Acceptance and mindfulness-based therapy: New wave or old hat?
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.
Section snippets
Essential features of CBT
CBT is based on the notion that behavioral and emotional responses are strongly moderated and influenced by cognitions and the perception of events. The word cognitive in CBT implies that treatment focuses to a great deal on thought processes. However, therapy is not limited to cognitive modification. Effective CBT has to target all aspects of an emotional disorder, including cognitions, emotional experience, and behavior. Accordingly, Beck (1979) distinguishes among the intellectual, the
Basic CBT approaches
Since CBT was first introduced for the treatment of depression, specific treatment strategies have been closely tailored to the various emotional disorders. Therefore, it would be overly simplistic to talk about the CBT. Instead, it is more accurate to refer to a family of interventions that share a number of key treatment components and the same general structure (for an overview, see Beck, 1979). The therapeutic process in CBT is divided into various steps, with an emphasis on a number of
Essential features of ACT
The theoretical basis of ACT is rooted in Relational Frame Theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001). RFT is derived from a philosophical view called functional contextualism (e.g., Gifford and Hayes, 1993, Pepper, 1942), which attempts to offer a way to integrate cognition and language into a behavioral analytic frame work by “adding the principles needed to account for cognition from a functional contextual or behavior analytic point of view” (Hayes, Luoma, Bond, Masuda, & Lillis, 2006
Basic ACT approach
The general goals of ACT are to foster acceptance of unwanted thoughts and feelings, and to stimulate action tendencies that contribute to an improvement in circumstances of living (Eifert and Forsyth, 2005, Hayes, 2005). More specifically, the goal of ACT is discourage experiential avoidance, which is the unwillingness to experience negatively evaluated feelings, physical sensations, and thoughts (Hayes et al., 2004, Hayes et al., 2004, Hayes et al., 2004). Individuals who show high levels of
ACT's critique of CBT
In order to provide an objective, unbiased summary of the critique of ACT against CBT, we will provide the concrete citations that include the critique. We will then provide a brief point by point discussion of these issues.
One frequently raised issue in the ACT literature is the critique that CBT is based on a mechanistic model (Hayes et al., 1999):
Some types of cognitive–behavioral therapy, for example, are based on a computer metaphor (as is much of cognitive psychology itself). Like a
The role of cognitions
As we already described in detail earlier, cognitive processes constitute the center-piece of CBT. Cognitions are synonymous for thought processes and include automatic thoughts and schemas, which are general beliefs about the world, the self, and the future. These schemata determine the general “rules” a person has adopted; they are often expressed in absolutistic shoulds, oughts, and musts. Patients are likely to experience unnecessary emotional distress when they impose rigid expectations on
General discussion
Is there a third wave? Clearly, the opinions on this issue vary. The founders of ACT consider our time to be “a time of upheaval in behavioral and cognitive therapy, particularly due to the rapid rise of acceptance and mindfulness-based interventions” (Hayes et al., 2006; p. 3). Hayes further states that “examples of third wave CBT interventions include ACT, dialectic behavior therapy (DBT; Linehan, 1993), mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2001), and
Acknowledgements
We thank Georg Eifert for his valuable comments and Steve Hayes for his fresh, provocative, and intelligent, ideas that motivated us to write this article.
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