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Mindfulness-based and Acceptance-based therapies are gaining vast momentum in the treatment of mental illnesses. These therapy modalities are seen to share some similarity with Cognitive Behaviour Therapy (CBT) (Ost, 2008), however, I am curious to know what conflicts exist in a therapist-client relationship when adopting some of the techniques/foundations from both therapy forms?

For example, in Acceptance and Commitment Therapy (ACT) - defusion (the process of distancing ourselves from our throughts) seems to present some form of conflict to CBT which suggests that cognitive restructuring is fundamental to behavioural change, i.e. "trying to change our thoughts". There may be some conflict within a therapeutic setting.

Questions:

  1. What conflicts can occur in the therapist-client relationship when using mindfulness and acceptance exercises with cognitive behaviour therapy exercises?
  2. In what ways may the two groups complement each other in achieving therapeutic outcomes ^ for the client?

^ Therapeutic outcomes can be assumed as symptomatic alleviation of the mental illness or any other positive outcome towards the alleviation of a mental illness.

Some further examples would be great.

References:

  • Öst, L.G. (2008). Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis. Behaviour Research and Therapy, 46(3), pp.296-321
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    $\begingroup$ Interesting question. Side note, sometimes broad is not always better, as it is easier to write a more specific answer than tackle such a huge area.. Just a thought :) $\endgroup$ – user10932 Sep 24 '13 at 22:16
  • $\begingroup$ Thanks ThinksALot. I made the question broader so that I wasn't only focused on Acceptance and Commitment Therapy (ACT) which users may or may not have a heap of knowledge about. $\endgroup$ – coeus Sep 24 '13 at 23:14
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No takers so I've decided to do some research and theorise if there are any conflicts between these two therapy modalities. Drawing on research by Hofmann & Asmundson (2008), three distinct differences are identified between Cognitive Behaviour Therapy (CBT) and Acceptance and Commitment Therapy (ACT):

The role of cognitions. "CBT helps patients to identify, challenge, and re-evaluate these rigid rules and adopt a more relaxed and satisfying system of values in order to enhance overall life satisfaction. Instead, ACT subsumes cognitions under the more general term behavior as it is used in behavior analysis, namely “as a term for all forms of psychological activity, both public and private, including cognition” (Hayes et al., 2006, p. 2). In essence, the word cognition has a different meaning in ACT than in CBT; it is a thought process in CBT and a private behavior in ACT."

The role of emotions. "CBT and ACT target different stages in the emotion-generative process: CBT promotes adaptive antecedent-focused emotion regulation strategies, whereas ACT counter-acts maladaptive response-focused emotion regulation strategies. The cognitive restructuring techniques used in CBT are in line with the antecedent-focused emotion regulation strategies, providing skills that are often effective in reducing emotional distress in the long term. Acceptance and mindfulness-based strategies counter suppression and, thereby, alleviate emotional distress."

Philosophical foundation. ACT is based on functional contextualism, which has been proposed as the philosophical basis for behavior analysis to emphasize the functional relations between behavior and environmental events ... CBT is not directly linked to a particular philosophy. The philosophical foundation most closely associated with CBT is critical rationalism, an epistemological philosophy (Popper, 1959) that shares its philosophical roots with the natural sciences."

Potential conflicts

These are theorised based on the above differences between CBT and ACT:

  • Unclear criteria for the suitability of exercises. Since CBT and ACT are clearly disparate therapy modalities, there is no universal guide on when and how to adopt therapeutic exercises from either CBT or ACT in combination or separately. The decision to use certain exercises is influenced highly by the therapist's subjective judgment and past experiences.
  • Unknown effects of combining CBT and ACT. As far as I know, there are no studies on the effects of traditional exercises such as cognitive restructuring (CBT) and mindfulness practice (ACT) when combined together on specific mental illnesses. Prima facie, the former involves deliberate attempt to modify cognitions and the latter involves a systematic process of observing non-judgmentally cognitions. It is difficult to see no conflict without empirical counter-evidence.
  • Potential negating effects. In ACT, Cognitive Defusion involves the process of distancing or separating oneselves metaphorically from their thoughts (Moffitt et al., 2012). If a client initially uses cognitive restructuring techniques to alleviate distress from their mental illness and this becomes conditioned - using cognitive defusion subsequently after that could negate the positive effects of the previous CBT-based technique.

References

  • Hofmann, S.G. & Asmundson, G.J.G. (2008). Acceptance and mindfulness-based therapy: New wave or old hat? Clinical Psychology Review, 28, 1-16
  • Moffitt, R., Brinkworth, G., Noakes, M. & Mohr, P. (2012). A comparison of cognitive restructuring and cognitive defusion as strategies for resisting a craved food. Psychology & Health, 27(2), 74-90
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    $\begingroup$ I just realised no one answered your bounty. Next time, I'll post an "answer" you can award the bounty and I'll award it back on one of your posts. Just "ping" me @ThinksALot cheers $\endgroup$ – user10932 Oct 7 '13 at 16:04
  • $\begingroup$ very interesting answer. Do you have this paper: A comparison of cognitive restructuring and cognitive defusion as strategies for resisting a craved food. ? $\endgroup$ – ICanFeelIt Jan 30 '15 at 15:15
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I don’t really have much in the way of scientific evidence for combining the two. I have, however, information from personal experience that many therapists tend to combine the two approaches with varying effects. I think the combination can be useful if a particular case conceptualisation is chosen and diverse techniques are utilized. (I believe this is called technical eclecticism).

Take for example, a disorder I have struggled with, Social anxiety Disorder. The CT model (1)of the disorder claims that it is maintained by maladaptive cognitions about performance on social situations and the social cost of social failure. These maladaptive cognitions lead to increased anxiety which triggers behavioral avoidance of uncomfortable situations which only maintains the anxiety. Based on this model, cognitions have to be modified in order for behavior to be changed.

According to ACT however (2), anxiety is maintained by a constant struggle with thoughts and feelings, and attachment to the literal meaning of thoughts and desire to avoid negative emotions. Thus behavioral avoidance is an extension of the desire to avoid negative experiences.

One therapist I had resolved the differences by focusing on the similarity - the behavioral component. My social anxiety was conceptualized as being maintained by behavioral avoidance. Thus, my thoughts and feelings were seen as barriers to countering that avoidance. In order to remove these barriers, she used cognitive restructuring and defusion as tools depending on the type of thought. In my experience, cognitive restructuring was most useful if there was a side of the issue that was being ignored or if i really believed the maladaptive thoughts. I found that defusion was most helpful for thoughts that hindered me even though I knew that they were untrue or that there was no way of knowing if they were true. For example, I often believed that my friends secretly did not like me and were not telling me this. The cognitive therapy approach is to label this thought as a distortion - mind reading - and attempt to come to a conclusion that can be logically come to based on the available evidence. I found this to be absolutely useless with the thought - because I was certain it was mind reading but it still held power over me. Defusion helped me to modify the power of the thought since I could not modify it. Over time, I discovered that it was helpful to me to do cognitive restructuring first to reduce the believability of a thought and then defuse the thought if I knew the logical truth but could not really believe it.

Another therapist I had helpfully illustrates the conflict with using diverse case conceptualisation. This therapist both suggested that using coping statements (realistic facts that could counter negative thoughts) was helpful and trying to decipher the real facts of a situation while in it was unhelpful which is very contradictory. He also used both ACT and CT conceptualisation in the most confusing ways. For example, he advised that mindfulness exercises not be utilized as ways to reduce anxiety but to reduce experiential avoidance (an ACT concept) yet he conceptualized exposures in the CT way, which stresses habituation and fear reduction rather than engaging in scary activities for valued living (ACT). He also stressed the importance of aiming for behavior change rather than having less anxiety (an ACT concept) yet he rated the subjective levels of distress while engaging in a task and considered an exposure a success once the distress had fallen. I think the problem was that he had taken a standard CBT social anxiety group therapy and thrown in ACT case conceptualisation without removing the elements from CBT that do not fit with the ACT approach. I was lucky that I had discovered how to use the differing strategies with the previous therapist I had. Otherwise, I would have been very confused. I don’t think any of the techniques would have negated each other - just that it would have been difficult for me to decide which technique was useful in which situation. This therapist was mostly helpful for me in teaching me the empirically supported social anxiety exposures - which happens to be largely the same for both therapies.

As an interesting side note, I later discovered I have Attention Deficit/Hyperactivity Disorder which affects me mostly when I have to sustain effort or attention on something I don’t want to do. For this problem, I have found CT to be useless because it involves telling me to do experiential experiments and to notice that I can do things well even if I have no motivation (3). The thing for me is that I know that but I still really don’t want to do the task and just won’t. Working with the second therapist in this issue was helpful because an ACT conceptualisation completely fit with the problems. And, since CBT doesn’t have a well-established protocol for ADHD, I did not have the same problems with a CBT protocol filtering in to an ACt therapy.

References:

  1. Clark, D. M. & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment. (pp. 69–93). New York: Guilford Press.

  2. Dalrymple K. L., and Herbert J. D. (2007) Acceptance and Commitment Therapy for Generalized Social Anxiety Disorder: A Pilot Study Behavior Modification Vol 31, Issue 5, pp. 543 - 568 https://doi.org/10.1177/0145445507302037

  3. Saulsman, L., & Nathan, P. (2008). Put Off Procrastinating. Perth, Western Australia: Centre for Clinical Interventions.

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