Cognitive therapy is one of a number of cognitive-behavioral approaches that, at their core, attempt to change emotional distress and maladaptive behavior “by altering thoughts, interpretations, assumptions, and strategies of responding” (Kazdin, 1978, p. 337).
Th e variety of approaches subsumed under the rubric of cognitive behavioral therapy fall into three major categories of therapies: (a) cognitive restructuring, (b) coping skills, and
(c) problem-solving. Th e commonalities and distinctions among these approaches have been reviewed elsewhere (e.g., Dobson & Dozois, 2010) and will not be reiterated here.
Given the focus of this volume, we draw our attention to the distinctions among Beckian cognitive therapy and the acceptance- and mindfulness-based approaches.
Although cognitive therapy has acquired signifi cant research support, it is not a panacea for all mental health problems, and the empirical literature suggests that there is room for improvement, particularly when the outcome is defi ned in terms of achiev- ing “recovery” (e.g., Westen & Morrison, 2001). Our view is that the application of acceptance- and mindfulness-based strategies has the potential to improve standard cog- nitive therapy. Some empirical research is consistent with this view (e.g., Forman, Herbert, Moitra, Yeomans, & Geller, 2007), although, at present, none these newer approaches independently fulfi ll the criteria for empirically supported therapies (Öst, 2008).
As mentioned previously, acceptance strategies have been advocated within the context of cognitive therapy for anxiety (Beck et al., 1985; also see Table 2.2). Beck has also stated that the ability to separate or distance one’s distress, pain, or anger from self-construal can result in the net eff ect of minimizing suff ering (Dalai Lama & Beck, 2005). In addition to altering cognition, many of the strategies advanced by cognitive theory work to achieve distance from and perspective about one’s predicament.
Th ough mindfulness- and acceptance-based strategies have not been emphasized in cognitive therapy relative to cognitive change interventions, their general approaches are not inconsistent with the cognitive model, and the approaches are, in many re- spects, more similar than distinct (Arch & Craske, 2008; Hofmann, 2008a; Hofmann
& Asmundson, 2008). As Roemer and Orsillo (2009) pointed out, acceptance-based behavioral approaches to treatment are “part of the evolution of the CBT tradition, not something that exists outside of it” (p. 3). Congruent with this argument, we view these approaches as extensions or complementary components of cognitive therapy and not a
“third wave” per se (see Hofmann, 2008a; Hofmann & Asmundson, 2008).
In our view, the recent focus on mindfulness- and acceptance-based approaches (e.g., Hayes, Follette, & Linehan, 2004; Hayes, Strosahl, & Wilson, 1999; Roemer
& Orsillo, 2009; Segal, Williams, & Teasdale, 2002) and their addition to cognitive therapy is perhaps akin to other extensions of the model. To illustrate, Beck proposed that the early childhood environment was important in the development of core beliefs and self-schemas (e.g., Kovacs & Beck, 1978). However, Beck’s writings did not focus on these early experiences. Rather, it was Jeff rey Young and his colleagues (e.g., Young et al., 2003; Young, Rygh, Weinberger, & Beck, 2008) who later expanded the cognitive model and added a more explicit focus on the developmental origins of early maladaptive sche- mas and their modifi cation. Although such work represented an important extension of the cognitive model and contained new conceptual elements (e.g., schema compensa- tion, schema maintenance) that advanced cognitive theory, it would not be considered a new “wave” of CBT. Such is our view of acceptance and mindfulness approaches.
Some of these approaches (e.g., dialectical behavior therapy; Linehan, 1993;
mindfulness-based cognitive therapy; Segal et al., 2002; metacognitive therapy; Wells,
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2002, 2008) have been well-integrated within the cognitive model (Roemer & Orsillo, 2009). Others (e.g., acceptance and commitment therapy [ACT]) appear to diff er from mainstream cognitive therapy in their underlying philosophical assumptions (Hayes et al., 1999). For example, cognitive therapists generally adhere to the realist assumption—the idea that a “real world” exists that is independent of our perception of it and that it is possible to misinterpret or misperceive this reality (Dobson & Dozois, 2010). It is the interaction of the circumstances that a person fi nds him- or herself in coupled with idiosyncratic beliefs, assumptions, and schemas (the latter of which may distort think- ing) that infl uence the appraisal of a specifi c situation or event (D. Dobson & Dobson, 2009). As such, cognitive therapy is typically oriented toward change strategies (e.g., helping someone become more evidence-based in his or her thinking). As noted previ- ously, however, if one’s appraisal is not inconsistent with the weight of the evidence, then other strategies (e.g., problem-solving, skill-building, or acceptance) are employed.
In contrast, ACT is based on the philosophy of functional contextualism. ACT does not assume that the world is organized into discoverable parts but, rather, that it should be viewed within the context of its function. According to Hayes et al. (1999), cogni- tive therapy attempts to alter the form of private experience, whereas ACT attempts to alter the function: “Th e main way to weaken verbal relations eff ectively is to alter the content supporting the verbal processes, not by focusing on the verbal content” (p. 46).
According to Hayes et al. (1999), viewing thoughts and feelings as the “problem” is itself part of the problem.
We contend that cognitive therapy actually attempts to modify both form and func- tion, depending on the circumstances, and that a functional analysis of thought content and process is important. When thinking is colored more by the activation of core be- liefs and schemas than by the evidence, cognitive therapists aim to help patients become scientists of their thinking to soften the “hardening of the categories” (Kelly, 1963), alter the fi lter of their cognitive “spectacles” (Kant, 1781/1929) and modify self-schemas, biased information processing, dysfunctional attitudes, and negative automatic thoughts. Th ere are times when mindfulness- and acceptance-based strategies are used to facilitate such cognitive change.
Dual-system models have recently added to our understanding of cognition in psychopathology (e.g., Beevers, 2005; Farb et al., 2007; Ouimet, Gawronski & Dozois, 2009). Th ese models, which have been adapted from the social-cognitive literature, assert that information processing is governed by two processes—one that operates in a relatively automatic fashion (associative-based processing) and one that is more cere- bral and refl ective (rule-based processing). Such processes correspond to neurological structures of the limbic system (e.g., the amygdala) and the prefrontal cortex, respec- tively. Th ere are several instances in which the associative-based system is more likely to dominate processing—for example, when one’s cognitive resources are low (e.g., due to cognitive load or fatigue) or when life stress disables refl ective processing (Beevers, 2005). Cognitive therapy and mindfulness-/acceptance-based approaches may operate in a complementary manner, the former helping individuals to recognize, test, and modify
negative self-referent thoughts and the latter to view such thoughts simply as mental events that occur and, at times, simply need to be accepted (Beevers, 2005).
We advocate for the use of acceptance-based strategies when one’s refl ective process- ing is disabled, when rule-based processing is engaged successfully (i.e., the individual has examined and aligned his or her thinking with the evidence) but the situation re- mains emotionally provocative, when the situation is not amenable to problem-solving (e.g., it is outside of one’s control), and to counteract suppression and avoidance tenden- cies (Hofmann, 2008a; Hofmann & Asmundson, 2008; Williams, Teasdale, Segal, &
Kabat-Zinn, 2007). However, we also contend that through acceptance there is cogni- tive change (e.g., via a metacognitive stance; see Alford & Beck, 1997; Segal et al., 2002;
Wells, 2002) which we believe is fundamental to emotional well-being:
One of the best-researched and most eff ective emotion regulation strategies is cognitive reappraisal . . . which is the core of CBT. Acceptance strategies intended to counteract suppression (experiential avoidance) are simply another tool in the arsenal of a CBT therapist to combat emotional disorders. (Hofmann &
Asmundson, 2008, p. 13)