by Tara Deliberto
Note: It may be best to read the post immediately prior to this one first, "Quibbles with Acceptance and Commitment Therapy."
Topic: Currently, Acceptance and Commitment Therapy completely rejects the use of thought manipulation techniques used in Cognitive Therapy in favor of meditative mindfulness techniques.
Thoughts: It seems like the next line of research in psychological treatment should focus on the implementation of specific techniques for specific problems (a`la Barlow's unified treatment protocol). Being that cognitive reappraisal (CR) and cognitive defusion (CD) are, in fact, two different techniques, I've simply been wondering (and I'm sure I'm not alone) whether or not one technique can be more useful than the other in certain situations.
[definitions: CR = a technique used in Cognitive Therapy that involves monitoring and evaluating negative thoughts and replacing them with positive thoughts/images; CD = a technique used in Acceptance and Commitment Therapy that involves deliteralizing the meaning of thoughts by actively "observing thoughts as thoughts" and recognizing that all thoughts may not be true ]
For the sake of providing an example, while CR may be more effective during moments of anhedonia (inability to experience pleasure) in that it could get the client actively engaged in positive thinking [which may or may not enable the person to engage in active behavior but I would argue, decreases suffering in the present moment], CD may be more suitable for moments of anxiety in that it has the quiet quality of observing and focus on being present while anxiety arouses people and can cause a lack of presence. I use the term "moments" here in order to highlight that comorbidity of anxiety and depression is common and implementing the different tools at different times for the same person may be beneficial. Simply, I think that abandoning cognitive therapy (CT) techniques such as CR completely without conclusive research indicating one method is superior in all cases to the other is premature.
Referring back to the comment about decreasing suffering by using CR as a technique for people w/ anhedonia: On a slightly more theoretical note, I have been struggling with the idea of whether or not the primary/ultimate goal of therapy should be on helping the person to live life in accordance with ones values as in Acceptance and Commitment Therapy (ACT) or to decrease the net amount of life suffering. Perhaps decreasing the total amount of life suffering should be done through helping the person live life in accordance with ones values. As per my previous post, I think that perhaps behaviorally activating by living life in accordance with one's values should decrease long-term suffering and shouldn't be an end in itself. Perhaps, somewhat ironically, if the client concentrates on symptom reduction as the end goal of behavioral activation (BA), less symptom reduction could possibly occur. With the mindset that engaging in BA will lead to symptom reduction, if the effects are not immediate, the person may abandon the strategy. Because ACT encourages people to engage in BA regardless of outcome, the person may be more likely to continue engaging in BA as a result of a lack of discouragement about immediate results; however, I would argue that it is important not to lose sight of the fact that decreasing suffering should be the ultimate goal, even if it is not presented to the client in this light. I fear the mindset that decreasing suffering or increasing positive emotion isn't important may lead to the rejection useful techniques such as CR that may help the person lead life in accordance with their values.
[definition: BA = getting the client to engage in meaningful behavior; this technique is now thought to be the most potent component across various forms of psychological treatments]
From a funcitonal perspective (and in keeping with the thoughts expressed in me previous blog post about the endogenous reward system) it seems that both thinking positively through CR and BA can activate the reward system in the brain. My guess is that BA would be more potent than changing a negative thought to a positive one, but both could produce similar effects- reward via positive reinforcement in the form of opioids. While BA and CR may work through positive reinforcement, CD may work through negative reinforcement- taking an aversive stimulus away (NOT to be confused with introducing a punishment). By distancing oneself from a negative thought, the aversiveness is decreased. If viewed in the light that both CR/BA and CD work on reinforcement schedules by decreasing suffering, the notion that it isn't important to decrease suffering in therapy no longer makes much sense to me.
It is worth noting that while BA releases opioids, it may not necessarily equate a feeling of happiness, and therefore a direct reward in the form of positive reinforcement. From a more biological perspective, during BA, the release of opioids may not result in an overall emotion of happiness, but perhaps their release has effects on a subconscious level (for lack of a better term). I'm trying to get at the essence of what maintains a behavior biologically. I implicate opioids, but it may be any known or unknown substance in the brain that is released during BA that helps form associations between action and reward (see the part Endogenous Reward System post pertaining to feedback loops).
From a psychological perspective, I would argue that although BA may not lead directly to a feeling of happiness (i.e. when a person with depression first gets off the couch, it is dreadful), it may still be maintained via positive reinforcement because by behaviorally activating, one is living life in accordance w/ ones values, which may lead to a more abstract reward than feeling intense bodily pleasure in the moment. I'm sure physiologists and hard scientists may have a problem with this view; however, my stance is one of actually erring on the side of pure biology. I think that all thoughts are biological - even the more abstract ones that science has yet to understand. I would argue that a biological reward must exist even for the experience and consequent emotions of abstract thought. After all, when biological brain tissue dies, so does abstract thought.