Faculty of Science and Technology

2022/2023
Level 7 Take-Away Sit Exam Paper
Course: Unit Name: Psychological Therapy
MSc Foundations in Clinical Psychology

Paper set by: Dr Maddy Greville-Harris, Dr QA: Dr Shanti Shanker

Helen Bolderston

Paper Issued: Tuesday 23rd May 2023 This is a take-away exam paper

Submission Deadline: 12.30pm on Friday Unit Weighting: 50 %

26 May
th

The paper is to be electronically submitted to Turnitin via Brightspace (Psychological

Therapies – assignment submission) by no later than 12:30pm on Friday 26 th May. Please
allow sufficient time to upload files before the deadline and in a Word document format.

Please type your answers to the questions on the paper in the space below each question

Assessment Task:

Answer any THREE questions

All questions will carry equal marks

1. Critically discuss the usefulness of Cognitive Behavioural Therapy (CBT) in the treatment of
anxiety disorders. Refer to research evidence to support your answer.

2. Define what a transdiagnostic psychotherapy is, and use research evidence to evaluate
Acceptance and Commitment Therapy (ACT) as an example of a transdiagnostic
psychotherapy.

3. What are the key features of Behavioural Activation (BA)? Critically evaluate this therapy as
a treatment for Major Depressive Disorder.

4. “Non- specific skills are important in therapy.” Discuss this statement with reference to
research evidence.
 5. What is Mindfulness Based Cognitive Therapy (MBCT)? Use research evidence to evaluate
the impact of MBCT on relapse in depression.

6. Referring to relevant research evidence, critically discuss ONE evidence-based

psychological therapy for the treatment of eating disorder(s).

Confirmation that this assignment assesses the relevant ILOs: Yes

 You will find the take-away exam paper submission link under the Assignment Submission area of
the Psychological Therapies unit on Brightspace
 As a guide, each exam paper represents an equivalent of 3000 words. Therefore, your answers to all
written questions should total 3000 words.
 If answers require an essay, then references must be included with an appropriate reference list.
This will not form part of your word count.
 Please submit your answers to Turnitin via Brightspace (Psychological Therapies Exam) by no later
than 12:30pm on the 26th May, in a Word document format.

Please note that as per the Standard Assessment Regulations any work submitted after the deadline
will be capped at 0%.

Capped work will be considered by the Board of Examiners and cannot be retrospectively uncapped
by Academic Staff.

You must keep a copy of your paper – the university will not take responsibility for lost submissions.

If you are unable to submit on time due to medical or other circumstances, if this is before the deadline you
can submit a request to postpone the exam(s) to the summer. If this is after the deadline there is the board
considerations process. Both postponement and board considerations do require independent supporting
evidence. Forms are available from the university website under Student Policies, Regulations and
Procedures / Assessment then Extenuating
Circumstances https://www1.bournemouth.ac.uk/students/help-advice/looking-support/exceptional-
circumstances

Plagiarism
Plagiarism is the act of copying the work or ideas of others without proper acknowledgement of this work.

Plagiarism also includes self-plagiarism or duplication: the inclusion in coursework/exam, or a dissertation, or

project, of any material which is identical or substantially similar to material which has already been submitted
for any other individual assessment within the University or elsewhere.

Avoiding plagiarism is best achieved through the use of proper academic referencing and minimising direct
quotations (i.e. re-write others’ ideas in your own words, but still provide the reference of where these ideas
came from).
Further information can be found here:
https://www.bournemouth.ac.uk/students/library/using-library/how-guides/how-avoid-plagiarism

and
https://www.bournemouth.ac.uk/students/library/using-library/how-guides/how-avoid-academic-offences
 1. Critically discuss the usefulness of Cognitive Behavioural Therapy (CBT) in the treatment
of anxiety disorders. Refer to research evidence to support your answer.

The DSM-5 states anxiety disorders (AD)s share characteristics of pathological fear, the
emotional response to perceived or real threat and anxiety and the anticipation of expected threat,
which both cause behavioural disturbances (American Psychiatric Association, 2013). Those with
ADs exhibit decreased productivity and quality of life and increased comorbidities to other
disorders (Bystritsky et al., 2012). ADs are suggested as chronic disorders that either remain stable
or decline as age increases, and generally affect more women than men (Remes et al., 2016). The
most prevalent ADs are Generalised Anxiety Disorder (GAD), Social anxiety disorder (SAD) and
panic disorder (PD), where 1 in 3 people are at risk of meeting AD criteria in life (Bystritsky,
2006). Furthermore, the COVID-19 pandemic led to an estimated 25.6% increase in cases of AD
globally (Santomauro, 2021). With a high prevalence and increase in AD, finding appropriate
treatment is of great importance to relieve psychological suffering. The most studied and
recommended treatment for AD is Cognitive Behavioural Therapy (CBT) (Bandelow & Michaelis,
2015). This review critically discusses the efficacy of CBT in the treatment of AD.
CBT is a skill focused treatment that is typically administered over a short-term period,
(Kaczkurkin & Foa, 2015). Central components of CBT for AD are through teaching cognitive
coping skills and delivering exposure to feared stimuli to reduce anxiety and avoidance behaviours
(Glenn et al., 2013). CBT can be internet-delivered or through face-to-face treatments, however, a
meta-analysis has shown that face-to-face treatment is more effective at improving quality of life in
AD patients (Hofmann et al., 2014). This may be due to the therapeutic relationship that is
identified as an important component of therapy to achieving desired outcomes (Dobson, 2022).
A meta-analysis from Hoffman & Smits (2008) found CBT to be an effective treatment for
AD when analysing the gold standard randomised placebo-controlled trials, where CBT delivered
significant benefits compared to placebo treatments when accounting for bias. Although CBT did
not reduce comorbid depression in those with GAD, SAD, and PD (Hoffman & Smits, 2008). A
more recent systematic review and meta-analysis of randomised clinical trial observed that CBT
delivered moderate symptom reductions at 12 months follow up for all ADs and longer significant
effects were found for GAD and SAD but not PD (van Dis et al., 2020). However, this study notes
heterogeneity was large within GAD studies, which creates uncertainty for results. Also, relapse
rates were low at 13% for SAD, 23% for PD and this was not reported for GAD (van Dis et al.,
2020). This demonstrates CBT effectiveness in treating the chronic condition of AD and
maintaining improvements after treatment for the majority. Although it also indicates CBT may
affect subgroups of AD differently. Furthermore, there were those that did not sustain
improvements which limits the effectiveness of CBT for SAD and PD, and GAD should be
interpreted with caution. Additionally, these meta-analyses do not specifically explain how CBT is
effective in treating AD.
 For GAD, specifically, the client’s expectation of self-improvement from CBT was found to
mitigate the effectiveness of CBT on anxiety symptoms (Vîslă et al., 2021). Lower outcome
expectations at the start of treatment were a risk for therapeutic ruptures that also decreased
expectation further and therefore decreased the CBT effectiveness (Vîslă et al., 2021). Furthermore,
Gómez Penedo et al. (2021) proposed that changes in interpersonal cognitions, that are biased in
GAD individuals, may be a mechanism of change in CBT for GAD. This may explain how
cognitive restructuring is important to change interpersonal cognitions. Likewise, this may explain
that interpersonal biases may affect GAD client’s expectations of CBT.
A review compiling evidence for the use of CBT in treating PD has shown that CBT is
effective in treating PD and can be helpful to reduce benzodiazepine medication in PD patients, as
this can cause PD symptoms (Ziffra, 2021). However, Totzeck et al. (2020) found that affective
styles of adjusting and tolerating increased significantly with CBT in PD patients, showing favour
to CBT. Although, a patient’s ability to adjust to circumstances, assessed before therapy, also
predicted remission after therapy. Totzeck et al. (2020) note that this could impact a patient’s
motivations and expectations to change behaviour and cognitions.
Lastly, regarding SAD, a non-randomised and rater-blind study found CBT with medication
showed improved treatment and maintenance of symptom reduction than medication alone
(Samantaray et al., 2020). This shows effectiveness for CBT but should be interpreted with caution
as non-randomisation could indicate biases. However, Morina et al. (2022) found CBT effectively
treated SAD and depression symptoms in a large sample of patients (n=231) in routine clinical
practice with psychotherapists in training. Although, this is not a gold standard practice of research,
it does show that the methods of CBT may be easier to deliver which increases its accessibility.
Additionally, Morina et al. (2022) saw 73.5% of the patients reported a positive change in SAD
symptoms, however, 3.8% reported a negative change, which is concerning. This shows
effectiveness of CBT for a majority, while also shows it may not be appropriate for everyone.
In all evidenced research of ADs there are those resistant to CBT treatment where 10-40%
of patients do not respond (Bystritsky, 2006). As ADs are often comorbid with other disorders,
there may be a subgroup of complex AD patients that require a longer or different intervention
(Bystritsky, 2006). Furthermore, Glenn et al. (2013) identified that completing exposure exercises,
high attendance to CBT therapy and adhering to homework predicted greater outcomes for ADs.
Those with complex or strong levels of ADs may prevent them from being able to do these process
that impact CBT effectiveness. This could also be affected by motivations, expectations, and
interpersonal abilities to relate to the therapist.
In conclusion, CBT is shown as an effective treatment for most AD patients, although CBT
can impact GAD, SAD, and PD individuals differently. Furthermore, in each study of CBT
treatment for AD there are those that do not benefit, and this may be due to the complexity and
comorbidity of ADs that reduces their ability to comply with CBT work. Future research should
focus on adapting CBT to address these complex AD patients and their motivations, expectations,
and interpersonal capabilities.
 References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders
Fifth Addition. Diagnostic and Statistical Manual of Mental Disorders, (5), 267–270.
https://doi.org/10.1176/appi.books.9780890425596.dsm20

Bandelow, B., & Michaelis, S. (2015). Epidemiology of Anxiety Disorders in the 21st Century.
Dialogues in Clinical Neuroscience, 17(3), 327–335.
https://doi.org/10.31887/dcns.2015.17.3/bbandelow

Bystritsky, A. (2006). Treatment resistant anxiety disorders. Bystritsky, 11(9), 805–814.

https://doi.org/https://doi.org/10.1038/sj.mp.4001852

Bystritsky, Alexander, Khalsa, S. S., Cameron, M. E., & Schiffman, J. (2012). Current Diagnosis
and Treatment of Anxiety Disorders. P&T, 38(1), 30–57.
https://doi.org/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173/

Dobson, K. S. (2022). Therapeutic Relationship. Science Direct, 20, 541–544.

https://doi.org/https://doi.org/10.1016/j.cbpra.2022.02.006

Glenn, D., Golinelli, D., Rose, R. D., Roy-Byrne, P., Stein, M. B., Sullivan, G., Bystritksy, A.,
Sherbourne, C., & Craske, M. G. (2013). Who gets the most out of cognitive behavioral
therapy for anxiety disorders? the role of treatment dose and patient engagement. Journal of
Consulting and Clinical Psychology, 81(4), 639–649. https://doi.org/10.1037/a0033403

Gómez Penedo, J. M., Hilpert, P., grosse Holtforth, M., & Flückiger, C. (2021). Interpersonal
cognitions as a mechanism of change in cognitive behavioral therapy for generalized anxiety
disorder? A multilevel dynamic structural equation model approach. Journal of Consulting
and Clinical Psychology, 89(11), 898–908. https://doi.org/10.1037/ccp0000690

Hoffman, S. G., & Smits, J. A. (2008). Cognitive-behavioural therapy for adult anxiety disorders: A
Meta-analysis of randomised placebo-controlled trials. The Journal of Clinical Psychiatry,
69(4), 621–632. https://doi.org/10.4088/jcp.v69n0415

Hofmann, S. G., Wu, J. Q., & Boettcher, H. (2014). Effect of cognitive-behavioral therapy for
anxiety disorders on quality of life: A meta-analysis. Journal of Consulting and Clinical
Psychology, 82(6), 1228–1228. https://doi.org/10.1037/a0038157

Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: An
update on the empirical evidence. Dialogues in Clinical Neuroscience, 17(3), 337–346.
https://doi.org/10.31887/dcns.2015.17.3/akaczkurkin
Morina, N., Seidemann, J., Andor, T., Sondern, L., Bürkner, P., Drenckhan, I., & Buhlmann, U.
(2022). The effectiveness of cognitive behavioural therapy for Social Anxiety Disorder in
routine clinical practice. Clinical Psychology & Psychotherapy, 30(2), 335–343.
https://doi.org/10.1002/cpp.2799

Remes, O., Brayne, C., van der Linde, R., & Lafortune, L. (2016). A systematic review of reviews
on the prevalence of anxiety disorders in adult populations. Brain and Behavior, 6(7).
https://doi.org/10.1002/brb3.497

Samantaray, N., Behera, N., Kar, N., Nayak, M., & Chaudhury, S. (2020). Effectiveness of
cognitive behavioral therapy on Social Anxiety Disorder: A comparative study. Industrial
Psychiatry Journal, 29(1), 76. https://doi.org/10.4103/ipj.ipj_2_20

Santomauro, D. (2021). Global prevalence and burden of depressive and anxiety  disorders in 204
countries and territories in 2020 due to the  COVID-19 pandemic. Www.Thelancet.Com, 398,
1700–1712. https://doi.org/https://doi.org/10.1016/ S0140-6736

Totzeck, C., Teismann, T., Hofmann, S. G., von Brachel, R., Zhang, X. C., Wannemüller, A.,
Pflug, V., & Margraf, J. (2020). Affective styles in panic disorder and specific phobia:
Changes through cognitive behavior therapy and prediction of remission. Behavior Therapy,
51(3), 375–385. https://doi.org/10.1016/j.beth.2019.06.006

van Dis, E. A., van Veen, S. C., Hagenaars, M. A., Batelaan, N. M., Bockting, C. L., van den
Heuvel, R. M., Cuijpers, P., & Engelhard, I. M. (2020). Long-term outcomes of cognitive
behavioral therapy for anxiety-related disorders. JAMA Psychiatry, 77(3), 265.
https://doi.org/10.1001/jamapsychiatry.2019.3986

Vîslă, A., Constantino, M. J., & Flückiger, C. (2021). Predictors of change in patient treatment
outcome expectation during cognitive-behavioral psychotherapy for generalized anxiety
disorder. Psychotherapy, 58(2), 219–229. https://doi.org/10.1037/pst0000371

Ziffra, M. (2021). Panic disorder: A review of treatment options. Annals of Clinical Psychiatry,
(Volume 33, No. 2). https://doi.org/10.12788/acp.0014
 3. What are the key features of Behavioural Activation (BA)? Critically evaluate this therapy
as a treatment for Major Depressive Disorder.

Major Depressive Disorder (MDD) is defined in the Diagnostic and Statistical Manual for
Mental Health Disorders-5 (DSM-5) as consistent and reoccurring low mood, fatigue or insomnia,
change in appetite and anhedonia, a loss of interest in pleasurable activities, for at least 2 weeks
(American Psychiatric Association, 2013). Depression, an integral symptom of MDD, and anxiety
have been identified as the most prevalent mental illness and these increased by 25% within the
first year of COVID-19 (World Health Organization, 2022). Depression is associated with personal,
relationship, productivity, and economic costs (Herrman et al., 2022). This high prevalence and
impact on the individual and society emphasises the importance of treatment. A form of treatment
recently receiving a lot of research is Behavioural Activation (BA), which was originally
established in the 1970’s (Kanter et al., 2009). This essay explains the unique features of BA and
critically evaluates BA as a treatment for MDD.
BA is a component of Cognitive Behavioural Therapy (CBT) that features a focus on
behaviour and the environment as the predictor of mood symptoms, rather than cognition and
involves repairing a patient’s response to their environment (Cuijpers et al., 2020). A key feature of
BA is its relation to Pavlovian conditioning or reinforcement learning that is based on expectation
or lack of expectation of reward and activation or inactivation to achieve reward (Huys et al.,
2022). BA specifies that depressive symptoms develop from decreased positive reinforcement or
from an increase in aversive conditions (Hemanny et al., 2019). This reinforcement causes low
mood and a downward spiral of coping strategies for withdrawal or avoidance of activities, limiting
opportunities for positive reinforcement (Soucy Chartier & Provencher, 2013). This emphasis of
avoidance is another feature of BA that aims to increase engagement in pleasant or productive
activities, decrease engagement in activities maintaining depression and solve behavioural
problems that limit reward or maintain aversive control (Cuijpers et al., 2023). Summarised, three
key features of BA are that depressive symptoms result from: behaviour and the environment and
not cognitions; reinforcement learning of decreased opportunities; and avoidance of activities.
An extra feature of BA driving the recent increase in research is the promise for
dissemination and less intensive administration (Soucy Chartier & Provencher, 2013). Soucy
Chartier & Provencher (2013) conducted a systematic review and found guided self-help BA was
effective in reducing mild to moderate depression, however, they did not specific the type of
studies included in their analysis, or the number or demographics of participants involved, which
could indicate bias. Another meta-analysis also investigating guided self-help BA for depression as
a low intensity intervention found that BA was effective in reducing mild to moderate depression in
adults (Ekers et al., 2014). This study specified that only randomised control trials, the gold
standard for research, were included, although many studies were evaluated as poor quality,
containing biases, small samples, and low statistical power. Furthermore, when the poor-quality
studies were removed for BA in comparison to medication, the significance effect favouring BA
was removed (Ekers et al., 2014). It has been argued that there is currently a publication bias crisis
developed from methodological and research biases in practice and reporting, which limits
significance of results, generalisability, and ecological validity (Amrhein & Greenland, 2017).
These 2 studies both advocate for BA in treating depression, however, through involving bias and
poor-quality studies, the results need cautious interpretation and lack efficiency for BA. Another
meta-analysis, involving randomised control trials, found 1-1 psychotherapy of BA had significant
effects for treating depression (Cuijpers et al., 2023). Cuijpers et al. (2023) mentioned that the
effects may be overestimated as publication bias was found, however, this analysis conducted
several sensitivity analyses which indicated the effects for BA were robust, providing evidence for
the efficacy of BA on depression. Although, these studies do not specify if depression is MDD or a
symptom of MDD, which could be interchangeable.
Comparing BA with the most evidenced therapy, CBT, for those who met DSM-5 criteria of
MDD, a randomised control and non-inferiority trial found that BA, when delivered through junior
mental health practitioners with less costly and intensive training, displayed an equivalent effect to
CBT with trained psychologists (Richards et al., 2016). Although Richards et al. (2016) note that
20-23% of patients found no change in their depression with BA or CBT. One pilot study identified
that individual differences regarding reinforcement learning may account for those that do not
benefit from BA where reinforcement learning is a key factor (Huys et al., 2022). Individuals who
could update reward expectations showed greater improvements in anhedonia symptoms. (Huys et
al., 2022). Moreover, another randomised trial found no difference between BA and CBT and both
were more effective than medication, however, with severe depression, BA was more effective
(Dimidjian et al., 2006). Depression incurs rumination, a cognitive process that increases with
depression severity (Miller et al., 2020). Therefore, focusing on reducing avoidance behaviours
through goal setting and proactivity, instead of cognition, may be more beneficial for those with
depression or MDD. These studies also indicate that BA may be easier and more economic for
administration, so more MDD patients may be able to receive treatment.
In conclusion, there are still many studies affected by bias and methodological problems
that limit results for BA effectiveness. However, improved meta-analyses and gold standard
randomised controlled trials have found evidence in favour of BA as an effective treatment for
depression and/or MDD. Additionally, BA may be more effective than CBT for those with severe
depression, which may indicate depression improves more with treatment focused on behaviour
than cognition. Furthermore, BA requires less training than CBT and is equally or more effective
which indicates it may be more easily accessible, which is important for the high prevalence of
depression. Future research is needed to address the minority of patients who do not respond to BA
or CBT and how reinforcement learning may be better addressed for these patients if this is a key
factor in BA.

References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders
Fifth Addition. Diagnostic and Statistical Manual of Mental Disorders, (5), 267–270.
https://doi.org/10.1176/appi.books.9780890425596.dsm20

Amrhein, V., & Greenland, S. (2017). Remove, rather than redefine, statistical significance. Nature
Human Behaviour, 2(1), 4–4. https://doi.org/10.1038/s41562-017-0224-0

Cuijpers, P., Karyotaki, E., de Wit, L., & Ebert, D. D. (2020). The effects of fifteen evidence-
supported therapies for adult depression: A Meta-Analytic Review. Psychotherapy Research,
30(3), 279–293. https://doi.org/10.1080/10503307.2019.1649732

Cuijpers, P., Karyotaki, E., Harrer, M., & Stikkelbroek, Y. (2023). Individual behavioral activation
in the treatment of depression: A meta analysis. Psychotherapy Research, 1–12.
https://doi.org/10.1080/10503307.2023.2197630

Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E.,
Gallop, R., McGlinchey, J. B., Markley, D. K., Gollan, J. K., Atkins, D. C., Dunner, D. L., &
Jacobson, N. S. (2006). Randomized trial of behavioral activation, cognitive therapy, and
antidepressant medication in the acute treatment of adults with major depression. Journal of
Consulting and Clinical Psychology, 74(4), 658–670. https://doi.org/10.1037/0022-
006x.74.4.658

Ekers, D., Webster, L., Van Straten, A., Cuijpers, P., Richards, D., & Gilbody, S. (2014).
Behavioural activation for depression; an update of meta-analysis of effectiveness and sub
group analysis. PLoS ONE, 9(6). https://doi.org/10.1371/journal.pone.0100100

Hemanny, C., Carvalho, C., Maia, N., Reis, D., Botelho, A. C., Bonavides, D., Seixas, C., & de
Oliveira, I. R. (2019). Efficacy of trial-based cognitive therapy, behavioral activation and
treatment as usual in the treatment of major depressive disorder: Preliminary findings from a
randomized clinical trial. CNS Spectrums, 25(4), 535–544.
https://doi.org/10.1017/s1092852919001457

Herrman, H., Patel, V., Kieling, C., Berk, M., Buchweitz, C., Cuijpers, P., Furukawa, T. A.,
Kessler, R. C., Kohrt, B. A., Maj, M., McGorry, P., Reynolds, C. F., Weissman, M. M.,
Chibanda, D., Dowrick, C., Howard, L. M., Hoven, C. W., Knapp, M., Mayberg, H. S., …
Wolpert, M. (2022). Time for united action on depression: A Lancet–World Psychiatric
Association Commission. The Lancet, 399(10328), 957–1022. https://doi.org/10.1016/s0140-
6736(21)02141-3

Huys, Q. J., Russek, E. M., Abitante, G., Kahnt, T., & Gollan, J. K. (2022a). Components of
behavioral activation therapy for depression engage specific reinforcement learning
 mechanisms in a pilot study. Computational Psychiatry, 6(1), 238.
https://doi.org/10.5334/cpsy.81

Huys, Q. J., Russek, E. M., Abitante, G., Kahnt, T., & Gollan, J. K. (2022b). Components of
behavioral activation therapy for depression engage specific reinforcement learning
mechanisms in a pilot study. Computational Psychiatry, 6(1), 238.
https://doi.org/10.5334/cpsy.81

Kanter, J., Busch, A. M., & Rusch, L. C. (2009). Behavioral activation: Distinctive features.
Routledge.

Miller, C. H., Davis, E. G., King, L. S., Sacchet, M. D., Grill-Spector, K., & Gotlib, I. H. (2020).
The structure of depressive symptoms and characteristics and their relation to overall severity
in major depressive disorder. Psychiatry Research, 294, 113399.
https://doi.org/10.1016/j.psychres.2020.113399

Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., Barrett, B.,
Farrand, P. A., Gilbody, S., Kuyken, W., O’Mahen, H., Watkins, E. R., Wright, K. A.,
Hollon, S. D., Reed, N., Rhodes, S., Fletcher, E., & Finning, K. (2016). Cost and outcome of
behavioural activation versus cognitive behavioural therapy for depression (COBRA): A
randomised, controlled, non-inferiority trial. The Lancet, 388(10047), 871–880.
https://doi.org/10.1016/s0140-6736(16)31140-0

Soucy Chartier, I., & Provencher, M. D. (2013). Behavioural activation for depression: Efficacy,
effectiveness and dissemination. Journal of Affective Disorders, 145(3), 292–299.
https://doi.org/10.1016/j.jad.2012.07.023

World Health Organization. (2022). The World Mental Health Report: Transforming Mental Health
for all. World Health Organization, 21(3), 1–4.
https://doi.org/https://www.who.int/publications/i/item/9789240049338
 5. What is Mindfulness Based Cognitive Therapy (MBCT)? Use research evidence to evaluate
the impact of MBCT on relapse in depression.

Depression is one of the most distressing affective disorders, affecting psychological,

biological, and social functioning (van der Velden et al., 2015). The World Health Organization
(2022) identifies depression as one of the highest prevalent mental disorders and prevalence
increased during the COVID-19 pandemic. Depression often takes a recurrent course, after one
episode the risk of relapse recurrence is 50% and this is expected to increase with each episode
(van der Velden et al., 2015). A treatment developed specifically as prophylaxis for relapse in
depression, for those with a history of depression but currently in remission is Mindfulness Based
Cognitive Therapy (MBCT) (Teasdale et al., 2000). Conducted in a group setting, patients learn
affective and cognitive strategies, to acknowledge and allow negative thoughts and emotions
without judgment or reactions to prevent rumination and escalation of negative affecting states and
enduring relapse episodes (Goldberg et al., 2019). MBCT has an emphasis on teaching self-
compassion and focuses treatment on the process of cognition rather than cognition content, that is
a focus in Cognitive Behavioural Therapy (Cladder-Micus et al., 2015). This paper evaluates the
research evidence of the impact of MBCT on relapse in depression.
Evidence from a systematic review of randomised controlled trials indicated that MBCT is
statistically more efficient in preventing relapses in depression long-term than treatment as usual
(TAU) and placebo treatment (McCartney et al., 2020). This study also included booster sessions
and recommended four follow-up sessions within 12 months after treatment (McCartney et al.,
2020). Furthermore, two meta-analyses of randomised controlled trials demonstrated that MBCT
delivered significant reductions in depressive relapses over 60-weeks in comparison to usual care
and maintenance antidepressants (Kuyken et al., 2016, Kuyken et al., 2019). Kuyken et al. (2016)
also showed that MBCT affected all individuals regardless of age, sex, relationship status or
education, which shows the generalisability of MBCT. All studies mentioned the uncertainty of
availability of studies, where unpublished studies that may be important for evaluating the
effectiveness of MBCT for depression relapse may have been subjected to the file drawer effect
(McCartney et al., 2020, (Kuyken et al., 2016, Kuyken et al., 2019). However, due to the large
number of included studies form all analyses involved, MBCT may be effective for relapse
depression.
It is important to understand the mechanisms of change that MBCT produces to enhance
treatment outcomes (Holmes et al., 2014). Van der Velden et al. (2015) identified the core
components of MBCT, mindfulness, meta-awareness, reducing worry and self-compassion were
mechanisms mediating the risk reduction of depressive relapse, however, they found less evidence
for rumination. Furthermore, self-criticism was identified as a potential vulnerability for
reoccurring depressive episodes and participants at risk of depression relapses in MBCT improved
abilities to self-sooth and be less critical, but they did not significantly improve self-compassion
(Schanche et al., 2021). Self-criticism improvements may relate to reducing worry, mindfulness,
and meta-awareness in the first study. However, individual differences relating to self-compassion
in relapse depression patients may be due to higher levels in neuroticism, baseline depression
severity, childhood abuse or lower self-esteem or self-efficacy or physical function which are
positively correlated with risk of relapse (Prieto-Vila et al., 2021). Additionally, Geurts et al.
(2020) discovered that unemployed patients compared to employed patients and higher levels of
psychiatric comorbidity showed reduced MBCT beneficial effects on depressive relapse. These
individual differences may affect the differences in identifying self-compassion as a mechanism of
change.
Another proposed mechanism of change for MBCT in relapse depression, is the
mindfulness practice of decentring, the ability to observe thoughts and feelings as objective and
temporary mind events (Moore et al., 2022). This study discovered in a randomised controlled, no
blocking trial that self-reported decentring showed greater benefits in MBCT for relapse depression
compared to a relaxation group (RG) or TAU. However, MBCT was also found to be equivalent in
reducing relapse of depression to RG and TAU over 12months after intervention, although those in
the TAU group received MBCT at the end of intervention (Moore et al., 2022). Additionally,
decentring exhibited significant growth for depression relapse patients in both MBCT and a
wellness-based cognitive therapy (WBCT) that found equivalent results (Segal et al., 2019).
Finding decentring effects in both interventions may show that the interventions were too similar
for differences in relapse rates or may show reducing depression relapses work on different
mechanisms than those only proposed in MBCT.
Additionally, an intention to treat analysis study and a randomised control trial found
MBCT and an active control condition of a Health Enhancement Program (HEP), both conducted
by trained professionals, to be equally as effective in preventing depression relapses (Shallcross et
al., 2015, Shallcross et al., 2018). The HEP in both studies included wellbeing education and
activities of physical activity, nutrition and music therapy but lacked the mindfulness component
(Shallcross et al., 2015, Shallcross et al., 2018). This may contradict the mechanisms of MBCT that
mindfulness is necessary to reduce depression relapse and improving well-being understanding and
reducing experiential avoidance that may also produce decentring could be found in multiple types
of therapies. Moreover, Kuyken et al. (2019) identified that MBCT may be more beneficial for
those at greater risk of depressive relapse. The severity of depressive relapse was not documented
in the above studies which may require a mindfulness component delivered from MBCT, future
research should investigate.
In conclusion, MBCT has been shown to be effective for a range of demographic patients at
risk of depressive relapse, however, there are some patient history individual differences that may
benefit less from MBCT. It is unknown how these individual differences would be affected by
other interventions that have found success at treating depression relapse. Furthermore, decentring
may be a mechanism of action of MBCT, but this is not limited to MBCT. Future research is
needed to address how mindfulness, wellbeing education and booster sessions differentially
improves the risk of relapse and compare the risk severity of depression relapses.
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