by Jo Marchant
The course is called Mindfulness-Based Cognitive Therapy (MBCT). Developed by Oxford University’s Mark Williams and his colleagues, it is largely based on MBSR but with a focus on depression. The conventional medical view is that depression results from a chemical imbalance in the brain—a lack of the neurotransmitter serotonin. Most antidepressants boost serotonin levels. But drugs alone help only around a third of patients out of depression, and as we saw in chapter one, much of their benefit is actually a result of the placebo effect. And, like most drugs, they are associated with side effects (from gut problems and sexual dysfunction to suicidal thoughts).
Psychological therapies are an increasingly popular alternative. The best studied is cognitive behavioral therapy (CBT), in which therapists talk to patients about their lives and problems, aiming to help them identify negative, unhelpful thought patterns and to change them. But MBCT (which combines mindfulness with some elements from CBT) is fast catching up. Whereas CBT is an acute treatment for those who are already ill, MBCT is designed as a tool that people can use in everyday life, to help them stay well. Today’s session is a refresher for people who have finished the course, run by psychologists Willem Kuyken and Alison Evans.
There are 30 people here of varying ages and backgrounds, and they have all suffered from recurrent bouts of severe depression in the past. Evans takes us through some different exercises, punctuating each by striking a resonant metal bowl. After focusing on our breathing, she asks us to attend to our bodies and any physical sensations we’re feeling. Then comes the more active jiggling about. The idea is that paying attention to your body’s movements helps you focus on the present, rather than getting caught up in worries about the past or future.
“You’re seeking safety in the moment,” explains Kuyken14 from the front of the seminar room—tall, chiseled, intense. “And if you can cope with this moment, that shapes the next moment.” Trainees are encouraged to carry this principle into their everyday lives—going for a walk and paying attention to the trees and sky, for example, or just breathing—to escape negative patterns of thinking that threaten to overwhelm them. Another trick is to use everyday cues—red traffic lights, opening the fridge—as a reminder to be aware and notice their surroundings.
Trial results for MBCT so far are impressive. In studies published in 2000 and 2004, Williams and his colleagues found that MBCT cut the relapse rate in patients with recurrent major depression in half.15 This caused the therapy to be recommended by the U.K.’s National Institute for Health and Care Excellence (NICE). Then in 2008 Kuyken carried out a further study, reporting that patients given MBCT had fewer symptoms, better quality of life and a lower relapse rate than those on drugs.16
The patients here in Exeter seem convinced by the benefits of mindfulness. “I hated antidepressants,” says Vicky, 43, a short, practical woman who has suffered from depression for 20 years. “I’d always get off them as soon as I could, then move on and try to forget that time. But a little thing would provide a trigger and I’d be down in the depths again.” Each time it happened, she says, it was worse than before, and harder to hide from her kids. When she was depressed, she wouldn’t want to get out of bed for days on end.
Vicky finished the course two years ago, and says it has helped her to notice warning signs—things like being constantly busy, not sleeping properly, feeling anxious all the time—that indicate she could be on the brink of relapse. Before, “I couldn’t understand why I had suddenly fallen down a mineshaft,” she says. “Now I’m much more mindful of how I’m feeling. It’s like a safety ladder that can get me back out of that shaft.”
Another attendee, 33-year-old Sue, is a keen rock climber and had a promising career as an oceanographer until being bullied at work triggered a bout of severe depression. “It was like a switch flicked,” she says. “I’d get so worked up my heart would be racing. I’d be sweating, nauseous, I couldn’t get out of the front door.” After being prescribed antidepressants for an episode of depression ten years earlier, Sue vowed never to take the drugs again. “They’re really hard to come off, and have horrible side effects. And they don’t solve the underlying problem.”
She had a course of CBT, before being referred to Kuyken. With CBT, “You try to stop having ‘wonky’ thoughts,” she says. “But it’s easy to beat yourself up, to think that you’ve been feeling the wrong way.” With mindfulness, “I was relieved not to be talking through everything,” she says. “This is more accepting. It’s not your fault.” She does have some concerns—for example that the constant sparking of ideas in her head might have been necessary for her creative ability as a scientist. But she approaches mindfulness as just another experiment. “If I can’t do something, I’ll do three minutes of breathing and try again. It’s amazing what a difference it makes.”
Then there’s Ann, a 57-year-old with a wrinkled face and white hair in a ponytail, who has suffered from recurrent depression for most of her life. At her lowest she was suicidal, believing that her children would be better off without her. She too hated being on antidepressants. “They zombified me,” she says. “They didn’t just cut off the negative feelings, they cut off all feelings.” Now she meditates every day and is confident that it will help her to stay well without the drugs. “I’ve realized that thoughts cannot harm you.”
When I ask how her life is different because of MBCT, her reply is simple: “I’m alive.”
Once the session is over, Kuyken and I sit in his sunlit office, where he tells me he’s hopeful that MBCT can be adapted to help people suffering from other mental conditions too, such as chronic anxiety, social phobia or eating disorders. Ultimately, however, he believes that mindfulness might help all of us to cope with the demands of modern society.
“We’re increasingly living our lives on autopilot,” he says. “Kids are getting mental disorders younger and younger.” In particular, he believes that always-on technologies such as email, mobile phones and Facebook can be harmful if we don’t learn how to control their effects on us. “We’re constantly having to deal with incoming data.” It’s very hard to do that with awareness, he says, responding thoughtfully to what’s happening around us rather than reacting blindly.
First, however, he hopes to amass even stronger evidence for the benefits of MBCT in patients with recurrent depression. At the time of writing, he and his colleagues have just published a trial that followed more than 400 patients for two years: MBCT protected them against relapse just as well as antidepressant drugs.17 (When pooled with data from previous trials, patients who took a course of MBCT were 24% less likely to relapse than those on medication.)
“There are millions of people with depression in the world,” says Kuyken (who has moved since I visited Exeter and is now director of the Oxford Mindfulness Center). “If we can provide them with an alternative to antidepressants, that’s huge.”
It’s a long way from where he started, back in 2000, when he nervously “came out of the closet” to study MBCT after a long-standing private interest in meditation. Williams, too, says he initially feared that even to study meditation might destroy his academic reputation: “When we did the first trial we thought we would meet enormous skepticism. Part of me was worried that my career might suffer. But scientists were really interested.”
That positive attitude is in large part because of a spate of recent findings that is now forcing scientists to take meditation seriously as a phenomenon with impressive physical effects. So I travel to Boston, Massachusetts, to meet the woman who has perhaps done more than anyone else to show what meditating does to the brain.
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“I USED to think the whole mind–body stuff was nonsense. But after a month of yoga class, I was hooked.”
Harvard neuroscientist Sara Lazar has bare feet and is sitting cross-legged on her chair. Her unruly hair is gray, but she has the energy and enthusiasm of a teenager. She laughs a lot and talks so fast that she skips some words altogether. “It rocked me. I could see t
here was way more to it than just stretching and exercise.”18
We meet in Lazar’s office in Boston’s Navy Yard, unremarkable except for a shelf above her desk, which is adorned with pink blossoms in a tall, green vase; a bronze Buddha figure; and a silver dancer in a seated yoga pose—leaning forward with one leg straight and one bent. “I like that one,” she says. “I was doing that pose in yoga when I had this big ‘Aha!’ moment.” Instead of struggling to push herself into the position as usual, she relaxed. “I went like three inches further,” she laughs. “Relaxing gets you further than stressing and straining!”
At graduate school, Lazar studied bacterial genetics. Then she injured her knee while training for a marathon. Temporarily unable to run, she started doing yoga to keep fit, and was amazed by the effect it had on her. Like Gareth, she felt that her brain was working differently. “It changed how I thought about things,” she says. She felt that she was calmer, had more empathy, and was better able to see different points of view. “I live in Boston, where there are lots of crazy drivers,” she says. “I realized that I don’t have to get angry with them. They’re probably in a hurry, they’re probably stressed too.”
Fascinated by what was happening to her brain, Lazar switched from bacteria to neuroscience. She trained in the use of magnetic resonance imaging (MRI)—the same technology that I watched doctors across town at the Boston Medical Center use to image the cyst in Daniel’s brain. It isn’t possible to do yoga in the cramped confines of a brain scanner, so instead she investigated the related practice of meditation.
She describes her decision to enter the world of mind–body medicine as “brave or crazy.” “Everyone sort of looked at me funny,” she says. At the time, in the late 1990s, meditation was seen as a hippie, drug-related practice, not a suitable subject for scientific research. But at around the same time, the NIH created a national center for alternative and complementary medicine (the same one that got placebo researcher Ted Kaptchuk hired at Harvard). “That gave me the confidence that I could do this, and I would get funding.”19
Other researchers were already studying how meditation affects brain activity, notably neuroscientist Richard Davidson at the University of Wisconsin–Madison. The Dalai Lama sent Davidson eight of his most experienced monks, each of whom had meditated for tens of thousands of hours.20 Compared to student volunteers, when the monks meditated Davidson saw a dramatic increase in high-frequency brain activity called gamma waves—higher than neuroscientists had ever reported before (in healthy brains anyway; very high gamma waves are also seen during epileptic seizures).
This surge of gamma waves suggested that when the monks meditated, their brains were very highly organized and coordinated, with large numbers of neurons firing together. They also had very high activity in their left prefrontal cortex, a region linked to positive thoughts and emotions. The results were intriguing. These seasoned meditators were clearly able to induce states of consciousness outside of the normal realm of experience.
Lazar did something different, however. She was convinced that her yoga practice had induced not just a passing state of consciousness but a permanent shift in how her brain worked. “I knew that my brain had changed,” she says. So rather than looking at the activity of the brain, she probed its physical structure. She didn’t have access to monks, so she studied “average Joes” from Boston—a therapist, a chef, a lawyer, an IT guy—who were experienced meditators and practiced daily.
To show me what she found, Lazar pulls up a series of scans on her computer screen. She must have seen tens of thousands of these over her career, but she’s still wide-eyed with wonder at this window inside the human skull. “It astounds me that you can get this detailed picture of a brain,” she says. “There are some that look crystal clear, it’s amazing.”
Lazar is astounded by what we can see in these images, but I’m also struck by what we can’t. This is a human being, yet in these intricate, detailed structures there’s nothing to tell us who this person cares about, their first memory, the music they love, the food they hate. We still have an achingly long way to go in our understanding of the brain. For now though, these black-and-white images are the best window we have on its secrets. What mark would meditation leave?
Lazar published her results in 2005. Compared to a control group, the meditators’ cerebral cortex, including the prefrontal cortex, had grown in thickness by around a tenth of a millimeter. “The change is really tiny,” says Lazar. “But it’s significant.” It was enough to show that rather than just being a transient state, meditation can change the physical structure of the brain.
“That really shook everything up,” says Lazar. Scientists had only just worked out that it’s even possible for the adult brain to change in response to its environment. It was long thought that by the time we reach adulthood, our brains are on a downwards trajectory. Neurons can die, but they can’t be born. In 1998, however, postmortems on the brains of elderly cancer patients showed that new cells were being created even at the end of their lives.21
After that, studies started to show that everyone from violinists to taxi drivers beef up relevant brain areas with new cells and connections, just as we build muscles with physical exercise. Lazar’s study showed that meditation can do this too. For the first time, it was possible to explain how the practice might permanently change psychology and physiology.
Other researchers followed, reporting similar results for several different kinds of meditation. There was still a problem, however. These studies left open the possibility that “meditators are weird,” as Lazar puts it. Perhaps people who choose to meditate have particular lifestyles (many of them are also vegetarian, for example) that may affect their brains, or perhaps people with certain types of brains are more likely to meditate in the first place. To prove that meditation was causing the changes, it would be necessary to take people who had never meditated before, and see how the practice affected them.
So that’s what Lazar did, in two studies published in 2010 and 2011. Compared to a control group, those who took an eight-week course of MBSR had increased gray matter in brain areas involved in learning, memory and emotion regulation, including the hippocampus. They also felt less stressed, and this change was accompanied by reduced density of gray matter in the amygdala.22
“That’s important,” says Lazar. As we saw in chapter eight, chronic stress and depression leave people with a smaller hippocampus and prefrontal cortex and a bigger, better-connected amygdala. After just eight weeks’ training, Lazar was seeing some of those changes in reverse. Her finding suggests that meditation can stack the odds back in our favor, making us more resistant to stress.
Lazar is now running a study to test whether physical exercise (which also reduces stress) causes similar changes. And she’s investigating the potential of meditation for warding off dementia. The hippocampus and prefrontal cortex tend to shrink as we age, mirroring some of the changes caused by chronic stress, and contributing to cognitive decline. Several studies have hinted that meditation might help to slow this process. The difference in cortical thickness that Lazar saw was most marked in older meditators, while several different teams have now found that cognitive performance and gray matter volume decline more slowly with age in meditators than they do in controls.23
In a study published in 2014, Lazar also found that fluid intelligence (a measure similar to IQ) declines more slowly with age in yoga practitioners and meditators compared to controls, and that different areas of their brains remain more connected.24 “That’s part of fluid intelligence and that’s what goes with age,” she says. “It suggests that meditation is helping to keep those regions talking to each other.”
Lazar’s research is part of a huge NIH effort to find ways to prevent and treat Alzheimer’s as the population ages. Her decision to study meditation might have seemed crazy at the time, but she’s part of the establishment now.
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I’M NOW persuaded that in those who p
ractice regularly, at least, mindfulness meditation has the potential to change both our minds and our brains. But I still want to know—do those stress-busting effects reach beyond the brain to influence our immune system? And could being mindful possibly help to slow the progression of an autoimmune disorder like MS?
Back in the Yorkshire café, I ask Gareth what he thinks. He tells me that in 2011, shortly after he began meditating, he was diagnosed with the more serious “progressive” form of MS, in which instead of having periodic attacks, people just get steadily worse. But in the five years or so since then he has surprised his doctors, because his condition has remained largely stable.
When he suggests to them that his meditation practice might be helping to slow the progression of his disease, Gareth says he gets “a scornful look.” But he’s convinced that mindfulness is a factor: “I’ve had progressive MS for five years, I should be worse than this.”
There is growing acknowledgment, however, that by causing chronic inflammation, stress does exacerbate the progression of autoimmune conditions like MS. A 2004 meta-analysis of 14 studies published in the British Medical Journal concluded that there is a “consistent” and “clinically meaningful” association between stressful life events and subsequent attacks in relapsing remitting MS.25 For example, a Dutch study that followed 73 MS patients found that stressful life events—such as downsizing, or the death of a relative or friend—doubled the risk of exacerbation over the following month.26
And in 2012, a randomized controlled trial of a stress management therapy in 121 patients with relapsing remitting MS found that those in the stress management group had fewer new brain lesions (a sensitive marker of the disease’s progression) than the controls.27 The effect size was similar to that seen in equivalent trials of new drugs. But the benefit didn’t last once the therapy finished—six months later, there were no longer any differences between the two groups.
