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Terapias Cognitivas Baseadas em Mindfullness

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Terapias Cognitivas Baseadas em Mindfullness

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Plano de Projeto:

Objetivos do trabalho;

Breve descrição dos pressupostos Cognitivo-Comportamentais;

Apresentação das técnicas:

Práticas formais:

Meditações sentadas;

Meditações em movimento;

Partilha em grupo.

Práticas informais:

Atividade consciente;

Exercícios estruturados;

Leitura consciente;

Mini-meditações.

Descrição da técnica:

origem;

objetivos;

indicações e contraindicações;

como se executa;

vantagens e desvantagens.

Reflexão: o que aprendemos com este trabalho.

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Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., Segal, Z. V., Abbey, S., Speca, M., Velting, D., & Devins, G. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11(3), 230–241. https://doi.org/10.1093/clipsy.bph077

Cambridge University Press (2018, janeiro 02). Mindfulness in psychotherapy: an introduction. https://www.cambridge.org/core/journals/advances-in-psychiatric-treatment/article/mindfulness-in-psychotherapy-an-introduction/FB9E0A4DAA70BA12FDBFCDC6DDD0A063

Olivine, A. (2022, janeiro 12). What Is Mindfulness Therapy?. Verywell health. https://www.verywellhealth.com/mindfulness-therapy-5212796

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. Guilford Press

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'Mindfulness' is a common translation of a term from Buddhist psychology that means 'awareness' or 'bare attention'. It is frequently used to refer to a way of paying attention that is sensitive, accepting and independent of any thoughts that may be present. The definitions quoted in Box 1 represent some different ways of expressing this. Although mindfulness can sound quite ordinary and spontaneous, it is the antithesis of mental habits in which the mind is on 'automatic pilot'. In this usual state, most experiences pass by completely unrecognised, and awareness is dominated by a stream of internal comment whose insensitivity to what is immediately present can seem mindless. Although most people knowingly experience mindfulness for very brief periods only, it can be developed with practice.

Mindfulness is:

'facing the bare facts of experience, seeing each event as though occurring for the first time' ( Reference GolemanGoleman, 1988: p. 20)

'keeping one's consciousness alive to the present reality' ( Reference HanhHanh, 1991: p. 11)

'paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally' ( Reference Kabat-ZinnKabat-Zinn, 1994: p. 4)

'awareness of present experience with acceptance' ( Reference Germer, Germer, Siegel and FultonGermer, 2005: p. 7)

Differences can be discerned in how different practitioners use mindfulness. Some of these reflect the hazards of translation and others reflect longstanding ambiguities within Buddhist psychology (for an extended discussion see Reference Mace, Ancho, Miller and MathersMace, 2006b, Reference Mace2007). One nuance that should not be overlooked, because it has implications for therapeutic practice, is evident from the way mindfulness can be used to denote self-awareness or self-consciousness as well as an awareness of what is immediately present. There is an important element of self-recollection in traditional Buddhist conceptions of mindfulness too, evident when the awareness of internal psychological events such as feelings and patterns of thought is promoted through deliberate verbal reflection, as in 'Now I am doing x, now I am feeling y'. Although this sort of internal commentary, and its emphasis on a central 'I', is not at the heart of modern conceptions (cf. Box 1) it helps in understanding how mindfulness sometimes gets confused with Reference Fonagy, Gergely and JuristFonagy et al's (2002) concept of mentalisation. As a reflective capacity that is neatly summarised as 'mind-mindedness', or the capacity to discern whole mental states in others, mentalisation remains distinct from any of these conceptions of mindfulness because of what Reference Brown and RyanBrown & Ryan (2004) refer to as the latter's 'prereflexive' quality.

Although definitions such as those in Box 1 are not misleading, they can fail to convey the implications of being mindful. It might be hard to understand why, in ordinary circumstances, anybody should seek this sort of adjustment in awareness, other than for a relaxing mental recharge. One answer, in psychological terms, is that practising being mindful leads progressively to awareness of and freedom from mental conditioning. (There is some objective evidence for this from responses to projective tests: e.g. Reference Brown, Engler, Wilber, Engler and BrownBrown & Engler, 1986.)

Interest in the potential health benefits of mindfulness has fuelled attempts to define its components more clearly through empirical research. These are in their infancy, but indicate that two components could be primary: a capacity to direct and maintain receptive awareness, and sustaining an accepting attitude towards all experience ( Reference Bishop, Lau and ShapiroBishop et al, 2004). Studies of relatively inexperienced practitioners of mindfulness show such a high correlation between these aspects that it has been suggested the first alone might be taken as a marker of its depth ( Reference Brown and RyanBrown & Ryan, 2003). However, recent tentative findings suggest that accumulating experience leads to a continuing deepening of non-reactivity once the capacity to maintain an open awareness develops to a consistent level (R. A. Baer, 2006, personal communication). Indeed, research continues to confirm that some facets of mindfulness emerge only with experience ( Reference Mace and Delle FaveMace, 2006a), making it essential that length of practice is taken into account in experimental assessments.

Given that not all commentators agree on what is specific to mindfulness, and its capacity to vary according to individuals' experience, generalisations about neurobiological correlates have to be treated with caution. It does seem that development of the capacity to maintain a continuing non-verbal awareness of being aware has been associated with increased coherence of the electroencephalograph (EEG), and that bilateral slowing is commonly found during mindful meditation ( Reference AustinAustin, 2006). More speculative findings concerning asymmetric prefrontal activation in new students of mindfulness remain to be confirmed ( Reference Davidson, Kabat-Zinn and SchumacherDavidson et al, 2003), but have interesting implications as they have also been associated with positive changes in affect.

Techniques for developing mindfulness

Some people develop mindfulness because pursuits such as regularly playing a musical instrument can foster it. However, it is usually learned through a mixture of guided instruction and personal practice. The techniques that are generally used ( Boxes 2 and 3) can be divided into those that require periods of withdrawal from other activities to practise extended exercises (formal practices) and those that can be undertaken throughout the day, amid other activities (informal practices).

Formal practices

Informal practices

Mindfulness and psychotherapy

Mindfulness places 'attention' at the heart of psychotherapy. Given that psychotherapy depends so heavily on the interaction between therapist and patient, it is remarkable how little prominence attention has received. Notable exceptions have included Freud, who believed psychoanalysts' attention to be essential to their practice. The psychoanalyst should maintain:

An equally significant injunction of this kind can be found, appropriately, in the English psychoanalyst Wilfred Bion's Attention and Interpretation:

The strictures of Freud and Bion are intended to sharpen the analyst's receptivity and acuity of observation, including the uncomprehending apprehension of features that would otherwise be obliterated by the usual habits of the analyst's mind. Attention becomes important because training it helps the analyst to observe and to analyse more effectively.

While Bion was still formulating his views on psychoanalytic procedure, Karen Horney had made attention the cornerstone of the analyst's technique. She insisted that effective work reflects the quality of the analyst's attention, which should have three qualities: whole-heartedness, comprehensiveness and productiveness. The first two of these stand for the functions of self-forgetting and openness that are effectively prefigured in Freud and Bion. The third, however, introduces an additional element - how attention can 'set something going' for the patient in terms of their self-awareness and self-realisation ( Reference Horney and ParisHorney, 1951: p. 189).

It may be no accident that Horney had some contact with Buddhism at the time of formulating how, in addition to helping the analyst function as a trained observer, the extension of attention towards the patient can be therapeutic in itself. Two other analytic writers who successfully integrated Buddhist understanding in their work have provided clarifications about 'bare attention'. Mark Epstein writes 'It is the fundamental tenet of Buddhist psychology that this kind of attention is, in itself, healing' ( Reference EpsteinEpstein, 1996: p. 110). And Nina Coltart applies this directly to psychoanalysis:

Epstein and Coltart also illustrate quite different ways of introducing mindful awareness to psychoanalytic psychotherapy. Coltart did nothing overtly to change the rules of analytic procedure with her patients. She recognised that the quality of her own close attention affected the atmosphere and activity of her sessions, commenting on how they would acquire the quality of a meditation as she worked intuitively in a way she likens to Bion's ideal ( Reference Coltart and MolinoColtart, 1998: p. 177).

Epstein has long put analytic thinking, particularly that of Winnicott, in the service of what he refers to as Buddhist psychotherapy. This is reflected in his attitude to technique. He likens his role to that of a coach who teaches people how to venture into their unexperienced feelings. The methods he uses differ from patient to patient, and can include instruction in meditation ( Reference EpsteinEpstein, 1998).

Quite distinct ways of incorporating mindfulness within psychotherapy have arisen within the cognitive-behavioural tradition over the past 15 years. Cognitive psychology and Buddhist psychology are in broad agreement about the dependence of emotional disturbance on pervasive patterns of thinking and perception. In contrast to most psychodynamic therapies, recent cognitive-behavioural treatments tend to be designed as interventions for people with a specific set of clinical needs or disorder, rather than as a broad-range therapy. These aims have informed the design of a flood of new 'mindfulness-based' interventions, a sample of which is listed in Box 4.

Mindfulness and psychological distress

In what ways do these different therapeutic uses of mindfulness positively affect mental health? It is clear from the above that different approaches have different aims. Traditional mindfulness practice was expected to lead to differences at the level of being, in a way that is compatible with the optimistic formulations found in psychoanalytic conceptions of a 'true self'. The whole tendency of cognitive-behavioural practice has been to formulate goals that are more specific, problem-oriented and measurable. We might adopt this in summarising some of the specific applications to which mindfulness-based therapies have been applied ( Box 6).

It is already impossible within an introductory article to review methods and outcomes for all the permutations of interventions and applications. Moreover, there is a growing tendency for treatment packages to be designed that combine elements of, say, MBSR with exercises from acceptance and commitment therapy. The list in Box 6 does suggest that, if mindfulness-based interventions are truly effective across these different applications, there may be differences in how mindfulness is beneficial.

The use of mindfulness to reduce subjective anxiety appears to be an example of facilitated exposure that aims to reverse affective avoidance by strengthening the capacity to face and investigate warded-off fears while maintaining an open and accepting attitude ( Reference Roemer and OrsilloRoemer & Orsillo, 2002). The application of MBCT in relation to depressive ruminations is hypothesised to bring about a general switch in 'mental mode'. Accordingly, mindfulness brings about a 'decentring' in relation to each successive experience that is incompatible with the chain reactions characteristic of the ordinary mental mode. If depressive ruminations no longer receive the kind of reactive attention that allows them to amplify, the negative mood changes that are usually consequent on this will be prevented ( Reference Segal, Williams and TeasdaleSegal et al, 2002: p. 75). The expectation that MB-EAT relies on an increased capacity to recognise internal bodily cues has been mentioned already. Like the Segal et al hypothesis, it has also received some support from process measures during clinical trials. However, much of the explanation of apparent effects of mindfulness must remain speculative at this stage, and alternative accounts often exist. For instance, when mindfulness within DBT has been associated with a reduction in impulsive behaviour, this has been attributed both to an improved capacity to participate with awareness of all the processes that lead up to an action (e.g. Reference LinehanLinehan, 1993: p. 63) and to greater acceptance of the painful negative emotions that otherwise trigger impulsive actions (e.g. Reference Welch, Rizvi, Dimidjian and BaerWelch et al, 2006: p. 122).

The therapeutic future of mindfulness

Recognising the importance of how attention is used in psychotherapy cuts across divisions between the cognitive-behavioural and psychodynamic approaches that have been considered here (and others also). The challenges it poses are both theoretical and practical. We have seen how a mindful therapy can have distinctive goals, as well as novel ways of conceptualising what therapeutic success depends upon. Informing these is a psychological understanding based on a view of individualism, and of how people affect one another, that is different from those underpinning most established therapeutic models.

Declaration of interest

None.

MCQs

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Mindfulness in psychotherapy: an introduction | Advances in Psychiatric Treatment | Cambridge Core

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'Mindfulness' is a common translation of a term from Buddhist psychology that means 'awareness' or 'bare attention'. It is frequently used to refer to a way of paying attention that is sensitive, accepting and independent of any thoughts that may be present. The definitions quoted in Box 1 represent some different ways of expressing this.