Mindfulness and Cognitive Behavioral Therapy are two approaches that are becoming very popular in the counseling world. Their treatment of anxiety disorders is very effective and is proven with new MRI studies. The brain’s structural changes can be documented when individuals practice meditation, which is known to cause improved emotional regulation. This is important for individuals with Generalized Anxiety Disorder (GAD) because of the results of this disorder. This disorder underlies or can lead to mood disorders and other medical illnesses. Thus, an emphasis is placed on accurate assessment for proper diagnosis. By treating the underlying problem, many illnesses can be prevented. This paper examines the diagnostic criteria, differential diagnoses, assessment process, and the incidence and prevalence of GAD. In addition, this research explores combining mindfulness with CBT and integrating a Christian approach to therapy. This researcher discusses the importance of integrating a Christian perspective in counseling and, more specifically, the difference it can make.
Mindfulness-Based Cognitive Therapy for Generalized Anxiety Disorder
Cognitive Behavioral Therapy (CBT) and Mindfulness are two methods on the cutting-edge of evidence-based psychotherapy. Together these techniques are highly effective in treating anxiety. MRI is being used to see brain differences as a result of meditation practice, which is used in Mindfulness. Furthermore, research shows how combining Mindfulness and CBT reduces anxiety (Sharma, Mao, & Sudhir, 2012).
Anxiety disorders are the most common psychiatric problem affecting children and adults. Approximately 40 million American adults suffer from anxiety disorders (Anxiety and Depression Association of America, 2012). Specifically, Generalized Anxiety Disorder (GAD) affects 6.8 million adults, or 3.1% of the U.S. population, in any given year (Gliatto, 2000). Women are twice as likely to be affected. However, only approximately one-third of those suffering from this disorder receive treatment, even though anxiety disorders are highly treatable.
GAD comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age. Most frequently it is seen in women in their early 20s by their primary care physician. Although the exact cause of GAD is unknown, there is evidence that biological factors, family background, and life experiences, particularly stressful ones, can cause it (Gliatto, 2000).
Biological factors can cause GAD and be seen in a person’s temperament, too. This is called persistent or “trait” anxiety and is seen as part of an individual’s temperament (Gliatto, 2000). Clients usually report they have always been nervous but do not know why. Stressors can exacerbate the already low level of anxiety in these individuals.
A Christian worldview posits that we are “not to be anxious about anything” and thus, worry is a sin (Phil. 4:6 New International Version). However, life events can cause stress, but we are still responsible for our response to it. When we worry, we doubt God’s omnipotence, omniscience, and we believe we cannot depend on Him to care for us.
CBT agrees with a Christian worldview more than most popular therapies. Romans 12:2 emphasizes renewing our mind and taking thoughts into captivity unto the obedience of Christ. We know by controlling our thoughts and having right thinking we can decrease anxiety. CBT teaches self-awareness and controlling the thought life. We also see this in the Christian process of sanctification when we are made more like Christ by controlling our thoughts and meditating on Him. Indeed, our mind is a battlefield where thoughts determine behavior.
This research paper will attempt to show how Mindfulness-based Cognitive Therapy is the best treatment for GAD by explaining how Mindfulness works with Cognitive Behavioral Therapy. We will also examine the diagnostic criteria, differential diagnoses, and process of assessment. Furthermore, the Christian counselor can add a religious component to this treatment and have a Biblical approach for the care of souls.
The criteria for GAD are anxiety and several physiological symptoms. Often it is difficult to diagnose because of the variety of symptoms and its presentation with other medical and psychological disorders. GAD has approximately a 6% chance of existing in the lifetime of the general population (Gliatto, 2000). The onset of symptoms is usually gradual but can be triggered by acute stress. Often it is chronic with periods of exacerbation and remission, and when individuals seek help, it usually is from their family physician. Treatment usually consists of medication, and some do receive counseling. Benzodiazepines are usually prescribed for short-term usage and antidepressants for longer term use.
Anxiety is unwarranted fear that interferes with a person’s overall functioning. GAD is a chronic focus on future negative events with a sense of worry. Worrying leads to a person avoiding anxiety, which prevents the necessary emotional processing required in overcoming anxiety (Sharma et al., 2012). People with GAD are in the habit of responding to perceived threats that are nonexistent. We have heard it said that most everything we worry about never happens, and people with GAD are masters at it. Instead of focusing on the present moment, they subconsciously live in the future.
GAD is characterized by persistent, excessive, and unrealistic worry about everyday things. Individuals with the disorder experience exaggerated worry and tension, often expecting the worst even when there is no apparent reason for concern. They anticipate disaster and are overly concerned about money, health, family, work, or other issues. Sometimes just the thought of getting through the day produces anxiety. They don’t know how to stop the worry cycle and feel it is beyond their control even though they usually realize that their anxiety is worse than the situation warrants. However, when their anxiety level is mild, people with GAD can function socially and be gainfully employed. Although they may avoid some situations because of anxiety, some individuals can have difficulty with the simplest daily activities when their anxiety is severe (Gliatto, 2000).
Anxiety disorders occur more frequently in patients with chronic medical disorders. For example, hypertension, chronic obstructive pulmonary disease, irritable bowel syndrome, and diabetes can often coexist with GAD. In addition, individuals with anxiety disorders are more prone to develop illness and have higher mortality rates from all causes (Gliatto, 2000). In addition, chronic stress may cause long-lasting epigenetic changes (John Hopkins Medicine, 2010). GAD produces the stress hormone that affects the gene linked to depression and bipolar disorder. Long-term exposure to stress hormone changes DNA, which shows a correlation with mood disorders. Researchers gave mice the stress hormone corticosterone and observed how it led to anxiety and gene expression that is linked to mood disorders.
The symptoms of GAD are divided into three categories: distorted cognitions, hyper- vigilance, and ineffective coping strategies. The diagnostic criteria for GAD is that an individual experiences excess anxiety and worry about several events that are difficult to control. This must continue for more than half the days during a six month period of time during which they have three or more of the following symptoms (American Psychiatric Association [DSM-IV], 2000):
Feelings of being edgy and restless
Differential diagnoses must be ruled out. For example, the focus of the worry in GAD must not be characteristic of panic disorder, social phobia, obsessive-compulsive disorder, separation anxiety disorder, anorexia nervosa, somatization disorder, hypochondriasis, or post-traumatic stress disorder (Gliatto, 2000). In addition, the disorder is not due to direct effects of substance or medication or medical condition and does not occur only during a mood, psychotic, or pervasive developmental disorder. The symptoms must also cause significant distress that impairs important functioning. Again, GAD can be difficult to diagnose because it often exists with other psychological disorders such as depression, panic disorder, and substance abuse. Because of the comorbidity of GAD and other psychological disorders, it is important to evaluate them before a definitive diagnosis can be made. Sometimes anxiety causes depression, and depression can cause anxiety. Deciding whether to treat the anxiety or the depression can be challenging. Furthermore, obsessive-compulsive disorder, social phobia, and somatization are common comorbid psychological problems seen with GAD.
The process for evaluating individuals with GAD begins with ruling out medical illnesses by a physician. Examining medications, over-the-counter, and herbal remedies is important, too. Then, evaluating for substance use and abuse is important because nicotine and caffeine can exacerbate anxiety. Assessing stressors and impairments in functioning for severity determines if medication is necessary. Then, evaluating symptoms of anxiety and eliminating substances that cause it will lead to a diagnosis of panic disorder, major depression, or GAD (Gliatto, 2000).
GAD can present with a variety of symptoms and range of severity. For example, some individuals may only have insomnia or diarrhea, palpitations, dyspnea, and pain. This is why a medical evaluation is so important because these symptoms can be caused by many different illnesses. Neurologic and endocrine diseases such as diabetes and hyperthyroidism are the most common medical causes of anxiety (Gliatto, 2000). In addition, mitral valve prolapse, carcinoid syndrome, and pheochromocytoma can disguise themselves as anxiety. Medications such as steroids, over-the-counter sympathomimetics, SSRIs, digoxin, thyroxine, and theophylline can cause anxiety, too.
Individuals with mild to moderate anxiety should be treated with non-pharmacological methods such as cognitive therapy and relaxation techniques. Cognitive therapy helps manage anxiety by limiting cognitive distortions. Also, learning to manage stressors and using social support systems is important. Enlisting family members to help these individuals learn to problem-solve and decrease social isolation helps them ruminate less about their problems. In addition, anti-anxiety medication is highly addictive and should be used with caution for the short-term for moderately to severely impaired.
Cognitive Behavioral Therapy
CBT proposes that our emotions and behavior are the result of our perceptions of situations (Murdock, 2009). This agrees with a Biblical approach, which emphasis our thought life. Luke 6:45 says, “For the mouth speaks what the heart is full of “. These deeply embedded preconscious thoughts control our thoughts, emotions, and behavior.
We have three levels of thinking, which are preconscious or automatic thoughts, conscious, and metacognitive. The automatic level is based in survival instincts, which are mostly out of our awareness. This also agrees with our sin nature. In Romans 7:15, Paul said he could not do right not matter how hard he tried. Core beliefs are the hardest to modify because they are deeply imbedded. Intermediate beliefs are the shoulds and musts we learn early in life, which are mostly automatic. For example, a person may believe they are dumb if they do not get all A’s. The conscious level is our normal thinking, and metacognition is thinking about our thinking.
Automatic thoughts are quick, evaluative thoughts in our consciousness. Their quick response makes it even more difficult to recognize them. We are more aware of the emotion they cause than the thought that causes it. We learn early in life how to achieve self-worth and tend to repeat this as adults. Our anxiety is largely caused by an attempt to achieve worth but fearing failure (Hathaway & Tan, 2009).
The goals of CBT are to identify and change distorted beliefs to more adaptive ones. Usually, therapy focuses on changing automatic thoughts, and if time allows, core beliefs are addressed. By teaching clients how to use metacognition, they can learn to control their thoughts.
The techniques most commonly used are questioning, downward arrow, thought recording, and behavioral experiments (Murdock, 2009). By using Socratic questioning, the therapist leads the client to realize the illogic of the faulty belief. For example, a favorite question is to ask, “Where is the evidence for this thought/belief?” (Murdock, 2009). Downward arrow is used to connect superficial thoughts that are attached to core beliefs. By asking clients what the surface thought means about the client, it will usually lead to the core belief. The thought recording is a homework exercise where clients record their automatic thoughts and emotional responses. This helps them see patterns that need to be changed. Thought-recording increases self-awareness of patterns of negative thinking.
CBT is the most popular treatment for many psychological disorders and is considered to be an efficient tool for alleviating negative emotions. Therefore, it is very beneficial in treating anxiety disorders. CBT was found effective for GAD and other anxiety disorders. Researchers have found more support for CBT than placebo and especially for severe anxiety symptoms (Hofmann & Smits, 2008).
Mindfulness is a condition of remaining psychologically present and “with” whatever happens in or around one, without reacting in any way (Sharma et al., 2012). In other words, mindfulness is radical acceptance of the present moment. Clients are encouraged to accept unwanted thoughts and feelings rather than try to control or avoid them. This has proven to be a successful treatment approach because exposure response prevention therapy is considered to be one of the best ways to decrease anxiety (Sharma et al., 2012).
Mindfulness-based interventions are reported to be effective in treating GAD. A randomized controlled study assigned individuals with GAD to receive acceptance-based treatment or no treatment (Roemer, Orsillo, & Salters-Pedneault, 2008). They were assessed before treatment, afterwards, and even for 9-month follow-up. The treatment consisted of education for key concepts, meditation, and homework assignments. The individuals receiving treatment had much lower GAD symptoms compared with those who received no treatment. Afterwards only about 24% of those who received treatment still had GAD symptoms, but of those who did not receive treatment approximately 84% still had symptoms (Roemer et al., 2008). At follow-up, these gains were still maintained.
Therefore, mindfulness meditation allows people to respond reflectively and consciously instead of automatically reacting to their world. By focusing on the present moment and detaching from futuristic thinking, individuals can choose an adaptive response to circumstances. Habits of responding to environmental cues are replaced by self-awareness in the present moment. When incorporating mindfulness with cognitive-behavioral interventions, individuals become more aware of thought processes.
Jon Kabat-Zin (2012) has a longtime Zen-practicing history and is the founding director of the Stress Reduction Clinic and Center for Mindfulness. He emphasizes seven attitudinal foundations of mindfulness practice. These are non-judging, patience, beginner’s mind, trust, non-striving, acceptance, and letting go. Non-judging is accepting what is without having an assumption or bias. After all, what do we really know for sure? Patience means not trying to always be somewhere else but momentarily stepping out of time. Beginner’s mind is important because when we believe we understand meditation, we lose our humility, which is a key to mindfulness. Trust is important because we can rest in the fact that we do not have to fix everything. Non-striving is also important because this goes against our culture but is required for staying in the moment. Acceptance means to discover how to be in relationship to circumstances and not always needing to change them. Letting go is non-attachment or not grasping for what we want. These attitudes are foundations of mindfulness that must be practiced in order to be developed.
Also, deep breathing exercises are extremely beneficial because shallow breathing increases stress levels. Mindfulness emphasizes relaxation techniques essential for GAD. In addition, since worrying is the basic problem in GAD, it makes sense that mindfulness-based techniques are most effective in reducing anxiety.
Decentering is a new mindfulness technique and shows huge promise as a tool for de-stressing. This is gaining new support due to recent studies. When comparing mindful breathing’s (MB) effects to progressive muscle relaxation (PMR) and loving-kindness meditation (LKM), MB resulted in better stress management (Feldman, Greeson, & Senville, 2010). This was done to examine if decentering is unique to mindfulness meditation or common to other stress management techniques. 190 female undergraduates new to meditation were randomly assigned to participate in one of three 15-min stress-management exercises (MB, PMR, or LKM). Immediately afterwards, decentering, frequency of ruminative thoughts, and negative reaction to thoughts were measured. As hypothesized, participants utilizing MB reported greater decentering compared to PMR or LKM. The relationship between frequency of ruminative thought and negative emotions decreased more in MB compared to the PMR and LKM conditions. These two variables are very positively correlated. The independence between PMR and LKM in MB show that Mindful Breathing may help decrease reactivity to ruminative thoughts. Decentering is a beneficial technique that shows mindfulness to be a potential tool to implement in this therapy (Feldman et al., 2010).
An early controlled study of an acceptance-based treatment for GAD had two primary goals. These goals were acceptance of unwanted and even uncontrollable thoughts and feelings and to encourage commitment and action to living a better life. The treatment groups had significant decreases in anxiety after treatment (Martin, 2011). Based on these findings, mindfulness and acceptance-based treatments are a beneficial option for individuals with anxiety disorders. For example, mindfulness and acceptance-based techniques may help clients to confront anxiety provoking situations and thereby expose themselves to feared thoughts and emotions. Furthermore, the importance of accepting anxiety is included as a part of exposure-based and cognitive treatments. For example, Beck discussed the importance of encouraging acceptance in cognitive therapy. He defined acceptance as “acknowledging the existence of an event without placing judgment or label on it” (Martin, 2011). This is very similar to Jon Kabat-Zinn’s definition, too.
Mindfulness-Based Cognitive Therapy
A recent study evaluated Mindfulness-Based Cognitive Therapy (MBCT) in patients with anxiety disorders. Almost all the patients had GAD and were assessed by several established self-report questionnaires. The therapy consisted of anxiety education, training in mindfulness meditation, cognitive restructuring, and strategies to deal with worry. Some of the worry strategies were worry postponement, worry exposure, and problem solving. MBCT was shown to significantly reduce psychological and somatic symptoms of anxiety in individuals with GAD (Sharma et al., 2012). In addition, relaxation is an added benefit due to the breathing exercises in mindfulness meditation.
However, the modification of dysfunctional beliefs takes more time. With practice, individuals can change their dysfunctional thoughts if they are willing to use metacognition. Usually anxiety is the result of worrying about the future, so staying in the present moment helps guard against that mindset.
Another study examined faulty beliefs and coping styles and the effects of mindfulness meditation on anxiety in college students. The conditions used were long and brief meditation focused on attention and loving kindness. The longer meditation reduced anxiety significantly and increased hope (Sears & Kraus, 2009). Thus, cognitive changes that corrected distortions decreased anxiety.
MBCT aims at helping clients foster a different relationship towards negative emotions instead of using cognitive restructuring to change beliefs and emotions. This causes a decrease in suffering, which results from accepting the negative emotions.
Mindfulness teaches clients to recognize and detach from ruminative, negative thoughts by moving from a focus on content to process (Hathaway & Tan, 2009). This is different than basic cognitive therapy’s focus, which is to change the thought content, and instead attend to the method of how all experience is processed. By changing the relationship with negative thoughts and viewing them as passing events of the mind, clients can realize they are not necessarily facts.
When mindfulness is combined with cognitive techniques, clients can increase their awareness of encountering potential mood swings. For example, in a mindful state of acceptance, one can anticipate a negative thought and remind themselves of truth. Instead of old patterns of ruminative negative thoughts, clients can decenter from anxiety-provoking thoughts. Some researchers even say it is decentering that is responsible for effective change in cognitive therapy rather than change in belief content (Hathaway & Tan, 2009).
MBCT teaches clients concentration, awareness of thoughts, attending to a focal point (breathing), staying in the moment, decentering, acceptance of thoughts/emotions, kindly awareness, nonattachment, letting go, being instead of doing, non-goal attainment, and noticing how problems manifest physically (Hathaway & Tan, 2009). By welcoming our experiences, even the troubling ones, instead of avoiding them, we can desensitize ourselves to them. This is done by increasing our awareness of bodily sensations such as tension when we are stressed.
Two modes of being exist, which are the doing and being mode. The doing mode is a driven state triggered by fear of failure of goal attainment. Simply put, we are driven to meet our needs. We feel dissatisfied and focus on the lack of what we want, which can lead to rumination (Hathaway & Tan, 2009). However, the being mode is a state of radical acceptance instead of expecting or evaluating our experience. Therefore, we are able to be in the here and now, and feelings cannot trigger negative thoughts that make us feel dissatisfied.
Clients do not try to change their thoughts when practicing mindfulness but change their relationship to them. Thoughts are viewed as wandering or passing events of the mind. Likewise, the usual goal is to try to replace negative thoughts with positive ones. However, mindfulness teaches clients to accept their negative emotions, and they will soon realize they are fleeting. By disengaging from old patterns of trying to immediately problem-solve and fearing negative emotions, clients can give themselves permission to take a time-out. The acceptance that thoughts are not facts and negative feelings are impermanent helps clients prevent relapse. This action plan consists of three phases: (a) pause to deep breathe and decenter from distressing emotions and negative thoughts, (b) practice staying in the moment, (c) take action that gives pleasure or mastery and break down into smaller parts (Hathaway & Tan, 2009). By using exposure to reduce avoidance and increasing the flow of better information, clients can further reduce relapse.
Cognitive change processes are explicit in Christian spiritual formation just as in cognitive therapy. Many studies have been done showing religiously accommodative CBT to be an effective treatment. One study showed religious imagery to be superior (Hathaway & Tan, 2009).
Christian clients who want to incorporate their faith can meditate on God’s presence when they practice mindfulness and communicate with Him during that time. This intimacy can increase peace and thus, emotional stability. Being able to take the good and bad feelings without obsessing about eliminating them, decreases anxiety. Many Christians have incongruence regarding their beliefs in God and their cognitive habits. For example, they believe God is all-loving but do not trust Him to care for them. By confronting this discrepancy, they can develop positive modes of thinking.
Another method of Christian MBCT is inner healing prayer. By asking God to minister His comfort, grace, and love, clients can experience comfort during reprocessing of their traumatic experiences (Hathaway & Tan, 2009).
Loving-kindness meditation (LKM) is mindfulness-based and emphasizes connecting with others and caring for them. By using nonjudgmental awareness, attention, acceptance, presence, and self-regulation are enhanced (Leppma, 2012). This begins with directing caring feelings towards oneself and then others.
Due to the advent of the MRI, studies have shown that LKM increases gray matter in the brain (Leung et al., 2013). This is important for emotion regulation such as empathic response and anxiety control. In addition, LKM produces increased positive emotions, which are shown to compound over time to build a variety of personal resources (Fredrickson, Cohn, Coffey, Pek, & Finkel, 2008). Even decreased illness was shown to result from these positive emotions (Fredrickson et al., 2008).
In conclusion, we examined MBCT as the best approach for GAD based on recent studies. We discussed the importance of addressing GAD due to the ramifications of this disorder. The fact that it is the most prevalent psychiatric problem today and underlies many mental disorders, exacerbates, and even causes some medical illness emphasizes the need to treat it early. Noting the difficulty in diagnosis and the comorbidity makes the process a joint effort of physician and counselor.
Finally, joining a Christian component with MBCT shows great potential since spirituality is becoming more popular. People seem to be reaching out more and more for a power greater than themselves. As Christian counselors, we can take opportunity to explicitly integrate clients’ faith in counseling. Furthermore, this approach agrees with a Christian worldview since it helps clients learn to depend on God and be more accepting of circumstances and significant others.
If the goal of Christian counseling is to encourage individuals to love God and others more, MBCT is an excellent method of helping others connect with God. By doing this, we can learn to depend on God by having a relationship with Him. He is changing us from glory to glory into the same likeness as the Lord (2 Cor. 3:18).