Q: Mindful Meditation for Severe Depressive Episodes? When to Stop
Hi Dr. Phelps,
Thank you for all the valuable information online and in your book.
I have two questions:
1.) Do you know of any patients who have been able to effectively use
mindfulness meditation to deal with severe depressive episodes? I think it is a
valuable tool for OCD and other anxiety problems, but simply observing thoughts
and feelings during depressive episodes drags me down and leaves me feeling even
more overwhelmed by them. During depressive episodes, there is something to be
said for distracting activities-exercising, knitting, reading, volunteering,
etc-but I keep reading that if we stop fighting depressive symptoms and embrace
them, it will soften the experience. I simply can not relate to that.
2.) How long is too long for a patient with bipolar disorder to stay in therapy?
I am embarrassed that I have been going for six years. I have made great
progress with general anxiety and OCD. For about 3 decades, I spent several
hours everyday going through a lengthy list of compulsions, but that is history
now. I keep thinking I should be doing as well with the bipolar disorder by now,
but repeated bouts of severe depression and mixed states continue to be a
problem. There is definitely nothing wrong with my therapist because she uses
the same multi-faceted approach as you do and I continue to learn a lot in the
sessions. I just can't get the bipolar disorder under control like I did with
the OCD so it is very frustrating.
I apologize that this is so long. Thank you in advance for your answers to my
questions if you choose my submission to post a response to. (I realize that
given the number of submissions you probably receive, it may not be possible to
post a response to everyone. If you choose mine, please omit my name.)
Sincere regards & thanks.
Dear Anon. --
As you are learning, there are different variations of "cognitive-behavioral
therapy". Some of them work better for one given person than others. As you
point out, "distraction" is regarded in some of these therapies as carrying the
risk of being a form of "avoidance"; and as you are aware from your OCD
treatment, avoiding avoidance is central to the treatment process.
However, as you also point out, the treatment of depression using cognitive
tools can be approached somewhat differently. Several different variations of
"mindfulness" have recently been injected into CBT. One of the first was
described in a textbook called Mindfulness-Based Cognitive Behavioral Therapy
for Depression, although this was more of a description of a research program
than a description of any significant new form of therapy. Nevertheless, it was
a remarkable synthesis of other work in psychotherapy (such as dialectic
behavior therapy, which has a strong mindfulness component) plus the traditional
A variation of mindfulness melded with CBT which might feel more natural to you
has recently been published in the form of a patient-friendly workbook called
Get Out Of Your Mind and into Your Life, by Stephen C. Hayes. Dr. Hayes has been
working on this method, which he calls Acceptance and Commitment Therapy, or
ACT, for about a decade. He has published the method several ways, and has
subjected it to randomized clinical trials, showing efficacy in treatment
Very few therapists are familiar with ACT, but the new manual makes it quite
accessible. You might get hold of a copy and show it to your therapist and ask
whether this might be a variation to try.
However, you raise another issue here, about "getting the bipolar disorder under
control" as you did with OCD. Without knowing your case, I can't at all be
certain about this, but I do generally operated under the assumption that
psychotherapy alone cannot completely control mood swings (although there are
some important non-medication ingredients, such as a regular pattern of sleep
and exercise, without which one may end up needing much more medication than
otherwise). In other words, it could be that you and your therapist have done
everything which could possibly be asked of each of you, and yet still your
symptoms are not sufficiently controlled, and that instead the focus would have
to be on using additional mood stabilizers to gain that last degree of stability
you might be seeking.
Finally, how does one know when one has had enough therapy? In your case comment
it sounds as though you continue to feel that you are learning and gaining from
the process. That might be enough right there to say that it is worth continuing
(particularly if you were to add a new angle, such as described above).
In general, however,, knowing when to stop psychotherapy is a very complex
issue. In theory, the result of such treatment is supposed to become integrated
into yourself to such an extent that ultimately you can maintain the gains
derived from it even after ending your ongoing relationship with a given
therapist. This is particularly true of the more modern psychotherapies that
emphasize acquiring skills as much or more than the relationship with the
therapist. Nevertheless, that relationship is also quite crucial to the outcome
in many cases and must be brought to a close with care and deliberate
discussion. Indeed, that last sentence about ending the relationship is the
subject of vast discussion in psychotherapy literature. Suffice it to say that
in general, when contemplating bringing psychotherapy to a close, it is best to
do so through an open discussion of the issue with your therapist, expecting
that this might take quite a few sessions to work through.
Thank you for your interesting and very polite question.
Published May, 2007