Mechanism and Application of Mindfulness in Psychotherapy to Treat Depression

. Nowadays, the mechanism of mindfulness gradually reveals a great attraction to scientists in a variety of research direction, and particularly, the application of mindfulness is highly valued in treating depression by using the strategy of psychotherapy. The past research has shown that people who are in depression would develop a uniform thinking pattern toward the external stimuli, which, consequently, resulting in that depressed people would consistently be lost in negative feelings. By keep having these distorted understandings toward their surrounding features, people who are in depression would keep being confronted with low mood and other negative feelings. However, Mindfulness could act as a technique and be defined to enable people to focus on the present and enables people to accept new information without carrying stereotyped thinking pattern. Hence, it would be used as a strategy to treat depression. In current research, mindfulness has been used as in different treatment to treat a variety of symptoms. This literature review examines the relationship and application of mindfulness as a strategy used in psychotherapy to treat depression and provided some suggestions of possible future research direction about using mindfulness in the treatment of depression.


Introduction
In recent years, depression has been a problem that confronted numbers of people in the world. According to data presented in 2021 from World Health Organization, 280 million people in the world have depression. Therefore, a lot of treatments are created based on different concepts for curing depression, and mindfulness has been found out to be one of these base concepts.
Mindfulness is a term describing the process of people accepting and learning novel distinctions. (Langer & Moldoveanu, 2000) Instead of living under mindlessness, which is a counterpart of mindfulness, demonstrating that people naturally thinking of context-free and accept all information around themselves by directly following the processes without doubting and thinking, people who mindfully treat information would receive the four following consequences toward their lives: (1) a greater sensitivity to one's environment, (2) more openness to new information, (3) the creation of new categories for structuring perception, and (4) enhanced awareness of multiple perspectives in problem-solving (Langer et al., 2000). Based on this basic definition of mindfulness, scientists and researchers have made treatments to treat different aspects of depression by using mindfulness' concept and characteristics.
Mindfulness is commonly introduced in psychotherapy. Psychotherapy is a treatment used to treat a collection of mental illnesses, including depression, bipolar disorder or eating disorder etc. It can be done in different forms, for example, individual, family, or group (including couple). There are different types including, for instance, humanistic or cognitive-behavioral, the most common one would be talk therapy which people mostly think of. (McAleavey & Castonguay, 2015) Also, the applications of mindfulness are mostly known as and used in treatment of Mindfulnessbased Stress Reduction (MBSR), Mindfulness-based Cognitive Therapy (MBCT), and Acceptance and Commitment Therapy (ACT). These three treatments are all used for depression, but they have focused on different field and aspect of depression. For example, MBCT is used to prevent the recurrence of depression.
However, nowadays, most application is used to help people focusing on their present and therefore change their mind. Also, the current treatment is basically provided in similar methods. There is not much application that is based on firstly changing people's perspectives by allowing more and new information accepted. The combination of mindfulness and drama therapy could be a new direction for research. Drama therapy is a treatment that is used to promote personal growth.
This literature review is providing a summary of mindfulness in treating depression. The whole literature review would be separated in the following four parts. (1) The history and development of mindfulness (2) Possibilities to treat depression by mindfulness (3) The mechanism of mindfulness in application treatment (4) The way and effectiveness of using mindfulness in application treatment. This literature review is used to give a brief overview toward people who want to do further research on using mindfulness in treating depression. Also, it provided a possible suggestion of using mindfulness into drama therapy. This summary includes the reason why depression occurs, mechanism of mindfulness and application including principle of mechanism and effectiveness. People could use this summary as a handout with theories to work on their research goals.

Histroy and development of mindfulness
In 2012, mindfulness was first spread by the practicing of meditation in the United States. (Germer et al, 2005) Later, mindfulness, including meditation, gradually became a widespread element of the psychotherapeutic element in therapies. Mindfulness has been used in a lot of different fields, including personal, medical, and experimental research.
The origin of mindfulness derives from spiritual institutions of eastern religion, including Buddhists' and Hindu's perspectives as mainstream current teachings while there are also other religions included such as Zen. (Shapiro et al., 2020) The central idea of Buddhism and Hinduism shares similar idea, for example, dharma, since they arose in the same region, however, Buddhism focuses more on the path to enlightenment. In the 1700s, when British scholars translate the book, Bhagavad Gita, from India to English, it started to be counted as the first formal introduction of mindfulness from Eastern culture to Western'. Then, instead of continuing mindfulness as a spiritual institution as the Easters did, the Westerners did these practices more as a secular practice, for instance, yoga, that filtered into people's daily lives. (Germer et al, 2005) In 1990, one of the most influential integrations and spread of the eastern concept, mindfulness, to the west was led by Kabat-Zinn. Kabat-Zinn started to use mindfulness at the University of Massachusetts Medical School. He combined this Eastern concept into Western medical treatment and develop MBSR, Mindfulness-based stress reduction. (Germer et al, 2005) From that time on, mindfulness appears to be transtheoretical and filtered in all aspects of psychological treatment, including in the treatment of mental and physical disorders or behavioral and psychodynamic etc. (Germer et al., 2005)

Possibilities to treat depression by mindfulness
Research have shown that people who are in depression would fall into a uniform perspective and thus have a distorted thinking toward the external stimuli. This constant thinking mode would be the break point of using mindfulness to treat depression.
People who suffer in depression would generally experience in low mood and loss of interest. Other than mood disorder, people also suffer in physical disorders like sleeping disorder, headaches, appetite changes, fatigue, and pain. (Greden, 2003) Depressed people always show sadness and have an inability to toward external stimuli. Their thinking way is preoccupied with their past of future obstacles that perplexed them, hence making them stop creating new categories from new information and limiting their perspective to the one that stuck them in the negative emotion and unable to leave. (Kube et al., 2020) In 1983, Guidano and Liotti concluded from a model that people who depressed would own an automatic thinking pattern toward the surrounding context and life events. Meanwhile, this cognitive pattern would accompany people consistently within the depression period. (Dobson & Shaw, 1986.) In 1979, some researchers have developed an experiment related to the hopelessness scale to test the cognitive and mood pattern of people with depression. They took a 17-day experiment to check the differences between depressed groups and the groups. They concluded from the collected data that the depression group have shown more hopelessness, biased attribution and negative attitudes reverted to other groups. This two-research suggested that people with depression often think in a uniform perspective, then accepting all context and stimuli around them as negative and aggressive to them, which, consequently, provides them with regular distorted thinking. (Dobson et al, 1986.) Instead of continuing perplexed by the emotional difficulties that people owned, mindfulness helps people to focus on the present moment and teaches people acceptance. People would no longer be trapped by their previous old perspective and start to practice awareness, which also means the sensitivity to receiving new information. Increased awareness would no longer receive cognitive distortions and bring people clear and objective understandings of the surrounding context. Therefore, people can accept both positive and negative emotions that external stimuli gave them. (Germer et al, 2005) This awareness is also called insight. Insight leads people to psychological and emotional freedom. In psychotherapy, insight refers to the recognition of distorted and hidden information that stays in peoples' subconscious. (Germer et al, 2005) The insight led by mindfulness is used to allow people to understand the differences between their ordinary responses and external stimuli. People would then realize that the suffering they receive before is the constructions that they made to limit themselves from receiving new information and creating new categories. Now, all the prerequisites of behavioral change are settled, hence, the mechanism of action starts to function.

The mechanism of mindulnwss inapplication treatment
Even though all treatment that would be introduced in this section are based on mindfulness, the goal and specific motivation of these treatment would be different. This section would be introducing Mindfulness-based Stress Reduction (MBSR), Mindfulness-based Cognitive Therapy (MBCT), and Acceptance and Commitment Therapy (ACT)'s developmental history and mechanism.

Mindfulness-based Stress Reduction (MBSR)
MBSR is a treatment which uses mindfulness meditation as a mechanism to treat stress problems, for example, anxiety and depression. (Lang, A. J., 2013). This program is developed by Professor Jon Kabat-Zinn at the University of Massachusetts Medical Centre in 1979. Jon Kabat-Zinn has highlighted MBSR in the words: "moment-to-moment, non-judgmental awareness as its key figure. He later recorded the details of MBSR in his book "Full Catastrophe Living" in 1993.

Mindfulness-based Cognitive Therapy (MBCT)
MBCT was firstly aimed to prevent the recurrence of depression in people who have had depression multiple times. However, there is only a few studies use MBCT as a tool for preventing the recurrence of depression. It is mainly used as treating depression, specifically, treating maladaptive cognitive processes. (Lang, A. J., 2013).
MBCT was created based on a model that has concluded in 1991, by Philip Barnard and John Teasdale, called Interacting Cognitive Subsystems (ICS). Barnard and Teasdale have concluded that people developed fixed modes of mind when reacting to similar external stimuli. This model claimed that individuals who get depression would only use the modes of mind that they used in depression to react to external stimuli, which inadvertently blocks other modes. They have concluded that the brain would control two modes of mind, being mode and doing mode, and being mode would lead to emotional changes. Therefore, MBCT is created by Teasdale and Barnard to prevent the reoccurrence of thinking mode in depression.
MBCT continues what MBSR follows, to help people practice and develop insight and acceptance. (Lang, A. J., 2013). Since the original of MBCT is to prevent the recurrence of depression, which means that patients would automatically return to their previous cognitive process, MBCT tried to reinforce the process of insight by practicing people's abilities to accept information from external stimuli objectively without thinking from their old perspectives. In other words, MBCT practices the ability to stop rumination.

Acceptance and Commitment Therapy (ACT)
ACT is a treatment that is used to strengthen people's acceptance to tolerate negative emotions reacted from external stimuli. It is one of the branches of clinical behavior analysis. It is a hybrid treatment made up of values on behavioral change and the experience of mindfulness. (Lang, A. J.,  2013).
The basic theories that ACT develops from are mindfulness, commitment, and behavior change. ACT allows participants to accept the external information by following what participants would originally react with. It is practicing the participants' tolerance and control ability of not overreacting to the external information they gained. Participants are asked to learn more about themselves and their feelings. It contains 6 elements in its process: 1) acceptance: participants need to understand what they want to express at the current moment. 2) Cognitive defusion: It helps participants to see their thoughts and inner needs objectively without having any added perspectives.
3) The observing self: Participants need to observe their thoughts. 4) Contact with the present moment: It practice participants' abilities to focus on the present and be mindful. 5) Values: participants need to find out what is important to them. 6) Commitment: It would start to change participants' behavior based on ACT core values.

Possible Mechanism of Drama Therapy
Drama therapy belongs to art therapy. This therapy processed through the media of drama, including storytelling, role-playing, and role-reversing. Therefore, both the therapist and the client have the chance to take different perspectives toward this event. After that, the therapist could guide the client to reach their search of meaning.
Through the previous three mechanism in other methods are introduced, drama therapy could be worker through a similar process. As aforementioned, people who are in depression would follow a uniform thinking pattern. Therefore, since drama therapy contains role-reversing, changing perspective could be learned in this part of the therapy.
Taking on new roles or improvising during a series of transforming scenes would allow clients to get rid of their constant thinking pattern and only focus on the present. This is all because of that they need to be in that identity and switched out of their old thinking pattern. (Gluck, 2013)

Mindfulness-based Stress Reduction (MBSR)
MBSR also includes yoga and body awareness as basic components in its eight-week program. The major intervention would be therapists holding group or personal classes that teach patients how to train their cognitive ability. People would learn different ways and practicing different tasks in their daily lives to develop insight and acceptance.
MBSR will affect people's cognitive abilities by changing their brain structures with attention and emotion regulation, which corresponds to the mechanism of mindfulness helping patients develop insights and acceptance. (Gu et al., 2015) Moreover, participants who have experienced MBSR have firstly shown that they focus more on the present instead of locking themselves into their original thinking cycle. Secondly, they are less likely to react toward negative emotions, for example, stress, anxiety, or depression. (Kuyken et al., 2010)

Mindfulness-based Cognitive Therapy (MBCT)
MBCT has reduced the reoccurrence of depression to almost half no matter the gender, age, and job status. MBCT also reduce the possibility of rumination and increases people's ability of insight of focus on the present objectively and acceptance.

Acceptance and Commitment Therapy (ACT)
In 2020, studies have shown that ACT is effective in the following conditions, including depression, anxiety, pain etc. Surprisingly, studies have concluded that ACT is more beneficial on inactive controls. (A-tjak et al., 2015).

Possible Method and Application of Drama Therapy
Suggested possible method for drama therapy in treating depression would be that acting out the things that confronted depressed people, firstly in first point of view. Then, acting as a third person point of view to see this whole event and asking questions to first person point of view self by following the guidance of therapist. The therapist should help the client to discover their thoughts hiding in unconsciousness part. Therefore, clients can learn themselves and accept new information by switching different identities and let the old thinking pattern go.

Conclusion
This literature review provides a summary of the mechanism of using mindfulness in psychotherapy to treat depression. It also provides some current applications of mindfulness used in psychotherapy. Mindfulness is a great technique that people could practice in everyday lives to develop insight and acceptance. The flaw of this literature review is that there is no method particularly developed for treating depression, most of the application right now is still based on changing people's mind mode and then focusing on the behavioral change. Moreover, the current theories of mindfulness used in the application are mostly focusing on insight and acceptance. Meanwhile, meditation seems to be an impartible part of all treatments. There is not much application that is based on firstly changing people's perspectives by allowing more and new information accepted. The combination of mindfulness and drama therapy could be a new direction for research's flaw of this research is that there are no specific data and evidence supporting for using drama therapy to treat depression, and it only suggest one possible mechanism and method to apply it in real treatment. In short, this literature review could be used as a handout for researching mindfulness applicating in new field, art therapy.