Here on this rainy lazy Sunday in NYC, I was drinking my usual morning green tea and thinking about the cases I've seen of alexithymia - or the inability to recognize emotions - in children. What do we do about alexithymia? Well, definitely the usual stuff like playing games like emotion charades where we have to guess what emotions / feelings we're acting out, practice problems solving / acting out solutions to various conflicts, etc. But what else?
Here's a made up case to illustrate my thoughts:
Let's say that I'd been treating a 8 year old boy with alexithymia with the usual techniques until one day his mother asked to talk to me womano-a-womano. She says that he doesn't understand important feelings she has about a specific family situation and takes the opportunity to tell me about her emotions. So I go into session and directly discuss what mom might be feeling in these tough family scenarios. The boy is surprised to learn how she might be feeling and feels a bit badly about his behavior. Then we discuss what he can do differently in the future that takes his mothers emotions into consideration. During the next week's session, mother reports that the boy was appropriately attentive to her from the moment they left therapy and throughout the entire week.
Now, even though our hypothetical session - that is a hybrid of multiple sessions with various patients - apparently produced the most effective behavior change outside of session, it was probably the most (mildly) aversive session we ever had. Compared to past sessions where I have been teaching through games, this was no walk in the park.
During a game like emotional charades, the emotions remain impressionistic by nature. So where do we go from there? Sure this may be a good starting point and we also spend some time discussing issues that are upsetting outside of the session, but what about evoking real emotion in session?
By discussing the feelings that his mom might have, a little light bulb went off in his head. He first reported feeling sad, but after some pressing, he also reported feeling a little bit guilty about his lack of attentiveness to his mother. After all, we are talking about a very kind child, here.
Notably, those emotions of sadness and guilt were freshly created as a direct result of newly learned content in the session. These emotions were not re-conjured from past events outside of session, nor impressionistic. Something to think about.
Because this session was mildly aversive though, my concern for next week was that he would not want to come back. After all, in his mind, we typically just play games. (Sure, these techniques can produce some change, but it is my opinion that they remain surface.)
Flying in the face of my nagging worry, this little guy was actually quite eager to return to session the following week. I suppose that I'll never be sure as to why. We can only speculate that perhaps it was because of a long standing therapeutic rapport and a learning history that coming to therapy is fun. A second option is that he did not experience the sadness and guilt intensely enough for it to deter him longer term.
But what about the results of Walter Mischel's studies? We know some children can appreciate something more aversive & meaningful in the long-term, but not a barrel of laughs in the short term.
Maybe this little guy appreciated learning something new and subsequently having his environment change. After all, mom did say things were much better at home following that session.
Who knows?
To summarize, there are three ways of dealing with emotion in session:
1) evoking then processing new emotion in session as a result of new information / insight
2) rehashing previously felt emotion
3) creating impressionistic expressions of emotions
Maybe #1 is preferable. Something to think about.
Showing posts with label Therapy. Show all posts
Showing posts with label Therapy. Show all posts
Sunday, April 22, 2012
Tuesday, January 17, 2012
Therapy and Eastern Religion
As I mentioned in the post, Near Death Euphoria and the Link to Suicide, I love www.Reddit.com. On this site, a member asked me about the connection between CBT and Eastern Religions. This was my response:
So, there have been three "waves" of CBT. The first was behavior therapy, the second was cognitive behavior therapy, and the third is mindfulness/meditation related.
The Third Wave CBT approaches are very tied into Eastern religion. The names of the most well known Third Wave approaches are Acceptance and Commitment Therapy (ACT; pronounced "act"), Compassion Focused Therapy, and DBT (which I mention elsewhere on this blog). I am a huge fan of Third Wave approaches.
The cognitive Second Wave approaches work on correcting "irrational" beliefs (e.g. I am a worthless person). For instance, we might examine the evidence for and against the argument that you're worthless. As it turns out, once you think about it, maybe you're not really all that worthless.
But the Eastern-influenced Third Wave CBT treatments emphatically do not aim to correct irrational beliefs!
Third Wave approaches mainly focus on noticing thoughts like "I'm worthless" and trying to change one's relationship to the thought, but not the content of the thought itself.
For instance, a Third Wave approach might simply focus on the fact that "I'm worthless" is coming into the mind and that it isn't a particularly useful thought to attend to. The treatment would aim to pull the person out of their head and into contact with the present. So instead of attending to the thought "I am worthless," a person may be encouraged to shift the attention to the breath, for example.
Third Wave approaches offer a lot more than just this, and are very rich approaches, but I think this represents the general idea.
If you're interested in learning more, I highly suggest reading The Compassionate Mind and The Compassionate Mind Approach to Overcoming Anxiety.
For more posts, check out The Psychology Easel and follow me on Twitter at @TaraDeliberto.
So, there have been three "waves" of CBT. The first was behavior therapy, the second was cognitive behavior therapy, and the third is mindfulness/meditation related.
The Third Wave CBT approaches are very tied into Eastern religion. The names of the most well known Third Wave approaches are Acceptance and Commitment Therapy (ACT; pronounced "act"), Compassion Focused Therapy, and DBT (which I mention elsewhere on this blog). I am a huge fan of Third Wave approaches.
The cognitive Second Wave approaches work on correcting "irrational" beliefs (e.g. I am a worthless person). For instance, we might examine the evidence for and against the argument that you're worthless. As it turns out, once you think about it, maybe you're not really all that worthless.
But the Eastern-influenced Third Wave CBT treatments emphatically do not aim to correct irrational beliefs!
Third Wave approaches mainly focus on noticing thoughts like "I'm worthless" and trying to change one's relationship to the thought, but not the content of the thought itself.
For instance, a Third Wave approach might simply focus on the fact that "I'm worthless" is coming into the mind and that it isn't a particularly useful thought to attend to. The treatment would aim to pull the person out of their head and into contact with the present. So instead of attending to the thought "I am worthless," a person may be encouraged to shift the attention to the breath, for example.
Third Wave approaches offer a lot more than just this, and are very rich approaches, but I think this represents the general idea.
If you're interested in learning more, I highly suggest reading The Compassionate Mind and The Compassionate Mind Approach to Overcoming Anxiety.
For more posts, check out The Psychology Easel and follow me on Twitter at @TaraDeliberto.
Sunday, October 16, 2011
Yet Another Reason CBT & ACT are Compatible
Every now & again on this blog, I'm going to really dork-out and get technical. While most of the posts are certainly for the general public, this one is coming from my inner Ph.D.-student.
While folding laundry, I was ironically in my head thinking about the concept of coming into contact with the present moment. This is the thought that indirectly caused me to put my shirts in the sock drawer: CBT instructs people not to ruminate about the past or worry about the future, while ACT provides a substitute behavior (i.e. mindfully coming into contact with the present moment). In other words, roughly speaking, CBT works from the negative and ACT works from the positive in terms of action.
This is yet another reason why I think CT might be useful for some people before an ACT intervention. Allow me to explain. If you were writing a research proposal, for example, first you'd go through all of the problems with the past research and explain why it isn't sufficient. After this, you'd go onto explain exactly what you intend to do instead. Therefore, in order to make some changes on a research level, first you need to understand the problem, then you do something new. Similarly, I think cognitive techniques are useful in explaining what does not work, while ACT is really good at providing what does work.
Of course, this is not to say that out-of-the-office and on-the-spot cognitive disputation isn't ineffective. In fact, I really think it is - especially when one is either first grappling with identifying maladpative cognitions or is having a particularly difficult time. The point is that after one has identified a maladaptive cognition and worked out why it isn't effective, it is helpful to then learn what to do next (i.e. to shift into the present moment). In this way, I think ACT techniques are perfect for where CBT leaves off.
Ok, back to laundry!
While folding laundry, I was ironically in my head thinking about the concept of coming into contact with the present moment. This is the thought that indirectly caused me to put my shirts in the sock drawer: CBT instructs people not to ruminate about the past or worry about the future, while ACT provides a substitute behavior (i.e. mindfully coming into contact with the present moment). In other words, roughly speaking, CBT works from the negative and ACT works from the positive in terms of action.
This is yet another reason why I think CT might be useful for some people before an ACT intervention. Allow me to explain. If you were writing a research proposal, for example, first you'd go through all of the problems with the past research and explain why it isn't sufficient. After this, you'd go onto explain exactly what you intend to do instead. Therefore, in order to make some changes on a research level, first you need to understand the problem, then you do something new. Similarly, I think cognitive techniques are useful in explaining what does not work, while ACT is really good at providing what does work.
Of course, this is not to say that out-of-the-office and on-the-spot cognitive disputation isn't ineffective. In fact, I really think it is - especially when one is either first grappling with identifying maladpative cognitions or is having a particularly difficult time. The point is that after one has identified a maladaptive cognition and worked out why it isn't effective, it is helpful to then learn what to do next (i.e. to shift into the present moment). In this way, I think ACT techniques are perfect for where CBT leaves off.
Ok, back to laundry!
Sunday, March 13, 2011
Sex - Benefits of Talk Therapy Over Medication
Unlike stereotypical versions of talk therapy where a doctor claims you want to have sex with your mother, a newer treatment called Cognitive Behavioral Therapy (CBT), has been shown by plenty of studies to actually work.
Not only that, it changes your biology. Unlike other talk therapies, this type of treatment involves active learning and homework. As such, it can cause beneficial increases in the size of your brain that controls complex thinking - the cerebral cortex. In fact, CBT has also been shown to be just as effective as medication, just with longer lasting effects.
I would imagine that CBT continues to be beneficial after ending treatment because the time was taken over numerous sessions to rewire the brain. On the other hand, medication may act more by forcing it to function differently for a short period of time. Many drugs also come with a lot of negative side effects.
Unlike a lot of depression medications, CBT just doesn't numb your sexual experience. As Kiera Van Gelder so eloquently describes in her fantastic recovery memoir, The Buddha and The Borderline: "Sometimes when I see his body or smell his scent, I want to consume him with all of my senses. Then, when we meet skin on skin, it's like hitting a thick glass wall. 'It's the medication.' I tell him."
Although it may be advisable for some people to be on medication while in CBT, if you are choosing between talk therapy and drugs, make sure to do your homework. Trying a CBT therapist before medication might be a favorable option for you.
For more posts, check out The Psychology Easel and follow me on Twitter at @TaraDeliberto.
Not only that, it changes your biology. Unlike other talk therapies, this type of treatment involves active learning and homework. As such, it can cause beneficial increases in the size of your brain that controls complex thinking - the cerebral cortex. In fact, CBT has also been shown to be just as effective as medication, just with longer lasting effects.
I would imagine that CBT continues to be beneficial after ending treatment because the time was taken over numerous sessions to rewire the brain. On the other hand, medication may act more by forcing it to function differently for a short period of time. Many drugs also come with a lot of negative side effects.
Unlike a lot of depression medications, CBT just doesn't numb your sexual experience. As Kiera Van Gelder so eloquently describes in her fantastic recovery memoir, The Buddha and The Borderline: "Sometimes when I see his body or smell his scent, I want to consume him with all of my senses. Then, when we meet skin on skin, it's like hitting a thick glass wall. 'It's the medication.' I tell him."
Although it may be advisable for some people to be on medication while in CBT, if you are choosing between talk therapy and drugs, make sure to do your homework. Trying a CBT therapist before medication might be a favorable option for you.
For more posts, check out The Psychology Easel and follow me on Twitter at @TaraDeliberto.
Friday, March 4, 2011
Does A Therapist Judges You?
Today I received a question from a man in Mumbai asking if I went into being a psychologist so I could be in a position to judge people. He expressed the sentiment that everyone must understand that we are in no place to judge others and that he prefers a live at let live philosophy.
Here's my response:
Thanks for the post. Since many people share your opinion, I think this question is particularly important to address.
I can understand that without an introduction to the type of treatment I practice, one may assume therapists just want to judge people. In fact, it is just the opposite! People come into my office with a series of judgments about themselves that we work together to debunk. I've seen people who have made wonderful contributions to society but seem to think that they are completely worthless. My job is simply to neutralize judgments. We help people to stop harshly judging themselves so that they can function better and suffer less.
While many people are not in need of treatment, I'm afraid that many people are seriously troubled and on the fence abut whether or not they should end their own lives. With suicidal people, a live and let live philosophy wouldn't exactly work out. And just because someone is contemplating suicide, does not make them worthless and deserving to die, it just means they are suffering from what can feel like a tortured internal experience. They come to treatment of their own volition because there is a piece of them that wants to get better. Therapists don't force clients into treatment.
There have been many research studies on the type of therapy I do showing that the techniques are in fact useful in helping people build a life worth living. Therapy, when practiced well, is much more than a series of judgments - it is an effective way to retrain people's thoughts and behaviors.
Here's my response:
Thanks for the post. Since many people share your opinion, I think this question is particularly important to address.
I can understand that without an introduction to the type of treatment I practice, one may assume therapists just want to judge people. In fact, it is just the opposite! People come into my office with a series of judgments about themselves that we work together to debunk. I've seen people who have made wonderful contributions to society but seem to think that they are completely worthless. My job is simply to neutralize judgments. We help people to stop harshly judging themselves so that they can function better and suffer less.
While many people are not in need of treatment, I'm afraid that many people are seriously troubled and on the fence abut whether or not they should end their own lives. With suicidal people, a live and let live philosophy wouldn't exactly work out. And just because someone is contemplating suicide, does not make them worthless and deserving to die, it just means they are suffering from what can feel like a tortured internal experience. They come to treatment of their own volition because there is a piece of them that wants to get better. Therapists don't force clients into treatment.
There have been many research studies on the type of therapy I do showing that the techniques are in fact useful in helping people build a life worth living. Therapy, when practiced well, is much more than a series of judgments - it is an effective way to retrain people's thoughts and behaviors.
Tuesday, December 28, 2010
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.
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.
Sunday, December 5, 2010
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.
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.
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.
Thoughts?
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?
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