Mindfulness-Based Cognitive Therapy – A Conceptualisation

Therapeutic approaches like Cognitive Therapy, Narrative Therapy, Mindfulness-Based Cognitive Therapy and others (there are hundreds) are ways to conceptualise working with those in need of therapeutic assistance. Therapists are attracted to specific approaches for a number of reasons and once these therapists decide on the approaches they will use (some are quite eclectic and will borrow from multiple modalities), the therapist uses the approach to “make sense” of your issues. What does this mean? Therapists will hear your story and begin to fit your issues into an approach to help you. For me, these approaches are Narrative Therapy and Mindfulness-Based Cognitive Therapy (and Cognitive Therapy more generally).

When using Mindfulness-Based Cognitive Therapy (MBCT), I tend to think of the therapy model as comprised of three levels. These three levels help me to decide a treatment plan for clients and also help with setting expectations of therapy.

Level One – I call this “symptom relief” and many people think this is all Cognitive Therapy is (we will get to the “mindfulness” later). This perception is aided by the “quick help” – “Brief Therapy” for which (if a client is lucky) insurance companies will pay. Find the symptoms and give some immediate relief. Within Cognitive Therapy, this is looking for dysfunctional thinking, such as “automatic thoughts” and “cognitive distortions”. Once the almost automatic thoughts a client tells him or herself are identified, the therapist can help the client come up with ways to notice and change these thoughts. Similarly, if a client is in the habit of filtering life through cognitive distortions (e.g. black and white thinking or catastrophic thinking), the therapist helps the client review these thoughts, challenge them and then come up with alternate possibilities. While level one can provide some immediate relief, it is only the beginning in therapy. Many will stop therapy after this immediate relief, either from financial considerations or because they assume they are “cured”.

Level Two – This is where the client and therapist look at the combinations of thoughts into “schemas” and “modes”. Schemas are ways to organising information and relationships among this information. Moving beyond the surface dysfunctional thoughts of level one, the client and therapist dive into the schemas into which these thoughts are organised. Modes are a more recent addition to Cognitive Therapy and are an attempt to look at “the ‘synchronous interactions’ among the cognitive, affective, physiological, motivational, and behavioral systems of personality.” (see https://beckinstitute.org/suicide-mode/) Level two requires looking at how client beliefs are combined to form larger views of the world and responses to it.

Level Three – This is where mindfulness comes into play. Yes, basic mindfulness techniques can be used almost immediately, but mindfulness is a practice, not simply theory, and takes time to master. I have also listed this as level three because it is a different approach to thoughts, which I have found most applicable after learning the thought management techniques of levels one and two. In levels one and two, the client learns to examine, question and reconsider thoughts. In mindfulness, the goal is to calm the mind through focusing on the breath or an object. As this happens, the practitioner learns to watch thoughts come and go (arising in consciousness and falling away once not focused upon). In my experience as both a meditator and a therapist, this is a different relationship to thoughts than levels one and two. Adding mindfulness to Cognitive Therapy gives the client another way to approach their thoughts, realising that they are more than just the thoughts that arise and fall away in their minds.

This conceptualisation helps me both with working through my own thoughts and when helping others. As noted in reference to mindfulness (level three) these levels are not rigid – clients can be taught mindfulness techniques from the beginning and note can be made of schemas in level one – but these levels allow the client and therapist to work through MBCT in a progressive way. That is, starting with dysfunctional thoughts, moving to how the client brings these thoughts together into larger frameworks (schemas) and then helping the client to learn to step outside of the whirlwind of thoughts (sometimes referred to as “decentering”) through meditative practice.

If you are seeing a new therapist, ask him or her how they conceptualise their work with clients. If they cannot tell you, it might be worth considering another therapist.