Monday, November 22, 2010

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.



Leandra Hallis M.A. said...

I stumbled upon your blog post on the ACT site. I am doing a small lit review for some doctoral research and have been unable to find many studies on combined traditional CBT (with cognitive restructuring) and ACT. I'm especially looking for studies for depression as this is what I wanted to study. Do you know of any that exist? I think that whether or not they can be merged is an interesting question, and wonder about the additive benefits of ACT. Thanks!

Tara said...

Hi Leandra,

Thanks for checking out my blog post! I appreciate the comment. Actually, I was just at the conference for the Association for Behavioral and Cognitive Therapies in San Francisco where I saw a large range of studies presented on ACT v.s. CBT. There were not very many last year at all. Because people generally present data that is not yet published, I'm not sure which groups have and have not published their data. In short, the research is out there; however, not a lot of it is published yet. A place you may want to start looking is the ABCT website ( and look at some of the presentation titles. From there, you can look up the authors' contact info and ask for info on their presentations. After taking a quick glance at the site, i found a few titles such as

Differences in Therapist Behavior in Implementing ACT and CT for the Treatment of Anxiety Disorders K. B. McGrath; E. M. Forman; J. D. Herbert; J. J. Arch; M. Craske; G. Eifert

ACT and CBT in a Pure Self-Help Context: A Comparative Trial Evaluating Two Self-Help Workbooks on Depression, Anxiety, and Quality of Life in an International Sample A. R. Russo; J. P. Forsyth; S. C. Sheppard; C. R. Berghoff; P. Clark; J. Posey

Common and Unique Processes in the Alleviation of Anxious Suffering: A Comparative Trial Evaluating the Effectiveness of an ACT and Traditional CBT Self-Help Workbook A. R. Russo; J. P. Forsyth; S. C. Sheppard; C. R. Berghoff; A. Orayfig; C. Raffaele

Good luck in your search. If I think of anything else, I will email.

Please feel free to keep in touch!

Best Wishes,

Tara said...

P.S. I'm no so sure there are any studies combining the two treatments; however, there are studies comparing them.

Tara Deliberto said...

P.P.S. There is a newer treatment called Mindfulness Based Cognitive Thearpy (MBCT) that - as the name suggests - combines mindfulness and CT. A book you may want to check out is The Mindful Way Through Depression.