Tara.Deliberto's blog

Can ACT and CBT be Merged?

It doesn't seem to me that ACT and CT are incompatible.  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 basically 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 which cognitions are best to defuse from.  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.   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. 



Beginner's Eye

I have only four years of experience in the field of psychology. For the majority of the first two years, I collected and analyzed data in a Dialectical Behavioral Therapy (DBT) clinic through a laboratory at Harvard University in Cambridge, MA. I sat in on 5 hours a week of therapist consultation team meetings, didactic seminars, and individual supervision in exchange for tracking the progress of each client. I have only been participating in a few month’s worth of Acceptance and Commitment Therapy (ACT) meetings as a doctoral student.

Perhaps a beginner’s eye can be of some utility.

In a recent lab meeting, I was engaged in a discussion of the paradigm shift between the focus of therapy being symptom reduction, as seen in other therapies (i.e. cognitive-behavioral therapy), towards helping the client to live a life in accordance with their values, as in ACT. The irresolution of an argument centering on this point prompted me to write my first ever blog entry.

In ACT there is not only an emphasis on living life in accordance with one’s values, but it seems a fairly outright denunciation of any attempt to control or manipulate thoughts in an effort to regulate emotions. Although I am aware of the research indicating thought/expressive suppression is an unsuccessful method of controlling thoughts/emotions often resulting in increases in the targeted thoughts/emotions, there is evidence to suggest that cognitive reappraisal, the revaluation of negative thoughts, is effective (in fact, I presented research at the Associations for Behavioral and Cognitive Therapies conference in 2006 on cognitive reappraisal being a potential mechanism of change in intensive DBT). I understand that because attempts at suppressing thoughts are futile, as a therapist one should not encourage this; however, I do not understand what appears to possibly be an overgeneralization to advise against ever attempting forms of thought manipulation, especially when reappraising cognitions appears to be beneficial [If this blog entry were actual dialogue, this would be the point where I may get into a semantics discussion with ACT practitioners about the word “beneficial.” Although this word was previously used in reference to symptom reduction, I would argue that it is safe to say that using cognitive reappraisal as a tool can also help one to lead a life in accordance with one’s values.].

That is not to say, of course, that cognitive reappraisal should be a focus of the treatment or that mindfulness should be abandoned. Quite the opposite. I am merely suggesting that perhaps all attempts at thought/emotion manipulation should not be discounted. Perhaps mindfulness can be used as a tool the majority of the time for some problems whereas cognitive reappraisal can be used as a tool occasionally for other types.

Of note, I have come to conceptualize two types of mindfulness:
1) allowing oneself to fully experience a thought/emotion without attempt at suppression
2) allowing oneself to view thoughts/emotions objectively as thoughts/emotion

I realize the following thought is not original; however, it is worth noting here for the sake of comprehensiveness that the first conceptualization of mindfulness may be effective through means similar to that of exposure. Basically, if one stops avoiding or attempting to avoid the emotion, it is learned that the emotion can be experienced and survived.

I have not previously heard interpretations of why the second type of mindfulness may be effective. It may work because enough distance between one and one's thoughts/emotions is created that a "reappraisal" of sorts may naturally follow whether or not it was an intended benefit. In other words, by virtue of the distance created by mindfulness alone, cognitive defusion may follow, and reappraisal of the thought/emotion as non-intrusive or not-bad may occur. Whereby mindfulness practice may facilitate the thought transforming from having a negative to neutral valence, in cognitive reappraisal, the valence may go from bad to good or bad to neutral. It is not clear which method is more effective. In short, I think cognitive reappraisal and mindfulness may achieve similar ends through different means. The question of which means is better is obviously open to discussion; however, again, I would hypothesize that mindfulness is probably effective most of the time whereby cognitive reappraisal would be beneficial in other instances. It is known that people with emotional disorders are in the habit of attempting to suppress thoughts while healthy controls are more able to accept their negative emotions and function in society. Perhaps because people with emotional disorders have a tendency to do this, an approach geared away from thought manipulation in general may be appropriate.

In addition, I am aware that in light of the recent literature suggesting that behavioral activation- simply put, carrying out daily activities despite symptoms- is a main mechanism of change in many psychological treatments, all the talk of cognitions seems futile; however, I think it is necessary. It is interesting that behavioral activation is so closely in line with the goal of ACT: living life towards ones values in the context of one’s symptoms. With this as a treatment goal, one is essentially turning the client’s attention away from thought/emotional suppression and gearing them to behaviorally activate. The “gearing” or framework in which the behavioral activation is nestled may be the determining factor in whether or not one actually begins to behaviorally activate or start living life in accordance with one’s values. Therefore, packaging behavioral activation in ACT with mindfulness may be more useful than packaging it with the cognitive pieces of cognitive behavioral therapy.

It is also of note that while in cognitive-behavioral/behavioral therapy, behavioral activation is the means through which symptoms are reduced, in ACT, the goal is to behaviorally activate without necessary symptom reduction. It is possible that gearing the therapy without the expectation of symptom reduction may actually result in greater symptom reduction than CBT. Again, this could possibly be because people with emotional disorders are constantly struggling with control and suppression of thoughts/emotions so that when they are in a context encouraging them to largely give up control, behavioral activation could be facilitated and more symptoms reduced. Furthermore, if treatment doesn't immediately ameliorate symptoms, clients in ACT may be more likely to stay in treatment because of low expectations about symptom reduction.

If you are interested in this topic, please feel free to visit my blog at [[http://taradeliberto.blogspot.com/]]!

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