Zindel V. Segal, Ph.D., C.Psych Distinguished Professor of Psychology in Mood Disorders

1. How Do Mindfulness-Based Interventions Promote Adaptive Clinical and Neural Pathways of Emotion Regulation? Zindel V. Segal, Ph.D., C.Psych Distinguished Professor of Psychology in Mood Disorders Department of Psychology University of Toronto Scarborough

2. What do the Dalai Lama, Aaron Beck and Sigmund Freud Share in Common?

4. Insight Metacognition Decentering Mindfulness Mentalization Cognitive Defusion Learning how to Regulate Distressing Emotions is Aided by…

5. What is Mindfulness? Mindfulness is a type of awareness that is developed by paying attention in a particular way: on purpose, in the present moment, and without judgment. Like any skill it takes practice. Accesses the present moment, thereby clarifying the range of choices that are available to you.

7. Eating Mindfully Scanning the Body Mindful Walking or Stretching Mindfulness of the Breath Mindfulness of Thoughts Training Once Offered in Monasteries Is Now Increasingly Available In Health and Mental Health Care

8. Depressive and Anxiety Disorders are Frequently Recurrent Symptoms Episode Episode Episode Treatment Recovery

9. What Is Required to Help Patients Become their Own Therapists? Hollon, et al., 2005

10. Representation of negative views of self and emotion in semantic memory following an episode of depression Unloved Hopeless Sadness Worthless Failure Stupid

11. Each additional episode of depression strengthens these links. Unloved + + Hopeless + + + + Sadness + + Worthless Failure Stupid

12. These Modes of Mind Can Be Retriggered Even When Depression is Not Present and Inhibit Positive Information From Coming to Mind - Unloved - + + Honest Hopeless + + - + - + Ambitious - Sadness Warm - + + - Worthless - Failure Curious Generous Stupid

13. Two Ways of Knowing

14. Mindfulness Based Cognitive Therapy Mindfulness Based Stress Reduction 8 weekly group sessions 2 Hours per session, 8-12 participants Common diagnostic composition – depression / anxiety

15. Tangible Intangible Mindful Eating Body Scan Mindful Walking or Stretching Sitting with the Breath Sitting with Sounds Sitting with Thoughts Sitting with a Difficulty Gradient of Attentional Focus in Mindfulness Training

16. Open Monitoring No explicit focus on objects of awareness. Non-evaluative labeling of experience. Mindfulness Meditation Trains 2 Types of Attention (Lutz et al., 2008) Focal Attention • Directing attention on a chosen object. • Detecting mind wandering.

17. Benefits of MBCT Depend on Practice Between Group Sessions 40 minute Body Scan Mindfulness of a routine activity 40 minute Body Scan Mindfulness of a routine activity 40 minute mindfulness of Breath / or mindful stretching/Yoga 3 minute breathing space 40 minute mindfulness of emotion / or mindful walking 3 minute breathing space 40 minute mindfulness of difficult emotions 3 minute coping breathing space 40 minute mindfulness of difficult emotions 3 minute coping breathing space 40 minute practice of your choice 3 minute coping breathing space The rest of your life S1: Awareness and Automatic Pilot S2: Living in our Heads S3: Gathering the Scattered Mind S4: Recognizing Territory of Aversion S5: Allowing / Letting Be S6: Thoughts Are Not Facts S7: Taking Best Take Care of Myself S8: Maintaining and Extending New Learning

18. ANCHORED IN EMOTIONALLY TURBULENT WATERS

20. Pre-Post Effect Size Estimates in Mindfulness Based Treatments – Anxiety Funnel plot of precision by Hedges’s g for Anxiety measures = .63 (Hofmann et al., 2010)

21. Pre-Post Effect Size Estimates in Mindfulness Based Treatments - Depression Funnel plot of precision by Hedges’s g for Depression measures = .59(Hofmann et al., 2010)

22. Challenges Remain on the Efficacy Front

23. MBCT Increases Momentary Positive Emotions 1. Experience Sampling 6 days pre and 6 days post MBCT. • Assessed Domains of Positive Affect, Pleasant Activity and Reward. • Compared MBCT to Wait List Control Group. Geschwind et al., 2011

24. The ‘Present-Moment’ Pathway (Craig, 2009) (Craig, 2004)

25. Attending to the Breath Breath Monitoring (masking out exec function areas) Breath Monitoring Changes Mindfulness Trained > Waitlisted Controls Right insula is uniquely related to Mindfulness Training Farb et al., Cerebral Cortex, 2012 Farb et al., SCAN, 2013

26. Neural Changes Associated with Mindfulness & Sadness Challenge Neutral Clips Sad Clips Vs. HGTV (Crafts & Gardening) Terms of Endearment (1983) The Champ (1979)

27. Following exposure to sadness... Evaluation network goes up… Present moment network goes down..

28. Mindfulness Training: Reducing the Tradeoff… x = 8 Post. Midline Reduced ControlMBSR x = 35 Insula / Claustrum Restored ControlMBSR

29. Sensory Representations Matter Right insula reductions may be maladaptive… Restoration of activity to baseline during emotion challenge is protective Farb et al, 2010

30. Mood Linked Responses in Medial Prefrontal Cortex Predict Relapse @18 Months in Recurrent Unipolar Depression Farb et al., 2011

31. State Effects of Mindfulness Increase Approach and Acceptance: Increases in Relative Right Frontal Hemispheric Asymmetry Keune et al., 2013

32. Density of Practice Across 3 Treatment Types Within a Single Week

33. LESS A TREATMENT – MORE A WAY OF LIFE

34. Conclusions • Mindfulness is relevant to affect regulation. • Can be integrated into standard treatments for mood and anxiety disorders. • Benefits depend upon continued practice. • Neural evidence of increased interoceptive competence combined with approach helps modulate frontal driven fear and ruminative processing.

35. Future Research Questions • Consensus definition of practice metrics needed. • Relationship of participants’ practice to behavioural outcomes? • Relationship of instructor’s practice to behavioural outcomes? • Maintenance of behavioural and neural changes; • Thunderclap or Drip Feed model best fit the data?