7/28/2019 CBT and ACT

1/5

7/28/2019 CBT and ACT

2/5

fo r t he fu tu re o f m a n k in d ' (Skinner 1978) .To Sk inne r , hu m an i s t i c p sy cho log y was co nc e r ne d w i t h

f ree cho ice and was bas ica l l y se l f i sh , l ead ing to excess iveaggrand ise m en t of t he ind iv idua l a t the expense o f a t ten t ionto the e nv i ronm en ta l changes tha t wi l l l ead to m ore e f fec t ivecu l tu r a l pr ac ti c es i n the f i e l ds o f ed u ca t i o n , m an ag e m en tan d the rapy, fo r exam p le. So, wh i l e t he re m ay be d i ff erenceso n t he v a r i e ti e s o f hu m an i sm t ha t a re b e i ng d es c r i b ed , i ts eem s u n r easo na b le t o d eny t he b eha v iou ri s t tr ad i t i o n o fwo rk i n g to a i d t he u nd e r s t and i ng and im p ro vem en t o f thewo r l d o f wh i c h hu m an s a re a p a rt .

I ndeed , as Grant (2002), i n h i s t ho rough c r i t ique o f h um an -i sti c an d ev id ence b ased ap proache s t o m en t a l hea l th nu rs eeduc at ion , di scusses , th e Rogerian v iew is one based on ap e r sp ec t i v e o f t he ' p e r s o n as o m n i s c i e n t , so li p s is t i c an dind iv idua l i s t i c , as oppose d to a re la t ive ly cons t ra in ed soc ia lp h e n o m e n a ' .Symptom eliminationOne a rea in wh ic h th e f i e ld o f t rad i t iona l CBT has been opento c ri ti c i sm has b een i ts emp has i s o n s y m p to m e l im i na t i o n ,o r s y m p to m r eso lu t io n as a p rim a r y g o a l . A l t e r na t i v es t os y m p t o m e l i m i n a t i o n m o de l s b a s e d o n c o n s t ru c t i on a lap p ro ache s ( a f te r G o ld i am o nd 1 9 74 ) a r e we l l e s t ab li s hedin par ts o f t he c ogn i t ive beh av ioura l f i e ld , i n w h i c h t h e a i m so f t hera py are to he lp c l i en t s deve lop more pos i tive , he ip fu !beha v iours , ra ther tha n seek ing the e l im ina t ion o f unw an tedb eha v iou rs o r s y m p tom s as a p rima r y goal . Th i s ap p ro achneces s i ta t e s t ak i ng a 'wh o l e l i f e ' v i ew o f and w i t h t he c l ien tsee k ing he lp . I ndeed contem porary beh av ioura l approach es( that do no t res t r i c t t he i r ana lys i s to over t behav iour , bu ti n c l u d e th i n k i ng as o ne f o rm o f b eh av io u r) hav e r ec en t lyb eg u n f o cu s i ng o n p r i n c i p l e s o f a c c ep t ance , m i nd fu i nes san d def us ion tha t m ay have para ll e ls wi th eas tern m ed i ta t ivean d spi r it u a l t r ad i ti o ns , g es t a l t, hu m an i sm , an d em o t i o n -focused the rapy (Hayes e t al ^ 999).Cl in ica l behaviour anaiys isTwo beha v ioura l au thors an d sc ient is t s , Dougher a nd Hayes(2000) , use the te rm c l i n i ca l beh av iour ana lys i s (CBA) tod es c r i b e t he ap p l i c a t i o n o f b ehav io u r a l p r i n c i p l e s t o t heu n d e r s t a n d i n g a n d t re a t m e n t o f pr ob le m s s e e n i n a d u ltou tpat ie n t se t t ings . They cont ras t the m a in fea tu res o f CBAwi th thos e o f m a ins t rea m psycho logy, CBA, in the i r view, ischarac ter ised by contex tua l i sm, f unc t iona l i sm, m on ism , non -m en t a l ism , no n - r ed u c t i on i sm an d an i d i og rap h i c a p p ro achto people an d the ir problem s, th a t are respect ively con trastedw i t h t h e f e a tu re s o f m a i n s t re a m p s yc h o lo gy : m e c h a n i s m ,s t ru c t ur a l is m , d ua l i s m , m e n t a l is m , r e d uc t i on i s m a n d an o m o t h e t i c a p p r o a c h t o h u m a n e x p e r i e n c e . W e w o u l dargue th a t c r i t ic i sm s o f CBT (e.g . Hur ley e f al 2006 ) m ig h t

T h e c e n t r a l t e r m s t o c o n s i d e r b e r e a re c o n t e x t u a l i s man d func t iona l i sm , as the y are the key pb ilosoph ica l d i f fer -ences f ro m t he m ech an i s t ic a nd s tr u c tu r a l ap p ro ache s t h a tp e rhap s t y p if y mo r e co m m o n l y k n o wn o r 't r ad i t i o na l ' CBTap p ro aches .ContexTuallsm\ I n a co n t ex tu a l p sy cho lo gi c a l ap p ro ac h ,

a c t s a re c o n s i d e r e d a s d i s c re t e e v e n t s e m b e d d e d i n acon tex t th a t serves to g ive the ac t m ea n in g (Pepper 1942).Tha t i s , co n t e x t gi ves m ea n i n g , Beb av io u ra l au t ho r s hav esubsequent ly desc r ibed two contex tua l approaches (Hayes1993). Desc r ip tive contex tua l i sm , wh ere th e purpose o f anana lys is i s to iden t i fy a l l t he fea tu res o f c onte x t i n o rder tha tunders tand ing m ay be reached , and func t iona l con tex tua l ismwbere the func t ions o f an ac t , o r behav iour , i n i t s contex tare ana lysed no t on ly to a id unders tan d ing bu t a l so to gu idee f fe c t i ve ac t i on .

In c l i n i ca l behav iour ana lys is , contex tua l i sm is m os t e v identthrough the exp l ic i t a t t en t ion pa id , in vary ing degrees, to tbes i tuat iona l , en v i ronm en ta l , h i s to ri ca l , i n terperson a l , soc ia l ,cu l tu ra l and re la tionsh ip fac to rs th at a re , o r have be en , in f lu-en t ia l o n t he p e r son s e ek i ng tb e r ap y In ad d i t i on t o t he se , acon tex tua l approach a l so exp li c i t ly cons iders tbe the rap is t ,h i s or he r e nv i r o nm en t a nd b i s or b e r so c i a i , cu l t u ra l , an dp e r so na l h i s t o ry as im p o r t an t fea tu res t ha t i n f lu en ce t heprocess of thera py, as thes e are al l part of tbe c on text of th eb eha v iou r o f hu ma ns t b a t is c a ll ed p sy ch o the r ap yFunctlotialism: F u n c t i o n a l i s m r e f e r s t o t h e s e a r c h f o r

r e la t i onsh ip s b e tween ev en t s , o r ho w o ne ev en t i n f iu encesan o ther . Th is approac h i s der ived from Sk inne r 's a dop t iono f Erns t Mach 's approac h to phys ics tha t exp li c i t ly re jec tedNev i r ton ian exp lanat ions o f fo rces exer ted by one body asbe in g the cause o f movem en t i n an o ther (Ch iesa 1994) . Tbeprec ise ident i f i ca t ion, descnp t ion and ana iys i s o f func t iona lr e la t i ons b e twe en ev en t s a re ac h i ev ed t h ro u g h t he p ro ces so f func t iona l ana lys is (see Stu rm ey 1996) .

The h ea r t o f tb i s is sue is tbat t he fun c t ion o f be ha v iour ism o r e imp o r t an t tha n f o rm . Tha t i s , t he ' p u rp o se ' o r co n -s eq u ences o f an aa io n o r t b o u g b t is m o r e imp o r t an t t b anwh a t a b ehav io u r lo o ks l i ke , or the co n t en t o f tb e t ho u g h t .Cl in i ca l beha v iour ana lys ts do n o t sugges t tbat t he f on n o f abeh av iour (or group of beh av iours) is not im porta nt . Rathe r,s t ruc tu ra l schem es o f sym ptom c lass i f ica t ion o r d iagnos is ,wh i l e hav i ng som e u t il it y i n re s ea r c h an d co m m u n i c a t i o n ,m iss ou t a c ruc ia l f ea tu re o f beha v iour ~ na m ely its fun a ion ,Tb a t is , i t m igh t be necessary to ident i f y spec i f ic s ym ptoms ,bu t l i tt l e is revea led a bout tbe n atu re an d purpose o f tbosesym ptom s for the ind iv idual . A padi icu lar d i ff icu lty of a t tend in gto f o rm o ve r f unc t i o n i s t ha t the s am e b eha v iou r ma y hav ed i f f e r en t f u nc t i o ns i n d i f f e r en t s e t t i ng s , and many b eb av -iours may have the same func t ion (e .g . se l f - i n ju ry , Iwata e fa /1994) . For Hayes e f a / (1996) , ma ny see m ing ly unre la te db ehav io ur s t ha t tak e m ark ed ly d i ff e r en t f o rms ( e g , b ehav -

7/28/2019 CBT and ACT

3/5

the experience of tha t person.'Functional contextual ism' combines features of these tw oapproaches so that both function and context are explicitlyconsidered. That is, when applied to individuals, questionssuch as 'What purpose does this behaviour serve for anindividual?' and 'What is the context in which it occurs?'.Contrary to the notion tha t the context of cognition is notconsidered in CBT (Hurley eta /20 06) , functional contextualapproaches explicitly focus on the context in which thinkin goccurs, with the main aim being to help alter this contextand thereby help change the functions that certain thoughts

have, rather than changing their form .Clinical applications

Acceptance and Comrr}itment Therar-4CT'; (Hayes et al 1999),In ACT, the targets for change are the 'sond-order processes', such as the contextsupports the relationship between thoughand feelings, rather than the 'first-ordprocesses' of changing thoughts or feelindirectly. Central to this approach is the wpeople develop behaviours or agendas help them eliminate andcontroi unwantaspects of experience (experiential avoance). Therapy aims to help move peopfrom these essentially unwo rkable contagendas by contrasting the consequenceliving their life now wit h the consequencon their wider experience (i.e. one cannot a full, valued and vital life and avoid anxor fluctuations in mood). This is achievby helping people move from a positiof 'not wan ting', to one of 'willingnessexperience', thereby increasing acceptanpsychological flexibility and moving towachange. It has been suggested (Hayes e2006) that ACT shares its philosophical rowit h constructivism, narrative psycholodramaturgy, social constructionism, feminpsychology. Marxist psychology and othcontextual approaches, but th at th e goof these forms of descriptive contextuism are different, seeking description aunderstanding rather than prediction ainfluence.

BehaviouralActivation (Martell ef a/200a therapy approach that is again informeda philosophy of functional contextualismwhich the functions of the responses comonly seen in depression are more impothan the f orm of those responses.Drawing explicitly from Ferster's (197radical behavioural account of depresion the im portan t aspects of a persoexperience of depression is his or hresponse to the symptoms rather thanecessarily, the symptoms themselveThese responses, such as withdrawal aavoidance, are seen as part o f a perso

attempt to manage their own symptombut actually serve to further remove thefrom any positively reinforcing events, thereby m aintainithe depressive response though negative reinforcemeFrom this point of view, the origins or causes of depressmay be many and varied - although are often associatwith life events. What is important here is that thereusually a change in the contingencies of reinforcemein the person's life so wha t was positively reinforcingno longer so (e.g, satiation, 'burno ut'), there is a reducavailability of positively reinforcing events, and/or tenvironment is high in aversive control. With regardthe maintenance of th e depressive response, the persoactive attempts to deal with his or her symptoms anegatively reinforced, and there may be some positireinforcement from others.

7/28/2019 CBT and ACT

4/5

of collecting thoughts and testing out assumptions. From abehavioural point of view behavioural activation helps peoplemanage their responses to their symptoms differently andincrease the positively reinforcing activities in the ir lives.Second, behavioural aaivation deals with cognition (orthinking) as further symptoms of depression. In dealing w iththinking processes commonly seen in depression, behavioural

activation looks at the function of thinking rather than theform. So in response to a client expressing what the cogni-tive therapist m ight call 'negative automatic thou ghts ' thetherapist involved in behavioural activation wo uld help theclient examine the effect of his or her thinking on his orher subsequent responding, rather than help him or herchallenge the content (or meaning of the content) of hisor her thoughts.Dialectical Behaviour Therapy (DBT): DBT was developed asan applied behaviour therapy for suicidal patients {Linehan1987). This therapeutic approach acknowledges tha t suicidalindividuals o ften feel overwhelmed by change strategies thatcan generate high emotional arousal. Such an emphasis onchange alone often led to disengagement from the therapyand so DBT developed a balanced therapeutic stance betweenchange and acceptance m ethods. Change strategies includeskills trainin g, problem solving, exposure techniques, andcontingency management. These are delivered in a thera-peutic environment th at promotes the acceptance of life'sinevitable pain resulting from a variety of reasons. Wha t isstressed in the delivery of DBT is that some degree of toler-ance of unpleasant experience is necessary if th e client is tochange a particular problem and that all change strategieswill inevitably lead to emotional distress. This synthesis ofdialectical polarities o f change and acceptance is what givesthe therapy its name.

Mindfulness-based cognitive therapy (MBC7). In MBCTtheemphasis is on 'changing awareness of and relationshipto th ough ts, feelings and bodily sensations' (Segal ef al2004), rather than changing the content of thoughts.Although the theoretical and philosophical basis ofMBCT differs from those discussed above, similaritieshave emerged. MBCT uses some techniques that havetraditionally been part of cognitive therapy approaches,but the use and anticipated effect of these is markedlydifferent. While cognitive therapy broadly aims to helpclients change the conten t of cog nition , MBCT uses thosetechniques that facilitate 'dec entreing', that is detachingoneself from th e meaning of thou ghts and experiencingthem as naturally occurring internal events. MBCT wasoriginally developed for use wit h clients who were at riskof relapse of depression.ConclusionCBT is not one hom ogenous fieid in which all practitionersshare a worldv iew and a very limited set of assumptions.It is in fact a diverse field in which the relative contrib u-tions of thinking, feeling, the environment, and behaviourto psychological problems are vigorously examined andkeenly debated. While it might be possible to identifymechanistic, structuralist, and dualistic assumptions inparts of the CBT literature, this is certainly not repre-sentative of the field as a who le. We have highlightedin this paper how recent developments in cognitive andbehavioural therapies are consistent w ith the alternativeand even contrasting philosophies. While the evidencebase for these approaches is still emerging , they perhapsoffer additional, and exciting, perspectives on the natureand alleviation of human suffering to those involved inthe delivery of mental health care

Jo5eph CurranRMN, ENB CC650MSc, and SimonHoughton RMN,ENB CC650, MScare both PrincipaCognitiveBehaviouralPsychotherapistsworking atSheffield NHSCare Trust

ReferencesBeck AT, Rusli AJ, Shaw BF, Emeiy G (1979)Cognitive Therapy fo r Depression. GuiifordPress, New Y ork.Beck AT, Emery G, Greenberg RT (1985)Anxiety Disorders an d Phobias: a cognitive

perspective. Harper Colons, New Yoric.Blackledge JT (2003) An introduaion toRelational Frame Theory: Basics andapplication. The Behavior Analyst Today. 3,4. 421-433.ChJesa M I\'i94) RadicalBehaviourisrrt.Authors Cooperative, Boston.Curran J, Machin C, Gournay K (2006)Cognitive behavioural therapy for anxietyand depression. Nursing Standard. 21 , 7,44-52.Dougher M, Hayes SC (2000) Clinical behavioranalysis. In. M Oougher. (Ed). ClinicalBehaviorAnalysis. Context Press, Reno,NevadaEllis A (1962) Reason an d Emotiort inPsychotherapy. Lyie Stewart, New York.Ferster CB (1973) A fu nction al analysis ofdepression. Arr)erican Psychologist. 28 ,857-870

received wisdom (or some problemswith contemporary mental health nurseeducation in Bntain). Commentary. Journalof Psychiatric and Mental Health Nursing.9. 622-626.Hayes SC (1993) Analytic goals and thevarieties of scientific contextualism. In:SC Hayes. U Hayes. HW Reese, TR Sarbin(Eds) Varieties of Scientific Contextualism.Context Press Reno, Nevada.

Hayes SC, Wilson KG. Gifford E. Follette VM .Strosahl K (1996) Experiential avoidanceand behavioral disorders: A functionaldimensional approach to diagnosis andtreatment. Journal of Consulting an dClinical Psychology 64, 6, 1152-1168.Hayes SC, Luoma JB, Bond FW. Masuda A,Litli5 J (2006) Acceptance and Comm itmentTherapy: Mode l, processes and outcomesBehaviour Research an d Therapy. 44. 1-25Hayes SC, Strohsahl KD, Wilson KG (1999)Acceptance and Commitment Therapy: Anexperiential approach to behaviour change.

Guiiford, New York.Hurley J, Barratt P. Reet P (2006) le t ahundred flowers blossom, let a hundredschools of thought contend': a case for

Richman GS (1994) Toward a func tionalanalysis of self-injury. Journal of AppliedBehaviorAnalysis. 11 . 197-209. (Reprintedfrom Analysis and Intervention inDeveloprr\ental Disabilities. 2, 3-20. 1982.)Linehan MM (1987) Dialectical behaviurtherapy: a cognitive behavioural approachto parasuidcide. Journal of PersonalityDisorders. 1,328-333.

Martell CR, Addis ME. Jacobson NS (2001)Depression in context: Strategiea forguided action. Norton, New York.Newman B (1992) The Reluaant Alliance:Behaviorism and humanism. PrometheusBooks Buffalo. New York.Pepper SC (1942) World Hypotheses: A studyin evidence. University of California Press,Berkeley.Segal ZV. Teasdale JD, Williams JUG (2004)Mindfulness-based cognitive therapy:theoretical rationale and empirical status.

In: SC Hayes, VM Follette, MM Linehan(Eds) Mindfulness and Acceptance:Expanding the Cognitive-BehavioralTradition. Guitford Press, New York.Skinner BF (19 '8) Humanism an dBehaviorism. Refleaions on Behaviorism

7/28/2019 CBT and ACT

5/5