Wednesday, January 21, 2009

A Few Quibbles with Acceptance and Commitment Therapy

by Tara Deliberto

In a recent lab meeting, I was engaged in a discussion of the paradigm shift between the focus of therapy being symptom reduction, as seen in other therapies (i.e. cognitive-behavioral therapy), towards helping the client to live a life in accordance with their values, as in ACT. The irresolution of an argument centering on this point prompted me to write this entry.

In ACT there is not only an emphasis on living life in accordance with one’s values, but it seems a fairly outright denunciation of attempting to control or manipulate thoughts as a form of emotion regulation. Although I am aware of the research indicating thought/expressive suppression is an unsuccessful method of controlling thoughts/emotions, often resulting in increases in the targeted thoughts/emotions, there is evidence to suggest that cognitive reappraisal, the revaluation of negative thoughts, is effective (in fact, I presented research at the Associations for Behavioral and Cognitive Therapies conference in 2006 on cognitive reappraisal being a potential mechanism of change in intensive DBT). I understand that because attempts at suppressing thoughts are futile, as a therapist one should not encourage this; however, I do not understand what appears to possibly be an overgeneralization to advise against ever attempting forms of thought manipulation, especially when reappraising cognitions appears to be beneficial [If this blog entry were actual dialogue, this would be the point where I may get into a semantics discussion with ACT practitioners about the word “beneficial.” Although this word was previously used in reference to symptom reduction, I would argue that it is safe to say that using cognitive reappraisal as a tool can also help one to lead a life in accordance with one’s values.].

That is not to say, of course, that cognitive reappraisal should be a focus of the treatment or that mindfulness should be abandoned. Quite the opposite. I am merely suggesting that perhaps all attempts at thought/emotion manipulation should not be abandoned. Perhaps mindfulness can be used as a tool the majority of the time for some problems whereas cognitive reappraisal can be used as a tool occasionally for other types.

Of note, I have come to conceptualize two types of mindfulness, which may be incorrect, but here they are:
1) allowing oneself to fully experience a thought/emotion without attempt at suppression
2) allowing oneself to view thoughts/emotions objectively as thoughts/emotion

I realize the following thought is not original; however, it may be worth noting here that the first conceptualization of mindfulness may be effective through means similar to that of exposure. Basically, if one stops avoiding or attempting to avoid the emotion, it is learned that the emotion can be experienced and survived.

I have not previously heard interpretations of why I think the second type of mindfulness may be effective. I realize that while mindfulness and defusion are separate concepts, perhaps mindfulness facilitates defusion, the process of observing thoughts as thoughts. Through mindfulness practices such as watching our thoughts float by, maybe we are essentially creating distance with our thoughts. This distance may help facilitate a non-judgmental stance of one’s thoughts. I was attempting to make the point that maybe the non-judgmental quality of viewing thoughts in essence may be a “reappraisal” of the thoughts in that they no longer hold a negative valence (not that they are being judged as positive, per se). At the end of the process of cognitive reappraisal, thoughts also no longer hold negative valences. Perhaps the reasons why mindfulness & cognitive defusion along with cognitive reappraisal seem to be effective could be similar, not that they are necessarily the same process. In short, these processes may achieve similar ends through different means. I do, however, suspect that mindfulness probably achieves these means in a more effective manner. Because people with emotional disorders are in the habit of attempting to suppress thoughts while healthy controls are more able to accept their negative emotions and function in society, an approach geared away from thought manipulation in general may be appropriate.

In addition, I am aware that in light of the recent literature suggesting that behavioral activation- simply put, carrying out daily activities despite symptoms- is a main mechanism of change in many psychological treatments, all the talk of cognitions seems futile; however, I think it is necessary. It is interesting that behavioral activation is so closely in line with the goal of ACT: living life towards ones values in the context of one’s symptoms. With this as a treatment goal, one is essentially turning the client’s attention away from thought/emotional suppression and gearing them to behaviorally activate. The “gearing” or framework in which the behavioral activation is nestled may be the determining factor in whether or not one actually begins to behaviorally activate or start living life in accordance with one’s values. Therefore packaging behavioral activation in ACT with mindfulness may be more useful than packaging it with the cognitive (and other) pieces of cognitive behavioral therapy. It is also of note that while in cognitive-behavioral/behavioral therapy, behavioral activation is the means through which symptoms are reduced, in ACT, the goal is to behaviorally activate without necessary symptom reduction. It is possible that gearing the therapy without the expectation of symptom reduction, as in ACT, may actually result in greater symptom reduction than CBT for some people. Again, this could possibly be because people with emotional disorders are constantly struggling with control and suppression of thoughts/emotions so that when they are in a context encouraging them to largely give up control, behavioral activation could be facilitated more so than in a treatment focused on symptom reduction.
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