Acceptance and mindfulness-based therapy: New wave or old hat?

Abstract

Some contemporary theorists and clinicians champion acceptance and mindfulness-based interventions, such as Acceptance and Commitment Therapy (ACT), over cognitive–behavioral therapy (CBT) for the treatment of emotional disorders. The objective of this article is to juxtapose these two treatment approaches, synthesize, and clarify the differences between them. The two treatment modalities can be placed within a larger context of the emotion regulation literature. Accordingly, emotions can be regulated either by manipulating the evaluation of the external or internal emotion cues (antecedent-focused emotion regulation) or by manipulating the emotional responses (response-focused emotion regulation). CBT and ACT both encourage adaptive emotion regulation strategies but target different stages of the generative emotion process: CBT promotes adaptive antecedent-focused emotion regulation strategies, whereas acceptance strategies of ACT counteract maladaptive response-focused emotion regulation strategies, such as suppression. Although there are fundamental differences in the philosophical foundation, ACT techniques are fully compatible with CBT and may lead to improved interventions for some disorders. Areas of future treatment research are discussed.

Introduction

Cognitive–behavioral therapy (CBT) has become the dominant psychotherapy approach for a variety of mental disorders, ranging from anxiety and mood disorders to schizophrenia and personality disorders (see Butler, Chapman, Forman, & Beck, 2006, and Hofmann & Smits, in press, for a review). More recently, acceptance and mindfulness-based treatment approaches have been enthusiastically championed by some of its creators as the third wave treatments, succeeding behavior therapy and CBT. One of these approaches is Acceptance and Commitment Therapy, or ACT (e.g., Eifert and Forsyth, 2005, Hayes, 2004a, Hayes, 2004b, Hayes, 2005, Hayes et al., 1999).¹ The objectives of this article are to juxtapose these two treatment approaches and thereby (1) highlight some recent misconceptions about CBT espoused by champions of ACT, (2) clarify the differences between these approaches, and (3) place these differences in a larger context of contemporary emotion regulation models.

CBT is a well-established approach with clearly defined treatment steps. ACT is a new intervention with comparatively less clearly defined steps. It uses many of the same CBT techniques (such as exposure and guided questioning), but distinguishes itself from CBT by focusing on different aspects and pursuing a different treatment goal. When explaining the therapeutic strategies, ACT-oriented manuals (e.g., Eifert and Forsyth, 2005, Hayes, 2005) resort to directly comparing ACT to CBT, and focus on the presumed weaknesses of the latter approach. However, many of these presumed weaknesses of CBT are based on incorrect perceptions about the nature of CBT. We will present these issues and corrective information. For the purpose of discussing the critical difference between CBT and ACT, we will place the primary treatment principles in the larger context of contemporary emotion regulation theories. Specifically, we adopt the emotion-generative process model by Gross and colleagues (Gross, 1998, Gross, 2002, Gross and John, 2003, Gross and Levenson, 1997). Aside from differences in the philosophical foundation, the critical difference between CBT and ACT on the strategic level is that CBT techniques are primarily antecedent-emotion focused, whereas ACT and other mindfulness approaches are primarily response-focused. Thus, it is likely that CBT techniques primarily (but not exclusively) promote adaptive antecedent-focused emotion regulation strategies by focusing on reappraisal of the emotional stimuli; in contrast, ACT primarily targets maladaptive response-focused strategies by discouraging emotional suppression.