ Breaking the trance of unworthiness involves being in close touch with the self that’s fearful, wanting, feeling alone and separate.

Brach’s way out?  “When we learn to face and feel the fear and shame we habitually avoid, we begin to awaken from the trance.” (p. 57)

A principal way for the beginner to do this is with the sacred pause. It’s a way to stop running from experience. Brach lays out in clear detail how to learn the sacred pause, although for many it is better learned with the aid of a professional helper, as the feelings that come out can be strong.  The sacred pause is sort of like saying, “Here I am, (name your experience)…. let me feel it fully, let me be with it, regardless of how I feel about it.”

Having learned the pause, readers are encouraged to practice it often. The book introduces vipassana or mindfulness meditation to come into contact with experience, and metta or loving-kindness meditation to develop compassion for the deeper self that comes clearly into view.

People of all walks of life can gain from this book. Each chapter ends with the text of a guided meditation to practice and directly experience her teachings.

For professionals: In the process of describing Radical Acceptance Brach lays out an approach to mindful therapy that reveals itself only through the accumulation of examples she uses. But revealing it is, and worthy of study by the psychotherapist.  For the professional psychotherapist who wants to learn more, Dr. Brach has also taught workshops on Radical Acceptance for professionals. I studied this with her, and found it most helpful.  With some of my psychotherapy clients it becomes the focus of our work.

A helpful interview with Tara Brach occured in Elisha Goldstein’s blog at PsychCenral, 9/4/09.