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.