A CBT Practitioner's Guide to ACT, by Ciarrochi, Joseph V.
- ISBN: 9781572245518 | 1572245514
- Cover: Paperback
- Copyright: 12/3/2008
The open-minded see the truth in different things;
the narrow-minded see only the differences.
We humans are unique in all the animal kingdom in our ability to suffer, even when we have enough to eat and are not in any physical danger. We also have the unique ability to hurt each other. We make war, murder, or, more mundanely, say hurtful things to others and engage in bitter argument. As a consequence, we sometimes feel alone, angry, sad, and afraid of intimacy. We often struggle to have authentic, trusting relationships.
Yet there is something about our human history that gives us hope. For every base act, we can find a noble one. We can point to acts of generosity, compassion, and sacrifice. We know we are capable of living up to our ideals. This book is fundamentally about helping people (including ourselves) to live more vital, meaningful lives.The Need for Integration
The modern practitioner faces a bewildering number of techniques for helping people. There are behavioral techniques, such as shaping, exposure, and contingency management. There are cognitive strategies, such as reframing, restructuring, problem solving, and cognitive skills training. Then there is a new wave of therapies that utilize techniques such as mindfulness, paradox, yoga, confusion, chanting, and deep breathing. There are hundreds of different therapies and probably thousands of different techniques.
How can we determine the best way to help people? One possibility is to choose a single, empirically supported therapy and practice it exclusively. Unfortunately such an approach may exclude useful techniques. Another strategy is to be "eclectic," that is, to select techniques from a variety of therapies that may be useful and that, preferably, have been empirically supported.
However, we face problems when we focus on the level of technique (Hayes, Strosahl, & Wilson, 1999). Think of this level as being kind of like following a recipe book (or facilitator manual in therapy). The book tells us what to do for each type of condition. It is very precise. However, there are practical disadvantages to focusing on technique instead of being guided by philosophy and theory (Hayes et al., 1999). First, if all we know is a set of techniques for treating, say, depression, then we will have no basis for using our knowledge when confronted with a new problem. Maybe a different set of techniques is needed. Second, we have few ways to create new techniques. The therapy manual does not tell us how to do this. Third, we also run the risk of using techniques in a disorganized and incoherent fashion. Perhaps some techniques are incompatible with other techniques.Where Have We Come from and Where Are We Going?
Much of this book will be about helping practitioners use techniques from different therapies (mainly ACT and CBT) in a maximally coherent and effective manner. Before we get to the details of this, however, it is important to briefly take a step back and look at where ACT and CBT came from.
We are all located in a historical context. We have learned to see the world in certain ways and to make specific assumptions. It is difficult to step out of the historical context and take a look around. One potential way of "stepping out" is to understand the historical forces that led to this moment (though even this understanding is subject to historical forces). Therapies can be divided roughly into three waves (Hayes, 2004): behavioral, cognitive, and mindfulness-based.
The First Wave: Reign of the Behaviorists
Before behaviorism, Freudian psychotherapy was a strong force in clinical psychology. Introspection was a key method, and theories, based loosely on scientific principles, were difficult to study. B. F. Skinner and other behaviorists revolutionized applied psychology and made it accountable to scientific method (Skinner, 1950; Watson, 1913). Behaviorists conducted rigorous, highly controlled studies that uncovered key methods of influencing behavior (Catania, 1998). Such methods include exposure, extinction, reinforcement schedules, classical conditioning, and shaping. It is unlikely that any effective practitioner can stray far from behavioral principles, given that they have been found to be so effective. For example, prior to behaviorism, it was often believed that phobias could take years to cure. After behaviorism, amazingly, phobias could sometimes be cured in only a few sessions of exposure therapy. This must have seemed like a miracle to many.
Both CBT and ACT make extensive use of behavioral principles. Because the principles form a core part of how we speak about CBT and ACT, we have included an appendix with some of the key behavioral findings (see appendix B), in case the reader would like a brief refresher course on the subject.
Despite its tremendous success, traditional behaviorism eventually declined in popularity and has even been described as "dead" by some (Pinker, 1994, 2002). A number of key factors led to this state of affairs. First, people argued that behaviorism could not account for language processes because it did not make reference to internal, nonobservable constructs (Chomsky, 1959, 1965; Pinker, 1994). Second, people were interested in complex processes such as insight, problem solving, and reasoning. Behaviorism, with its emphasis on the observable, seemed to have no clear way of talking about these processes. Third, people believed (and still believe) that behaviorism lacked scope, that is, it was "too complex" and "too detailed" to describe the mind efficiently (David & Szentagotai, 2006). David and Szentagotai argue that each time behaviorists seek to explain behavior, they must search for a unique set of historical contingencies. This must be done for each of thousands of behaviors. For example, in order to describe memory biases induced by schema-type processing (that is, remembering schema-consistent information better than schema-inconsistent information), behaviorists would have to examine the particular history of contingencies associated with the items on a memory test. Thus, to explain why depressed people show a bias to recall negative information about their relationships, the behaviorist would supposedly have to know the history of each bit of recalled information. In contrast, the cognitive psychologist posits a "depressinogenic schema," and this one construct can explain a wide variety of biases.
Regardless of how accurate these criticisms are (see, for example, MacCorquodale, 1970), they did exert a powerful impact on psychology, reducing the popularity of behaviorism and helping to usher in the cognitive revolution. Even so, behaviorism continues to be a central part of applied psychology. Behavioral principles are used in most therapies (for example, exposure and shaping in CBT), and have now been shown to be sufficient to treat some problems, such as behavioral activation for depression (Cuijpers, van Straten, & Warmerdam, 2007; Jacobson, Martell, & Dimidjian, 2001). In addition, behavioral research has led to the development of new techniques (for example, introceptive exposure; Barlow, 2002). Behaviorism did not die; it just got swallowed up by the cognitive revolution.
The Second Wave: The Cognitive Revolution and CBT
One key idea of the cognitive revolution was that by studying, developing, and implementing successful processes in computer science, it would be possible to know more about human mental processes. Thus, the computer became a powerful metaphor for how people thought and behaved. People were seen to receive informational "input" from the environment, process it in certain ways, and then produce certain outputs (Osherson & Lasnik, 1990). (Of course the actual theories are more subtle and complex than this description suggests.) There are several key ideas in cognitive psychology:
The cognitive revolution had a dramatic influence on applied psychologists, both in the way they think about people and in their rejection of traditional behaviorism. For example, Aaron Beck threw down the gauntlet when he asked the question, "Can a fledgling psychotherapy [CBT] challenge the giants of the field—psychoanalysis and behavior therapy?" (A. T. Beck, 1976, p. 333). Thus, CBT was seen to be radically different from behaviorism.
The cognitive model of psychopathology posits that cognitive change is central to treating psychological disorder (A. T. Beck, 1970; DeRubeis, Tang, & Beck, 2001; Longmore & Worrell, in press). What distinguishes CBT from other therapeutic approaches is that the therapist and patient collaborate to identify distorted cognitions and maladaptive beliefs, which are subjected to logical analysis and empirical hypothesis testing. The goal is to help clients realign their thinking with reality (Clark, 1995).
There are a wide variety of cognitive therapy approaches, associated with such authors as Beck and Beck (A. T. Beck, 1976; J. S. Beck, 1995), Ellis (2001), Meichenbaum (1985), Barlow (2002), Young (Bricker, Young, & Flanagan, 1993), Wells (1997), and numerous others (see, for example, Cormier & Cormier, 1998). It is difficult to talk about these approaches as a group because each approach differs in important ways. To make matters even more difficult, the approaches are constantly evolving and changing. Therefore, the review in this section focuses on what these approaches have in common, and emphasizes the elements of the therapy that exemplify the second wave (though the newest version of the therapy might already be moving away from some aspects of this type of therapy).
Recently David and Szentagotai (2006) published a review of the different CBT models and provided a framework for unifying them. Table 1.1 presents the framework.
Table 1.1:A Cognitive Model of Human Feelings and Behaviors
The cognitive models assume that stimuli enter the information processing system. These stimuli are sometimes called "information," "antecedents," or "activating events." In step 2, attention may be shifted toward some stimuli and away from others. The stimuli can then be perceived and symbolically represented (step 3), interpreted (step 4), and evaluated (step 5). These evaluations or appraisals are fed into step 6, which involves emotional responses. Finally, step 7 involves coping mechanisms aimed at managing feelings, or potentially accepting or enduring them.
Each of these information processing steps might influence any of the other processing steps. Cognitive psychologists spend a substantial amount of research energy examining how the steps interact. They may examine how emotions (step 6) influence attention (step 2), representation of stimuli (step 4), and evaluative interpretations (step 5) (for example, Ciarrochi & Forgas, 2000; Ciarrochi & Forgas, 1999; Forgas, 1995).
Different techniques and forms of CBT can be understood in terms of the processing step they emphasize. For example, some CBT approaches attempt to reduce attentional biases to negative stimuli (step 2) by modifying the intensity of self-focus, attentional control, or the breadth of attention (Mathews, 2002; Wells, 1990, 1997). J. S. Beck’s form of CBT (1995) targets distorted thinking patterns (step 4), including such inferential errors as "black and white thinking," "mind reading," "overgeneralization," and "fortune telling." D’Zurilla and Nezu’s problem-solving therapy (1999) seeks to improve people’s ability to formulate problems and generate alternative solutions (step 4). Ellis’s form of CBT (2001) focuses more exclusively on evaluative beliefs (step 5), including global evaluations of the self (for example, "I am worthless"), of events in the world (for example, "Divorce is awful"), or of one’s own emotions (for example, "Feeling anxiety is unbearable"). Similarly, problem solving therapy focuses on changing unhelpful evaluative beliefs about problems (for example, that they are threats rather than challenges), and Beck’s therapy focuses on changing unhelpful evaluative beliefs concerning social acceptance and power (J. S. Beck, 1995). Meichenbaum’s self-instructional form of CBT (1985)seems to target coping with emotions (step 7). For example, clients are taught coping statements such as "It’s not the worst thing that can happen" and "My muscles are starting to feel tight. Time to relax and slow things down."
CBT technologies are often used to challenge dysfunctional schema or core beliefs (J. S. Beck, 1995; Bricker et al., 1993; Young, 1990), which have been defined as a structure for screening (step 2), coding (steps 3 and 4), and evaluating (step 5) stimuli (Padesky, 1994). Thus, schema interventions may impact multiple levels of cognitive processing. In general, given the interconnections between the processing steps, any of the interventions described previously are likely to impact multiple levels.
CBT can also be used to alter metacognitions (Dugas, Gagnon, Ladouceur, & Freeston, 1998; Wells, 1997). These are cognitions about cognitions. They include "Worrying is harmful," "My worries will take over and control me," "If I worry I can prevent bad things from happening," and "If I worry I can always be prepared" (Wells, 1997). In a sense, the worries themselves are what enters into step 1, and the metacognitions about the worries occur at steps 4 and 5.
These forms of CBT differ in important ways, but they all have one thing in common: they all primarily seek to alter the form or frequency of unhelpful thoughts and/or emotions.
The Third Wave: The Rise of Mindfulness-Based Therapies
A great deal has changed since the prebehavioral days of psychoanalysis. In 1920, we might have observed a client lying on a couch talking about a childhood experience. Today we might walk by a room and see clients chanting, eating raisins very slowly, stretching to reach a yoga position, or sitting still with their eyes closed, doing absolutely nothing. You might even hear the client say, "I’m confused," and the therapist respond, "Good, now we are getting somewhere."
Mindfulness practice, yoga, meditation, chanting, paradox, confusion—all these techniques show up in what some have termed the "third wave" of cognitive behavioral therapy (e.g., Hayes, 2004). Examples of such therapies include acceptance and commitment therapy (Hayes et al., 1999), mindfulness-based cognitive therapy for depression (Segal, Williams, & Teasdale, 2002), mindfulness-based stress management (Segal et al., 2002), and dialectic behavior therapy (Linehan, 1993).
We will focus here on ACT, which has perhaps the most developed theory and philosophy of the third-wave therapies. ACT, like CBT, has received substantial empirical support(Hayes, Masuda, Bissett, Luoma, & Guerrero, 2004). Over forty peer-reviewed articles support the tenets of relational frame theory (RFT), the language theory underlying ACT, (see, for example, Hayes, Barnes-Holmes, & Roche, 2001). An explosion of peer-reviewed publications support its efficacy in dealing with anxiety, schizophrenia, workplace stress and burnout, pain, depression, drug use, psychological adjustment to cancer, and diabetes self-management (Bach & Hayes, 2002; Bond & Bunce, 2000; Branstetter, Wislon, Hildebrandt, & Mutch, 2004; Dahl, Wilson, & Nilsson, 2004; Gifford et al., 2004; Gregg, Callaghan, Hayes, & Glenn-Lawson, in press; Guadiano & Herbert, 2006; Hayes, Luoma, Bond, Masuda, & Lillis, in press; Hayes, Masuda, et al., 2004; Hayes, Bissett, et al., 2004; Ossman & Wilson, 2006; Zettle, 2003).
ACT and RFT are fundamentally behavioral in their approach, but seek to go beyond the first wave of behavioral therapy by addressing cognitive processes utilizing behavioral techniques and concepts. They devote much less research effort than cognitive psychologists do to understanding the interactions between internal constructs, such as those between thoughts and feelings. Instead they focus on understanding how environmental manipulations can be used to influence people’s behavior. For example, they might explore how to reduce alcohol abuse by manipulating antecedents (such as reducing alcohol advertisements) or the consequences of abuse (making alcohol abuse less rewarding).
RFT is intended to address many of the criticisms leveled at behaviorist accounts of language (see, for example, Pinker, 1994). For example, RFT explains the generativity of language with operant conditioning principles rather than with innate structures or cognitive constructs. In addition, RFT analysis has been used to understand complicated cognitive processes, such as reasoning and problem solving, that were formerly seen as too complex or "internal" for behaviorists to tackle (Hayes et al., 2001). Finally, RFT is argued to have substantial scope, that is, it allows one to analyze a broad range of phenomena with a small set of analytic concepts. This argument challenges the view that behaviorism is too complex and too detailed to be efficient (see, for example, David & Szentagotai, 2006). A full discussion of these issues is beyond the scope of this book, but please see Hayes et al., 2001. Chapter 2 will present details of RFT and its applications.
Behaviorists are often surprised to hear cognitive psychologists say they are "dead." They can sometimes be heard quoting Mark Twain (after a newspaper mistakenly declared him dead): "The report of my death was an exaggeration."
ACT does different things than traditional CBT. It uses very little cognitive challenging and restructuring. It also tends not to set as its therapeutic goal the reduction of depression, anxiety, and stress. Instead, it focuses almost exclusively on the activation of value-congruent, observable behavior. Finally, it utilizes a number of techniques (for example, confusion, paradox) that are intended to discourage reasoning in many contexts. In contrast, CBT practitioners generally seek to increase effective reasoning.Toward a Unification of CBT and ACT
Despite the differences between ACT and CBT, we believe that there are many ways to use their techniques together in a philosophically and theoretically coherent fashion. The remainder of the book will help you explore this possibility. We hope the text and the worksheets (for both client and practitioner) will help you to
The main challenge of this book is to immediately offer you something useful. Many of you will have clients in the coming weeks and will want to try some new techniques. It may not be useful for you to wait until you have read the entire book, and absorbed all its philosophy and theory, before you get started. We have therefore structured the book so that we gradually introduce you to techniques and theory. You should be able to try some of these techniques in therapy without necessarily having to give up everything else that you normally do. As you continue through the book, we will delve deeper into the philosophy and theory.
Figure 1.1 illustrates the "flexibility model," psychological processes that will be focused on in the book. (Appendix A provides a detailed description of each process.) The words on the outside circle, such as "defusion," describe the processes that might be put into play in a therapy session. The words on the inside of the circle indicate the central therapeutic goal or the "outcome," so to speak. The outcome emphasizes flexibility and value congruency. All processes are used for promoting the therapeutic outcome, which is flexible, value-congruent behavior. Before we go any further, let’s define these terms.
Figure 1.1:The Flexibility Model
Value congruence.Avalueis a stated assumption about what a person wants to be doing with his or her life. Values are best stated as verbs, in that they are not something that is ever fully achieved. For example, a value might be "being a considerate husband" (see chapter 7 for more on values).Value congruenceis the extent to which the person’s behavior is consistent with the stated value.
Flexibility. The extent to which a person is able to persist with behavior or change behavior in the service of values isflexibility. To put this another way, flexibility is a person’s sensitivity to changing environmental demands.
The flexibility model contains a mixture of ACT and CBT processes. CBT practitioners will tend to be highly familiar with techniques involved in altering the form or frequency of thoughts or thinking (for example, cognitive challenging; chapter 3), promoting emotional understanding, and skills training (chapter 8). The ACT practitioner will tend to be most familiar with defusion and mindfulness (chapter 2), self as context (chapter 4), and values (chapter 7). Both ACT and CBT practitioners will be familiar with acceptance promoting techniques (chapter 6).
We will utilize the flexibility model throughout the book as a way of helping the therapist to utilize techniques in a coherent fashion. There are some key features to keep in mind about the model.
First, we need to think of the model as an indivisible entity rather than as a series of nine separate "processes." The processes and the outcome are inextricably linked and cannot be understood independently of each other. This is similar to the notion that you cannot understand the nature of water by studying hydrogen and oxygen separately. Hydrogen and oxygen when combined make something that is not reducible to its parts.
You can use the flexibility model as a guide to using techniques in a consistent fashion. For example, a mindfulness exercise might be used to support acceptance and value clarification. In addition, the mindfulness exercise would be used with the purpose of promoting flexible, value-congruent behavior. We will give numerous examples of this in the upcoming chapters.
Now consider an alternative process model presented in figure 1.2. Here the core therapeutic goal is the reduction of distress. Notice how mindfulness occurs in both the flexibility model and the distress reduction model. However, although they share the same name, the mindfulness techniques would be quite different. A practitioner following the flexibility model might have clients engage in a mindfulness practice in order to help them to contact and stay present to aversive thoughts and feelings. In contrast, a practitioner following the distress-reduction model might use a mindfulness practice in order to reduce aversive thoughts and feelings.
Figure 1.2:A Distress-Reduction ModelConclusion
Our basic premise in this book is that ACT and CBT can be unified within the flexibility model. Both CBT practitioners and ACT practitioners would agree that promoting flexible, value-congruent behavior is important in therapy. We do not assume the flexibility model is always best. Therefore, practitioners may also want to take techniques learned within the flexibility approach and utilize them in a distress-reduction model. The key here for us as practitioners is to become aware of when we shift models and change the function (or consequences) of our techniques.
This book will not only teach you new techniques, but will also allow you to look at old, familiar techniques in new ways. It will increase your independence from particular intervention packages. We hope the book takes you beyond the world of form (what a technique looks like) into the world of function (what a technique does, what process it targets). Ultimately we believe the theoretical and philosophical framework presented here will help you to create your own techniques and to become maximally efficient and flexible in helping your clients to live vital lives.