Control

by Tara Deliberto

While new Western treatments incorporating the use of mindfulness techniques have an emphasis on decreasing control, many practitioners and patients alike are confused by the apparent increase in control over thoughts and emotions it fosters.

By increasing one's awareness of the thoughts, bodily sensations, and interaction between the two, one creates distance between the mind and what is produced by the body. This naturally produces an increasing sense of mastery over the self, which in essence is control. If you are able to focus your attention on your left pinkie toe during a meditation, for example, you are absolutely controlling your thoughts.

Now, if meditation fosters control of the mind and has been shown by numerous studies to be extremely effective in treating psychological disorders, why is control generally considered to be a bad thing? Why do third wave treatments proudly claim to decrease control? Well, when people attempt control techniques such as forcefully suppressing thoughts or changing their environment in a service to avoid their emotions, it generally leads to more suffering. This type of control, which is likely mediated by absolutes or black and white thinking, is what I like to think of as ineffective control. It doesn't allow for the experience of emotions. This is what mindfulness-based treatments decrease. While people may actively try and control their experience by using alcohol to avoid emotions, for example, those who overuse this strategy and are labeled alcoholics are typically said to be "out of control." Used in this way, the phrase "out of control" implies a lack of mindful control over the attempts to ineffectively control one's emotions.

Conversely, learning to mindfully control one's attention has been shown to be a favorable strategy in coping with a very wide range of problematic behaviors. It also does not involve black and white thinking. There is an emphasis on being aware of one's thoughts, bodily sensations, and experiences, without actively trying to change what cannot be changed. The difference between trying to control one's experience through the suppression of emotions versus through active focus on present are extreme; however, (if you ask me) both are technically control strategies. The latter type of strategy though, leaves room for the experience of negative emotions and thoughts when avoiding them would lead to more struggling. This is effective and adaptive.

It should be noted, however, that avoiding negative emotions may be a very favorable strategy on some occasions - for example, a woman may avoid continuing to feel negative emotions brought on by an abusive husband by leaving. In my experience some mindfulness practitioners actually misapply the idea that one should experience negative emotion by encouraging clients to endure painful situations when in reality, their patients are actually avoiding another set of negative emotions such as loneliness or fear of the unknown. It is tolerance to this latter set of emotions that needs to be fostered. Eagerness in encouraging clients to experience any negative emotions must be curbed with reason and a careful examination of what types of emotions are functional to avoid. Strict adherence to any set of rules without individual reasoning is certainly not favorable.

In the literature and when discussing attempts to change one's experience from what it has been, I think techniques should be labeled as ineffective control strategies or mindfully aware control strategies on an individual and situational basis.

Combining Cognitive Therapy and Mindfulness

by Tara Deliberto


I was lucky enough to have the opportunity yesterday to get together with a neuroscientist friend and colleague with whom I used to work in Cambridge, MA. Eventually we got on the topic of merging ACT & CBT and he asked some thought provoking questions I thought I would share.

The first question - and the topic of this blog post - that got me really thinking was something like: "how long does it take before an alternative rational response replaces the (long-ingrained and continually environmentally reinforced) negative & irrational automatic thoughts?" In the moment I threw out some arbitrary response based on my extensive 2.5 years of clinical experience (lol), and immediately realized I had no clue what the answer was. Being as sharp as he is, he also immediately realized (but politely pointed out) that my response was b.s. Of course it will vary for every person, but we came to the conclusion that duration of irrational thought replacement it is probably a lot longer than the literature on how quickly people respond to CBT would suggest.

While CBT can reduce symptoms in a handful of sessions - maybe around 10-15 - and CBT w/ d-cycloserine for fear reconditioning can reduce symptoms in even fewer sessions, the time it takes before negative automatic thoughts are completely replaced could widely vary. In fact, they may never disappear. Members of the ACT community actually set expectations that negative automatic thoughts never decrease in frequency (for decent reasons I won't expound upon here). Furthermore, the difference between completely disappearing and having thoughts that one relates to effectively enough to show up as a statistically v.s. clinically significant decreases in symptoms are all very different things. While clinical improvement may be apparent from research, it is likely that people continue to have intrusive thoughts (that are experienced as at least unpleasant) well after their 10-15 sessions of CBT have ended.

There are also likely varying stages of having negative automatic thoughts disappear, ranging from:
- the thought pops up, it is suppressed, and reoccurs w/ a vengeance
- the thought pops up and one struggles to restructure it w/ a rational response
- the thought pops up and one is able to quickly ward it off w/ a rational response
- the thought pops up and one immediately labels it as irrational & mindfully releases it
- the thoughts generally tend to decrease in intensity/frequency over time
- the thought is completely irradiated

Now, the question my friend asked is important because it lead us to this idea: if there is some truth to these stages, mindfully dismissing something in the moment might interfere with the practicing of retraining the mind to have different and rational responses to the thoughts.

Perhaps if one truly retrains the mind away from irrational thoughts, they will decrease in frequency, which is arguably more favorable than continually having negative intrusive thoughts pop up that one learns to relate to differently with the use of mindfulness. It should be noted, however, that mindful awareness and release of thoughts may also, as a practice, decrease the frequency of thoughts over time. At this point, everything is speculative and is simply (what I would consider to be) interesting food for thought.

While the constant use of mindfulness early in treatment may hypothetically interfere in some way w/ long-term retraining, it is certainly a very useful practice in many situations like when refocus in the moment is paramount. Being mindfully aware of thoughts also has the major benefit of preventing people from slipping back into responding to certain irrational thoughts as if they were real and/or of utility.

I know a lot of people may have an issue with framing mindfully releasing a thought in this way; however, I am not suggesting it is a form of suppression. With mindfulness of thoughts, there is an active acknowledgement and awareness of the thoughts, which separates it from suppression. However, when it is feasible, encouraging the patient to extensively retrain themselves with engaging in active grappling with irrational thoughts might be favorable before moving into a mindfulness-based approach.

It should be noted. however, that thought disputation may not be a particularly useful type of practice for people with Borderline Personality Disorder. In fact, for this population, it might be favorable to start with mindfulness of thoughts and thought defusion exercises. In fact, research I presented in 2006 at a conference in Chicago suggests that appraising thoughts might actually be a mechanism of change in Dialectical Behavior Therapy - a treatment for BPD that does not (really) use cognitive disputation. So that mindfulness of thoughts may foster their reappraisal naturally.

Can Two Useful But Contradictory Treatments be Combined?

by Tara Deliberto


In no way do I think that Acceptance and Commitment Therapy (ACT) and Cognitive Therapy (CT) are incompatible. In fact, combining techniques from both treatment modalities in a preplanned sequence has great potential.

For argument's sake, let's assume that the two treatments can be merged in a meaningful way. If they can be merged, how would we go about integrating the different techniques (we'll save integrating the philosophies for a different day)? Well, some may argue that placing an emphasis on honing the ability to catch thoughts with the use of mindfulness techniques must precede the teaching of disputing irrational thoughts. At first glance this seems logical perhaps because it is assumed that one must be mindfully aware of a thought before being able to dispute it. I'm not so sure.

Through cognitive restructuring, if patients are first made aware of the fact that their thoughts are irrational, they may have a better framework in which to do ACT work. After cognitive restructuring, they have not only identified which thoughts are dysfunctional or irrational, but have been lead through a reasoning process of why these thoughts are inaccurate. Now with a deeper understanding of why their thoughts are irrational and a clinically significant lesser degree of belief in the verity of the content of these thoughts, they could be in a better position to recognize from which cognitions are best to defuse. Speaking practically from an ACT perspective, using the chessboard metaphor as an example, patients may better be able to identify the "black" pieces from which to defuse, while still being able to maintain self-as-context (i.e. understanding that they are the chessboard that houses the battling white and black pieces). After cognitive restructuring and focusing on self-as-context, it seems to me that people have a greater fighting chance of being able to accomplish the very cerebrally taxing feat of letting thoughts float by. In short, by first providing cognitive restructuring and framing the self as a container of both rational and irrational thoughts, increased understanding, use, and efficacy of mindfulness techniques may follow.

Of course I recognize that "irrational" thoughts are not the only type of cognitions associated with negative or dysregulated affect. There are a range of painful memories, facts, images, and maybe even manic tendencies with which disputation may not be particularly effective, and whereby defusion and mindfulness may be more appropriate; however, systematically disputing the cognitions associated with negative affect that are irrational before getting into ACT work may still generally be helpful.

Thoughts?

How We Value Money - Response to the Previous Post

A friend of mine recently had a very interesting comment on the last post:
You say that people assign a higher value to items once they own them. Could it be the opposite for status/striving items?

My response:
It makes complete sense that results could vary between studies where objects are earned versus given. My inclination is that some items without social status that are earned may actually garner more emotional attachment. For example, if a high school kid earned money to buy his own cheap car, he/she may be more emotionally attached to the car than a kid who was given the cheap car. On the other hand, it makes sense to me that if a person earns a particular object with the idea in mind that it will generate social status, they might value it less once it is attained. My quick thoughts on the reasons for this (that are actually clinical in nature) are that one may be jealous when seeing others with certain items and incorrectly assume that once they have these items, their jealousy will subside. In other words, there is an assumption that having certain items will create happiness (for example) because a lack of the items creates jealousy. Therefore, when the item is attained and does not provide the anticipated positive feelings, it may be emotionally devalued. At the core of the issue would be emotionality or perceived importance surrounding wealth. But I do realize that one can be goal oriented without jealousy. So if a person with a high desire for achievement were to attain a goal to buy a high social status item, they might be left feeling unfilled simply due to an insatiable drive for achievement. My guess is that people will have varying degrees of both jealousy and drive for achievement that will lead to different emotional valuations of both high and neutral status items.

In short, I would say that while emotional attachment might generally increase for items that were earned, perhaps it is a different story with earned items that an individual perceives to have social status when jealousy and drive for achievement are considered.

Monks & Money

by Tara Deliberto

The study of individual decision making is certainly incomplete without taking into account several elements of human psychology. Rather than thinking rationally about decisions to ensure a favorable outcome, people tend to make decisions without a rational foundation, often defaulting to a set of heuristics (Amir & Ariely, 2007). Without knowledge of these psychological components at work, risky or detrimental choices cannot be understood.

One of the most established phenomena in the psychology of human decision making is that people are generally loss averse. Not only do people feel negatively about loss, but losses tend to loom larger than gains (Ariely, Huber, & Wertenbroch, 2005). In other words, people view something as more valuable when they give it up than when they acquire it. Greater value is given to an item after it comes into one’s possession than beforehand. In a study conducted by Knestch (1989), the results showed that people were unwilling to trade the item they received, whether it be a mug or a candy bar, despite random assignment. While loss aversion has been found to exist with the exchange of goods in other studies as well (Kahneman, Knestch, and Thaler (1990), it has not been found to exist for the exchange of money or other goods that are used as currency (Heath & Soll, 1996, Thaler, 1985).

While a loss is inherently averse, it is subjective in that current endowment of both goods and money must be taken into consideration. For instance, the loss of a sandwich to a wealthy person is not felt as strongly as the loss of a sandwich to someone who is destitute. By the same token, the loss of $50 to a millionaire would be felt as less dramatically than a loss of $50 to a typical college student. This is known as the endowment effect.

Ariely et al. press the field forward by proposing potential mediators to both loss aversion and the endowment effect. First, emotional attachment goods may increase reluctance to part with them. In support of this theory, a study by Strahilevitz and Loewenstein (1998) showed that consumers adopt more ownership of items over time, providing support for moderation of loss aversion. Along with emotional attachment, Ariely et al. offer perspective change as a second mediator. While buyers are trying to minimize costs, sellers are trying to maximize gains. As a result, a price gap emerges. This gap is a product of the fact that people value items from different perspectives. In support of this notion, Carmon and Ariely (2000) have found that ticket sales to major sporting events depended on the manipulation of various benefits and opportunity costs, causing a shift in perspective about the purchase. In short, personal valuations of the monetary worth of products vary. Loss aversion could be mediated by one’s perspective of the good.

Furthermore, Dhar and Wertenbroch (2000) suggest that perhaps emotional attachment and cognitive perspective change could actually mediate the loss aversion for money. Although loss aversion has been seen to occur on a lesser scale than for money than goods, it is thought that cognitive allocation of money for certain goods could enhance loss aversion for currency. If the person’s perspective is that the money is to be spent on certain goods, feelings of loss over potential or intended goods may be felt.

While emotional attachment and perspective changes may very well mediate loss aversion and the endowment effect, another element of human perception of money particularly piques the author’s interest. Perhaps a mediator of the endowment effect for money could be the qualitative valuation differences of money. In other words, people place different levels on importance on money despite their current endowment. For example, the loss of $5,000 to a typical millionaire might be felt more dramatically than the loss of $5,000 to a hippy choosing to live on a commune who also happens to be a millionaire. The hippy may simply care less about money. Although their endowments are matched, they still may view the loss differently.

Perhaps this may partially be explained by a cultural overgeneralization of the value of the dollar. In other words, perhaps Americans tend to assume that other cultures may also highly value money. To demonstrate the point, an extreme example will be used: while many people in America strive to acquire wealth, Buddhist monks and people from communist countries, for example, place a very different personal value on currency. Although this concept is slightly similar to perspective change, Ariely et al discuss this potential mediator as short-term shifts rather than long-term persisting value differences. While they may be different constructs, perhaps perspective change and valuation are at opposing extremes of a larger unified construct of attitudes towards money. Furthermore, the construct of qualitative valuation differences of money is different than the idea of emotional attachment because it is not describing affection with a certain object, but a personalized concept of the importance of money. As previously mentioned, emotional attachment was only found with objects, not money. People who value money are not emotional attached to the money itself. An example of a group with a true emotional attachment to money might be coin collectors, while a group of people who think of money as important might be MBA students.

While it may be useful to utilize the example of Buddhist monks valuing money less than a typical American, it seems rational that varying degrees of qualitative valuations of money exist amongst Western people as well. The author thinks that differences in valuations are relevant because they have the capacity to highly impact decision making. Related to how one valuates money, may be irrational decision making. As a simple example, holding endowment constant, if one places importance on money itself, more of it may be saved rather than spent.

Other variables of interest might include the distinction between viewing money as a means to acquire goods versus a reward for work. It is the author's hypothesis that viewing money more as a reward than as a mean to acquire good would result in more conservative decision making.

An interesting study might assess differences in valuation of money amongst poker players and correlations to how they play the game. This particular subgroup was conceived as a sample for a hypothetical study because polarizations between placing high and low importance on money might be able to be studied in this population. Some may think of poker chips as directly relating to how many goods they are able to acquire, while other player may have more distance, and simply view the chips worth hefty amounts of money more as just small round discs of plastic. My guess is the players viewing money as chips may make more rational decisions in the game over time. While this doesn't exactly examine valuation of money, it may clearly depict how people make decisions based on how they perceive money.

Additionally, after this type of distinction is measured, a study might be able to code and quantify specific moves within a given set of games. Actual decision making regarding money could be observed this way. Perhaps there is a better way to execute the evaluation of the presence and socially relevant impact of varying valuations of money, but it is the author’s rough idea that poker players might be an interesting subgroup to study.

While the idea of individual valuation of money effecting decision making may seem reasonable, the author has not found literature on this topic. It was particularly surprising to find personal valuation of money was not mentioned anywhere as a potential mediator of the endowment effect. In short, research should be done in the area. First it must be determined if the phenomena exists. If it is found to exist, exploring it's role in decision making may provide useful insight into irrational and rational behavior regarding money.