Cognitive behavior therapy

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Cognitive behavior therapy

  1. 1. COGNITIVEBEHAVIOR THERAPY
  2. 2. COGNITIVE BEHAVIOR THERAPYApplying Empirically Supported Techniques in Your Practice Second Edition Edited by William O’Donohue Jane E. Fisher John Wiley & Sons, Inc.
  3. 3. This book is printed on acid-free paper.Copyright  2008 by John Wiley & Sons, Inc. All rights reserved.Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by anymeans, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted underSection 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of thePublisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center,Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750–8400, fax (978) 676–8600, or on the web atwww.copyright.com. Requests to the Publisher for permission should be addressed to the PermissionsDepartment, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748–6011, fax (201) 748–6008.Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts inpreparing this book, they make no representations or warranties with respect to the accuracy or completeness ofthe contents of this book and specifically disclaim any implied warranties of merchantability or fitness for aparticular purpose. No warranty may be created or extended by sales representatives or written sales materials.The advice and strategies contained herein may not be suitable for your situation. You should consult with aprofessional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any othercommercial damages, including but not limited to special, incidental, consequential, or other damages.This publication is designed to provide accurate and authoritative information in regard to the subject mattercovered. It is sold with the understanding that the publisher is not engaged in rendering professional services. Iflegal, accounting, medical, psychological or any other expert assistance is required, the services of a competentprofessional person should be sought.Designations used by companies to distinguish their products are often claimed as trademarks. In all instanceswhere John Wiley & Sons, Inc. is aware of a claim, the product names appear in initial capital or all capital letters.Readers, however, should contact the appropriate companies for more complete information regardingtrademarks and registration.For general information on our other products and services please contact our Customer Care Department withinthe U.S. at (800) 762–2974, outside the United States at (317) 572–3993 or fax (317) 572–4002.Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not beavailable in electronic books. For more information about Wiley products, visit our website at www.wiley.com.Library of Congress Cataloging-in-Publication Data:Cognitive behavior therapy : applying empirically supported techniques in your practice / edited by WilliamO’Donohue, Jane E. Fisher.–2nd ed. p. ; cm.Includes bibliographical references and indexes.ISBN 978-0-470-22778-7 (cloth : alk. paper)1. Cognitive therapy. I. O’Donohue, William T. II. Fisher, Jane E. (Jane Ellen), 1957-[DNLM: 1. Cognitive Therapy–methods. 2. Mental Disorders–therapy. WM 425.5.C6 C67677 2009]RC489.C63C6277 2009616.89’1425–dc22 2008026325Printed in the United States of America.10 9 8 7 6 5 4 3 2 1
  4. 4. CONTENTS Preface xiii Acknowledgments xv Contributors xvii1 Introduction 1 William O’Donohue and Jane E. Fisher2 Psychological Acceptance 4 James D. Herbert, Evan M. Forman, and Erica L. England3 Anger (Negative Impulse) Control 17 Brad Donohue, Kendra Tracy, and Suzanne Gorney4 Assertiveness Skills and the Management of Related Factors 26 Melanie P. Duckworth5 Attribution Change 35 Rebecca S. Laird and Gerald I. Metalsky6 Behavioral Activation for Depression 40 Christopher R. Martell7 Response Chaining 46 W. Larry Williams and Eric Burkholder8 Behavioral Contracting 53 Ramona Houmanfar, Kristen A. Maglieri, Horacio R. Roman, and Todd A. Ward9 Bibliotherapy Utilizing CBT 60 Negar Nicole Jacobs v
  5. 5. vi CONTENTS10 Breathing Retraining and Diaphragmatic Breathing Techniques 68 Holly Hazlett-Stevens and Michelle G. Craske11 Classroom Management 75 Steven G. Little and Angeleque Akin-Little12 Cognitive Defusion 83 Jason B. Luoma and Steven C.Hayes13 Cognitive Restructuring of the Disputing of Irrational Beliefs 91 Albert Ellis14 Cognitive Restructuring: Behavioral Tests of Negative Cognitions 96 Keith S. Dobson and Kate E. Hamilton15 Communication/Problem-Solving Skills Training 101 Pamella H. Oliver and Gayla Margolin16 Compliance with Medical Regimens 109 Elaine M. Heiby and Maxwell R. Frank17 Contingency Management Interventions 116 Claudia Drossel, Christina G. Garrison-Diehn, and Jane E. Fisher18 Daily Behavior Report Cards: Home–School Contingency Management Procedures 123 Mary Lou Kelley and Jennette L. Palcic19 Dialectics in Cognitive and Behavior Therapy 132 Armida Rubio Fruzzetti and Alan E. Fruzzetti20 Differential Reinforcement of Low-Rate Behavior 142 Mark Alavosius, Joseph Dagen, and William D. Newsome21 Differential Reinforcement of Other Behavior and Differential Reinforcement of Alternative Behavior 147 Michele D. Wallace and Adel C. Najdowski22 Directed Masturbation: a Treatment of Female Orgasmic Disorder 158 Stephanie Both and Ellen Laan
  6. 6. CONTENTS vii23 Distress Tolerance 167 Michael P. Twohig and Katherine A. Peterson24 Emotion Regulation 174 Alan E. Fruzzetti, Wendy Crook, Karen M. Erikson, Jung Eun Lee, and John M. Worrall25 Encopresis: Biobehavioral Treatment 187 Patrick C. Friman, Jennifer Resetar, and Kim DeRuyk26 Expressive Writing 197 Jenna L.Baddeley and James W. Pennebaker27 Flooding 202 Lori A. Zoellner, Jonathan S. Abramowitz, Sally A. Moore, and David M. Slagle28 Experimental Functional Analysis of Problem Behavior 211 James E. Carr, Linda A. LeBlanc, and Jessa R. Love29 Functional Communication Training to Treat Challenging Behavior 222 V. Mark Durand and Eileen Merges30 Functional Self-Instruction Training to Promote Generalized Learning 230 Frank R. Rusch and DouglasKostewicz31 Group Interventions 236 Claudia Drossel32 Habit Reversal Training 245 Amanda Nicolson Adams, Mark A. Adams, and Raymond G. Miltenberger33 Harm Reduction 253 Arthur W. Blume and G. Alan Marlatt34 Putting It on the Street: Homework in Cognitive Behavioral Therapy 260 Patricia Robinson35 The Prolonged CS Exposure Techniques of Implosive (Flooding) Therapy 272 Donald J. Levis
  7. 7. viii CONTENTS36 Cognitive Behavioral Treatment of Insomnia 283 Wilfred R. Pigeon and Michael L. Perlis37 Interoceptive Exposure for Panic Disorder 296 John P. Forsyth, Tiffany Fus´ , and Dean T. Acheson e38 Live (In Vivo) Exposure 309 Holly Hazlett-Stevens and Michelle G. Craske39 Applications of the Matching Law 317 John C. Borrero, Michelle A. Frank, and Nicole L. Hausman40 Mindfulness Practice 327 Sona Dimidjian and Marsha M. Linehan41 Moderate Drinking Training for Problem Drinkers 337 Frederick Rotgers42 Multimodal Behavior Therapy 342 Arnold A. Lazarus43 Positive Psychology: A Behavioral Conceptualization and Application to Contemporary Behavior Therapy 347 Alyssa H. Kalata and Amy E. Naugle44 Motivational Interviewing 357 Eric R. Levensky, Brian C. Kersh, Lavina L. Cavasos, and J. Annette Brooks45 Noncontingent Reinforcement as a Treatment for Problem Behavior 367 Timothy R. Vollmer and Carrie S. W. Borrero46 Pain Management 375 Robert J. Gatchel and Richard C. Robinson47 Parent Training 383 Kevin J. Moore and Gerald R. Patterson48 Self-Efficacy Interventions: Guided Mastery Therapy 390 Walter D. Scott and Daniel Cervone
  8. 8. CONTENTS ix49 Positive Attention 396 Stephen R. Boggs and Sheila M. Eyberg50 Problem-Solving Therapy 402 Arthur M. Nezu, Christine Maguth Nezu, and Mary McMurran51 Punishment 408 David P. Wacker, Jay Harding, Wendy Berg, Linda J. Cooper-Brown, and Anjali Barretto52 Rapid Smoking 415 Elizabeth V. Gifford and Deacon Shoenberger53 Relapse Prevention 422 Kirk A. B. Newring, Tamara M. Loverich, Cathi D. Harris, and Jennifer Wheeler54 Relaxation 434 Kyle E. Ferguson and Rachel E. Sgambati55 Response Prevention 445 Martin E. Franklin, Deborah A. Ledley and Edna B. Foa56 Satiation Therapy 452 CrissaDraper57 Identifying and Modifying Maladaptive Schemas 457 Cory F. Newman58 Self-Management 466 Lynn P. Rehm and Jennifer H. Adams59 Safety Training/Violence Prevention Using the SafeCare Parent Training Model 473 Daniel J. Whitaker, Dan Crimmins, Anna Edwards, and John R. Lutzker60 Self-Monitoring as a Treatment Vehicle 478 Kathryn L. Humphreys, Brian P. Marx, and Jennifer M. Lexington61 Sensate Focus 486 Lisa Regev and Joel Schmidt
  9. 9. x CONTENTS62 Shaping 493 Kyle E. Ferguson and Kim Christiansen63 Social Skills Training 502 Chris Segrin64 Squeeze Technique for the Treatment of Premature Ejaculation 510 Claudia Avina65 Stimulus Control 516 Alan Poling and Scott T. Gaynor66 Stimulus Preference Assessment 523 Jane E. Fisher, Jeffrey A. Buchanan, and Stacey Cherup-Leslie67 Stress Inoculation Training 529 Donald Meichenbaum68 Stress Management Intervention 533 Victoria E. Mercer69 Systematic Desensitization 542 Lara S. Head and Alan M. Gross70 Think-Aloud Techniques 550 Gerald C. Davison, Jennifer L. Best, and Marat Zanov71 Time-Out, Time-In, and Task-Based Grounding 557 Patrick C. Friman72 Guidelines for Developing and Managing a Token Economy 565 Patrick M. Ghezzi, Ginger R. Wilson, Rachel S. F. Tarbox, and Kenneth R. MacAleese73 Urge Surfing 571 Andy Lloyd74 Validation Principles and Strategies 576 Kelly Koerner and Marsha M. Linehan
  10. 10. CONTENTS xi75 Values Clarification 583 Michael P. Twohig and Jesse M. Crosby Author Index 589 Subject Index 623
  11. 11. PREFACEOver the last three decades there has been a significant increase in interest in cognitive behaviortherapy. This has occurred for several reasons: 1) Mounting experimental evidence supports theeffectiveness of cognitive behavioral therapy for certain psychological problems induding highincidence problems such as depression and the anxiety disorders. The well-known Chambless report,for example, identifies many cognitive behavioral therapies as being empirically supported. In fact,cognitive behavioral techniques comprise most of the list. 2) Cognitive behavior therapy tends to berelatively brief and often can be delivered in groups. Therefore it can be more cost-effective than somealternatives and be seen to offer good value. These qualities have become particularly important inthe era of managed care with its emphasis upon cost containment. 3) Cognitive behavior therapy hasbeen applied with varying success to a wide variety of problems (see Fisher and O’Donohue, 2006for over 70 behavioral health problems in which CBT can be considered an evidence based treatment.Thus, it has considerable scope and utility for the practitioner in general practice or the professionalinvolved in the training of therapists. 4) Cognitive behavior therapy is a relatively straight forwardand clearly operationalized approach to psychotherapy. This does not mean that case formulationor implementing these techniques is easy. However, CBT is more learnable that techniques such aspsychoanalysis or Gestalt therapy. 5) Cognitive behavioral therapy is a therapy system comprised ofmany individual techniques, with researchers and practitioners constantly adding to this inventory.A given behavior therapist, because of his or her specialty, may know or use only a small subset ofthese. A clinician or clinical researcher may want to creatively combine individual techniques to treatsome intransigent problem or an unfamiliar or complicated clinical presentation. This volume attempts to bring together all of the specific techniques of cognitive behavior therapy.It does this in an ecumenical fashion. Historically, and currently, there are divisions inside behaviortherapy that this book attempts to ignore. For example, cognitive and more traditionally behavioraltechniques are included. This offended some prospective authors who were clearly warriors in thecognitive-behavioral battle. We wanted to be inclusive, particularly because pragmatically the outcomeresearch favors both sides of this particular battle. Our major interest in compiling this book was twofold: First we noted the lack of a volumethat provides detailed descriptions of the techniques of cognitive behavioral therapy. Many booksmentioned these but few described the techniques in detail. The absence of a comprehensive collectionof the methods of cognitive-behavior therapy creates a gap in the training of students and in thefaithful practice of cognitive behavior therapy. Second, with the increased interest in cognitive behaviortherapy, particularly by the payers in managed care, there has been an increasing bastardization ofbehavior therapy. Some therapists are claiming they are administering some technique (e.g., relapseprevention or contingency management) when they clearly are not. This phenomenon, in ourexperience, rarely involves intentional deception but instead reflects an ignorance of the complexitiesof faith-fully implementing these techniques. This book is aimed at reducing this problem. There is an important question regarding the extent to which a clinician can faithfully implementthese techniques without a deeper understanding of behavior therapy. The evidence is not clear and ofcourse the question is actually more complicated. Perhaps a generically skilled therapist with certainkinds of clients and certain kinds of techniques can implement the techniques well. On the otherhand, a less skilled therapist dealing with a complicated clinical presentation utilizing a more subtletechnique might not do so well. There is certainly a Gordon Paul type ultimate question lurking here.Something like: ‘‘What kind of therapist, with what type of problem, using what kind of cognitive xiii
  12. 12. xiv PREFACEbehavior therapy technique, with what kind of training, can have what kinds of effects. . .’’ Withthe risk of being seen as self-promoting, the reader can learn about the learning and conditioningunderpinnings of many of thes techniques in O’Donohue (1998); and more of the theories associatedwith these techniques in O’Donohue and Krasner (1995). Fisher and O’Donohue (2006) provide adescription of particular problems that these techniques can be used with.ReferencesFisher, J.E.,& O’Donohue, W.T. (2006) Practitioner’s guide to evidence based psychotherapy. New York: Springer.O’Donohue, W., & Krasner, L. (Eds.). (1995). Theories of behavior therapy. Washington: APA Books.O’Donohue, W. (Ed.). (1998). Learning and behavior therapy. Boston: Allyn & Bacon.
  13. 13. ACKNOWLEDGMENTSWe wish to thank all the chapter authors. They uniformly wrote excellent chapters and completedthese quickly. We’d also like to thank our editor at John Wiley & Sons, Patricia Rossi. She shared our vision forthis book, gave us some excellent suggestions for improvement, and has been wonderful to workwith. We’d also like to thank Linda Goddard for all her secretarial skills and expert assistance in allaspects of the manuscript preparation; she was invaluable. Finally, we’d like to thank our families for their support, and especially our children, Katie andAnnie, for their enthusiasm and delightfulness. xv
  14. 14. CONTRIBUTORSJonathan S. Abramowitz Jennifer L. Best, Ph.D.University of North Carolina University of North CarolinaChapel Hill, NC Charlotte, NC Arthur W. Blume, Ph.D.Dean T. Acheson University of North CarolinaUniversity at Albany, SUNY Charlotte, NCAlbany, NY Stephen R. Boggs, Ph.D. University of FloridaJennifer H. Adams Gainesville, FLUniversity of Colorado at DenverDenver, CO John C. Borrero, Ph.D. University of MarylandMark A. Adams, Ph.D., B.C.B.A Baltimore, MDBest Consulting, Inc.Fresno, CA Carrie S.W. Borrero, Ph.D.K. Angeleque Akin-Little Kennedy-Krieger InstituteMassey University Baltimore, MDAuckland, New Zealand Stephanie Both, Ph. D.Mark Alavosius, Ph.D. Leiden University Medical CenterUniversity of Nevada, Reno Leiden, NetherlandsReno, NV J. Annette Brooks, Ph. D.Claudia Avina, Ph.D. New Mexico VA Healthcare SystemUniversity of Nevada, Reno Albuquerque, NMReno, NV Jeffery A. BuchananJenna L. Baddeley, M.A. Minnesota State UniversityThe University of Texas at Austin Mankato, MNAustin, TX Eric BurkholderAnjali Barretto, Ph.D. Dublin Unified School DistrictGonzaga University Department of Special EducationSpokane, WA Dublin, CAWendy K. Berg, M.A. James E. Carr, Ph.D.University of Iowa Western Michigan UniversityIowa City, IA Kalamazoo, MI xvii
  15. 15. xviii CONTRIBUTORSLavina L. Cavasos Sona Dimidjian, Ph.D.New Mexico VA Healthcare System University of ColoradoAlbuquerque, NM Boulder, CODaniel Cervone, Ph.D. Keith S. Dobson, Ph.D.University of Illinois at Chicago University of CalgaryChicago, IL Calgary, CanadaStacey M. Cherup Brad Donohue, Ph.D.University of Nevada, Reno University of Nevada, Las VegasReno, NV Las Vegas, NVKim Christiansen Crissa DraperCarson City, NV University of Nevada, Reno Reno, NVLinda J. Cooper-Brown, Ph.D.University of Iowa Children’s Hospital Claudia Drossel, Ph.D.Iowa City, IA University of Nevada, Reno Reno, NVMichelle G. Craske, Ph.D.UCLA Melanie P. Duckworth, Ph.D.Los Angeles, CA University of Nevada, Reno Reno, NVDan Crimmins, Ph.D.The Marcus Institute V. Mark DurandAtlanta, GA University of South Florida St. Petersburg, FLWendy CrookUniversity of Nevada, Reno Anna Edwards, Ph.D.Reno, NV The Marcus Institute Atlanta, GAJesse M. CrosbyUtah State University Albert Ellis, Ph.D.Logan, UT DeceasedJoseph Dagen Erica L. EnglandUniversity of Nevada, Reno Drexel UniversityReno, NV Philadelphia, PAGerald C. Davison, Ph.D. Sheila M. Eyberg, Ph.D.UCLA University of FloridaLos Angeles, CA Gainesville, FLKim DeRuyk, Ph.D. Kyle E. Ferguson, M.A.Boys’ Town Riverview HospitalBoys’ Town, NE Coquitlam, BC, Canada
  16. 16. CONTRIBUTORS xixJane E. Fisher, Ph.D. Robert J. Gatchel, Ph.D.University of Nevada, Reno University of Texas at ArlingtonReno, NV Arlington, TXEdna B. Foa, Ph.D. Scott Gaynor, Ph.D.University of Pennsylvania Western Michigan UniversityPhiladelphia, PA Kalamazoo, MIEvan M. Forman Patrick M. Ghezzi, Ph.D.Drexel University University of Nevada, RenoPhiladelphia, PA Reno, NVJohn P. Forsyth, Ph.D. Elizabeth V. Gifford, Ph.D.University at Albany (SUNY) University of Nevada, RenoAlbany, NY Reno, NVMaxwell R. Frank Alan M. GrossUniversity of Hawaii at Manoa University of MississippiHonolulu, HI University, MIMichelle A. Frank Kate E. HamiltonKennedy-Krieger Institute Peter Lougheed CentreBaltimore, MD Calgary, CanadaMartin E. Franklin, Ph.D. Jay Harding, Ed.S.University of Pennsylvania University of IowaPhiladelphia, PA Iowa City, IAPatrick C. Friman, Ph.D. Cathi D. Harris, M.A.Father Flanagan’s Boys’ Home Washington Special Commitment CenterBoys’ Town, NE Steilacoom, WAArmida R. Fruzzetti Nicole L. HausmanUniversity of Nevada, Reno Kennedy-Krieger InstituteReno, NV Baltimore, MDAlan E. Fruzzetti, Ph.D. Steven C. HayesUniversity of Nevada, Reno University of Nevada, RenoReno, NV Reno, NVTiffany Fuse, Ph.D. Holly Hazlett-StevensNational Center for PTSD University of Nevada, RenoJamaica Plain, MA Reno, NVChristina G. Garrison-Diehn Lara S. Head, Ph.D.University of Nevada, Reno University of WisconsinReno, NV Madison, WI
  17. 17. xx CONTRIBUTORSElaine M. Heiby Linda A. LeBlanc, Ph.D.University of Hawaii at Manoa Western Michigan UniversityHonolulu, HI Kalamazoo, MIJames D. Herbert, Ph.D. Deborah A. Ledley, Ph.D.Drexel University University of PennsylvaniaPhiladelphia, PA Penn Valley, PARamona Houmanfar, Ph.D. Jung Eun LeeUniversity of Nevada, Reno University of Nevada, RenoReno, NV Reno, NV Eric R. Levensky, Ph.D.Kathryn L. Humphreys, Ph.D. New Mexico VA Healthcare SystemNational Center for PTSD, Albuquerque, NM VA Boston Healthcare SystemBoston, MA Donald J. Levis, Ph.D. Binghamton UniversityNicole N. Jacobs, Ph.D. Binghamton, NYUniversity of Nebraska Jennifer M. Lexington, Ph.D.Alyssa H. Kalata, M.A. University of Massachusetts AmherstWestern Michigan University Amherst, MAKalamazoo, MI Marsha M. Linehan, Ph.D.Mary Lou Kelley, Ph.D. University of WashingtonLouisiana State University Seattle, WABaton Rouge, LA Steven G. Little, Ph.D.Brian C. Kersh, Ph.D. Massey UniversityNew Mexico VA Healthcare System Auckland, New ZealandAlbuquerque, NM Andy Lloyd, Ph.D.Kelly Koerner U.S. ArmyEBP Jessa R. LoveSeattle, WA Western Michigan University Kalamazoo, MIDouglas Kostewicz, Ph.D.University of Pittsburgh Tamara M. Loverich, Ph.D.Pittsburgh, PA Eastern Michigan UniversityEllen Laan, Ph.D. Jason B. Luoma, Ph.D.University of Amsterdam Portland Psychotherapy ClinicAmsterdam, Netherlands Portland, ORArnold A. Lazarus, Ph.D. John R. Lutzker, Ph.D.Rutgers, The State University of New Jersey The Marcus InstitutePiscataway, NJ Atlanta, GA
  18. 18. CONTRIBUTORS xxiKenneth R. MacAleese, M.A., B.C.B.A. Raymond G. Miltenberger, Ph.D., B.C.B.A.Reno, NV University of South Florida Tampa, FLKristen A. Maglieri, Ph.D.Trinity College Sally A. MooreDublin, Ireland University of Washington Seattle, WAChristine Maguth Nezu, Ph.D.Drexel University Kevin J. MoorePhiladelphia, PA Oregon Social Learning Center, Community ProgramsGayla Margolin, Ph.D. Eugene, ORUCLALos Angeles, CA Karen Murphy University of Nevada, RenoG. Alan Marlatt, Ph.D. Reno, NVUniversity of WashingtonSeattle, WA Adel C. Najdowski Center for Autism and RelatedChristopher Martell Disorders, Inc.Private Practice Tarzana, CASeattle, WA Amy E. Naugle, Ph.D. Western Michigan UniversityBrian P. Marx, Ph.D. Kalamazoo, MINational Center for PTSD, VA Boston Healthcare System Cory F. Newman, Ph.D.Boston, MA University of Pennsylvania Philadelphia, PAMary McMurranUniversity of Nottingham Kirk A.B. Newring, Ph.D.Nottingham, United Kingdom Nebraska Dept. of Correctional ServicesDonald Meichenbaum, Ph.D. William D. NewsomeUniversity of Waterloo University of Nevada, RenoWaterloo, Ontario, Canada Reno, NVVictoria E. Mercer Arthur M. Nezu, Ph.D.University of Nevada, Reno Drexel UniversityReno, NV Philadelphia, PAEileen Merges Amanda Nicholson-Adams, Ph.D., B.C.B.A.St. John Fisher College California State University at FresnoRochester, NY Fresno, CAGerald I. Metalsky, Ph.D. William T. O’Donohue, Ph.D.Lawrence University University of Nevada, RenoAppleton, WI Reno, NV
  19. 19. xxii CONTRIBUTORSPamella H. Oliver, Ph.D. Richard C. Robertson, Ph.D.California State University, Fullerton Baylor University Medical CenterFullerton, CA Dallas, TXJennette L. Palcic Frederick Rotgers, Psy.D., ABPPLouisiana State University Philadelphia College of OsteopathicBaton Rouge, LA Medicine Philadelphia, PAGerald R. Patterson, Ph.D.Oregon Social Learning Center Frank R. Rush, Ph.D.Eugene, OR Pennsylvania State University University Park, PAJames W. PennebakerThe University of Texas at Austin Joel Schmidt, Ph.D.Austin, TX VA Northern California Healthcare System Oakland, CAMichael L. Perlis, Ph.D. Walter D. Scott, Ph.D.University of Rochester University of WyomingRochester, NY Laramie, WYKatherine A. Peterson Christine SegrinUtah State University University of ArizonaLogan, UT Tucson, AZWilfred R. Pigeon, Ph.D. Rachel E. SgambatiUniversity of Rochester Medical Center Carson City, NVRochester, NY Deacon ShoenbergerAlan Poling, Ph.D. University of Nevada, RenoWestern Michigan University Reno, NVKalamazoo, MI David M. SlagleLisa Regev, Ph.D. University of WashingtonUniversity of Nevada, Reno Seattle, WAReno, NV Rachel S.F. TarboxLynn P. Rehm, Ph.D. The Chicago School of ProfessionalUniversity of Houston Psychology at Los AngelesHouston, TX Los Angeles, CAJennifer Resetar, Ph.D. Kendra TracyBoys’ Town University of Nevada, Las VegasBoys’ Town, NE Las Vegas, NVPatricia Robinson, Ph.D. Michael P. Twohig, Ph.D.Mountainview Consulting Group, Inc. Utah State UniversityZillah, WA Logan, UT
  20. 20. CONTRIBUTORS xxiiiTimothy R. Vollmer, Ph.D. Larry W. Williams, Ph.D.University of Florida University of Nevada, RenoGainesville, FL Reno, NVDavid P. Wacker, Ph.D. Ginger R. Wilson, Ph.D.University of Iowa Children’s Hospital The ABRITE OrganizationIowa City, IA Santa Cruz, CAMichelle D. Wallace, Ph.D. J. M. WorrallCalifornia State University, Los Angeles University of Nevada, RenoLos Angeles, CA Reno, NVTodd A. Ward Marat ZanovUniversity of Wellington University of Southern CaliforniaWellington, New Zealand Los Angeles, CAJennifer Wheeler, Ph.D. Lori A. Zoellner, Ph.D.Private Practice University of WashingtonSeattle, WA Seattle, WADaniel J. Whitaker, Ph.D.The Marcus InstituteAtlanta, GA
  21. 21. COGNITIVEBEHAVIOR THERAPY
  22. 22. 1 INTRODUCTION William O’Donohue and Jane E. FisherCognitive behavior therapy (CBT) is an approach recent decades there has been an unfortunateto human problems that can be viewed from sev- trend away from a philosophical understandingeral interrelated perspectives: philosophical, the- of behavior therapy to a more technique-orientedoretical, methodological, assessment oriented, understanding.and technological. This book focuses on the last The second aspect of behavior therapy is itsaspect, so crucial to clinical practice, but sit- theoretical structure. Here the issues are lessuated in the other four, much as any one of philosophical—less about general epistemica cube’s six sides is situated among all of the issues—and more about substantive assertionsothers. regarding more specific problems as well as Philosophically, CBT can be viewed as being the principles appealed to in making theseassociated (or, according to some who put it more assertions. What is panic? What are its causes?strongly, derived) with one or another variety What is the role of operant conditioning inof behaviorism (O’Donohue & Kitchener, 1999). children’s oppositional behavior? How does oneThe behaviorisms are generally philosophies of prevent relapse? Should cognitions be modifiedscience and philosophies of mind—that is, ways or accepted?of defining and approaching the understand- There are also a wide variety of theoriesing of the problems traditionally associated with associated with behavior therapy (O’Donohuepsychology. & Krasner, 1995), including: There are at least two broad issues at thephilosophical level: (1) What particular form of • Reciprocal inhibitionbehaviorism is being embraced (O’Donohue & • Response deprivationKitchener, 1999, have identified at least 14), and • Molar regulatory theory(2) what is the nature of the relationship or associ- • Two-factor fear theoryation between this philosophy and the practice of • Implosion theoryCBT? Some have argued that behaviorism is irrel- • Learned alarmsevant to behavior therapy—that one can practice • Bioinformational theorybehavior therapy and either reject behaviorism • Self-control theoryor be agnostic with regard to all forms of it. • Developmental theoriesWhile an individual practitioner can behave in • Coercion theorythis way, some of the deeper structure that can • Self-efficacy theorybe generative and guiding is lost. One can drive • Attribution theorya car without an understanding of its workings, • Information processing theorybut one probably can’t design a better car or • Relational frame theorymodify an existing car without such an under- • Relapse preventionstanding. Similarly, a knowledge of behaviorism • Evolutionary theoryallows greater understanding of the choice points • Marxist theoryimplicit in any technology. For example, why not • Feminist theoryview the client’s problem as a neurological dif- • Dialectical theoryficulty and intervene at this level? Behaviorism • Acceptance theoryoften provides possible answers to this kind of • Functional analytic theorygeneral challenge. However, we suggest that in • Interbehavioral theory 1
  23. 23. 2 COGNITIVE BEHAVIOR THERAPY Theories can provide answers or at least & Jarrett, 1987). Some of the chapters in thistestable hypotheses for questions regarding more volume deal with assessment techniques eitherspecific problems, such as these: What is the basic because they are central to therapy or becausenature of this kind of clinical problem? How assessment methods themselves are so reactivedoes this problem develop? What maintains this that they may be seen, in part, as treatment.problem? What are its associated features and However, in the main, this book does not focuswhy? How is this problem possibly modified? on the measurement aspect, leaving that task toWhat makes this technique work? What are con- other fine anthologies (e.g., Haynes & Heiby , intraindications? What are boundary conditions? press). The third aspect of CBT is its program for The final aspect of CBT is techne—skilledknowledge generation. In the main, CBT is exper- practice. No amount of philosophy or theoryimental and relies on a mixture of group experi- will relieve clinicians from this level of analy-mental designs (e.g., the randomized controlled sis. A surgeon may be a biological deterministtrial) and single-subject experimental designs philosophically and may hold to certain the-(although in the largest perspective it can be ories of cancer and cancer treatment, but toseen to include correlational designs and even help patients the surgeon still needs to imple-case studies). Methodologically, CBT generally ment surgical technique in a skilled manner.embraces constructs such as social validity, clin- Similarly, cognitive behavior therapists need toical significance, follow-up measurements, man- be skilled in the execution of their techniques.ualized treatment, adherence and competence In fact, an interesting set of research questionschecks, the measurement of process variables, involves the relationship between the degree ofindependent replications, and real-world effec- skill (e.g., poor, novice, experienced, master) andtiveness research. This toolbox is complex, but therapy outcome. This may also be a functionone can discern a few distinct styles—such as of specific technique (e.g., progressive musclethat of the applied behavior analyst and that relaxation may have different relationship withof the cognitive therapist (O’Donohue & Houts, skill level than emotional regulation training).1985). Other styles can be seen when the nature For example, if a clinician arranges potentialof the question differs—for example, when the positive reinforcers that are too distal in contin-interest is in measurement development and gency manager it will be less effective. Similarly,validation or in the questions typically associ- if a clinician conducts systematic desensitiza-ated with experimental psychopathology. CBT tion with only a few steps in a fear hierarchy,is solidly in the stream of ‘‘clinical science’’ with weakly trained progressive muscle relax-and as part of this general approach views an ation skills, and pairings that are few and of veryexperimental approach as key (see Lilienfeld short duration, it is unlikely to be as effective asand O’Donohue, 2007, for a fuller exposition it could otherwise be.of clinical science). We’ve identified approximately 80 distinct The fourth aspect of CBT is its approach to techniques in CBT, covering both standardmeasurement. Here, a key issue is how to accu- behavior therapy and cognitive therapyrately detect and quantify variables of interest. techniques, and relatively recently developedCognitive behavior therapy is associated with procedures such as acceptance strategies andboth a distinctive delineation of the domain of mindfulness. This number has to qualify CBT asinterest and distinct methods for measuring this. one of the most variegated therapy systems. ThisIn general, behavioral assessment can be dis- diversity no doubt derives from an interplay oftinguished from more traditional measurement complex factors:approaches by its focus on sampling of behaviorrather than looking for signs of more abstract • The multiple learning theories upon whichconstructs. There are diverse streams of thought traditional behavior therapy is basedwithin the CBT tradition, however, from the (O’Donohue, 1998).embrace of traditional psychometric standards • The multielemental nature of each of theseto the radically functional (e.g., Hayes, Nelson, theories (e.g., setting events, discrimination
  24. 24. 1 • INTRODUCTION 3 training, schedules of reinforcement, general- (i.e., what process or pathway it may be asso- ization processes, fading, etc.). ciated with), and some of the evidence for its• The influence of other elements of experimen- effectiveness. The major section of the chapter is tal psychology such as experimental cognitive a step-by-step guide that explains exactly how science. to implement the technique. Finally, we asked• The influence of other branches of psychology authors to include a brief table outlining the such as social psychology. major elements of the technique.• The influences of other intellectual domains The very number and diversity of CBT tech- (dialectics) or other fields of inquiry (mind- niques place a significant burden on any practi- fulness). tioner of CBT and, even more so, on the student.• The interface of these with a particular kind of It is our hope that this volume, by clearly and clinical problem (e.g., borderline personality concisely describing these techniques, will ease disorder). this burden. We also hope that precision about• The creativity and ambitions of the devel- techniques can help the field continue to keep opers. its eye on Gordon Paul’s (1969) classic ques- tion: What techniques, delivered by what type But whatever the source of this tremendous of therapist, for what kind of client, with whatvariety, the presence of such a large number kind of clinical problem, in what kind of setting,of major distinctive techniques leaves no doubt produces what kind of result, by what kind ofas to the multifactorial nature of contemporary process?CBT. It leaves an interesting question regardinghow broad competence ought to be across these Referencestechniques in order for one to be considered awell-trained cognitive behavior therapist. One Haynes, S., & Heiby, E. (in press). The encyclopedia ofof the key variables emerging in the medical behavioral assessment. Hayes, S. C., Nelson, R. O., & Jarrett, R. (1987). Treat-literature regarding quality is number of times ment utility of assessment: A functional approachthe physician has implemented the particular to evaluating the quality of assessment. Americantechnique. One generally finds that hundreds Psychologist, 42, 963–974.or thousands of times produces outcomes better Lilienfeld, S., & O’Donohue, W. (Eds.). (2007). The greatthan those in the dozens. Thus, there can be a ideas of clinical science. New York: Routledge.bandwith/fidelity trade-off in behavior therapy O’Donohue, W. (Ed.). (1998). Learning and behavior ther-that can have interesting associations with qual- apy. Boston: Allyn and Bacon. O’Donohue, W., & Houts, A. C. (1985). The two dis-ity. Those that know more techniques may be ciplines of behavior therapy. Psychological Record,less skilled at implementing any particular one. 35(2), 155–163. We’ve asked each of the chapter authors to fol- O’Donohue, W., & Kitchener, R. (1999). Handbook oflow a standard format, because we thought these behaviorism. San Diego: Academic Press.main topics would delineate a bit of the context O’Donohue, W., & Kramer, L. (Eds.). (1995). Theories ofand all of the essential features needed to com- behavior therapy. Washington, DC: APA Books.petently execute these techniques. We wanted Paul, G. L. (1969). Behavior modification research: Design and tactics. In C. M. Franks (Ed.),them to describe who might benefit from this Behavior therapy: Appraisal and status (pp. 29–62).technique, contraindications, other factors rele- New York: McGraw-Hill.vant to making the decision to use or not to usethe technique, how the technique might work
  25. 25. 2 PSYCHOLOGICAL ACCEPTANCE James D. Herbert, Evan M. Forman, and Erica L. EnglandIn one form or another, all psychotherapies conceived to include distressing thoughts andseek to produce change. Individuals seek con- feelings in addition to overt behavior. Althoughsultation from psychotherapists when they are one might need to accept temporary, short-termexperiencing emotional pain, struggling with life distress associated with certain interventions,problems, or when they are not functioning well the overall focus was on changing the form orin school, work, or relationships. The explicit goal frequency of distressing behaviors rather thanis to achieve changes that will reduce pain or suf- accepting them. This approach was dramaticallyfering, resolve outstanding problems, or enhance successful. Effective technologies were devel-functioning. There has also been a longstand- oped to increase social skills, desensitize fears,ing recognition that such change requires some and manage disruptive behavior among chil-sense of self-acceptance, understood as the ability dren, as well as to address many other problemsto respond less self-critically and judgmentally, (Bongar & Beutler, 1995; Goldfried & Davison,thereby establishing the context for more effec- 1994). As behavior therapy matured throughtive functioning. Prior to the advent of behavior the last decades of the twentieth century, theretherapy, psychotherapists traditionally focused evolved an increased focus on changing thoughtsless on changing distressing symptoms them- and beliefs, and the field itself came to be knownselves, concentrating instead on modifying other by the term cognitive behavior therapy (CBT). Theprocesses on the assumption that changes in various clinical strategies and techniques fallingsuch processes would result in more fundamen- under the rubric of CBT all shared a focus ontal, profound, and permanent improvements in directly targeting problems using instrumentaldistress (Sulloway, 1983). Psychoanalysts sought change strategies. Although acceptance of one’sto increase insight into the developmental ori- distressing experiences was indirectly targetedgins of unconscious conflicts. By rendering the in some cases (e.g., acceptance of anxious sen-unconscious conscious, unacceptable drives and sations during exposure-based therapies), evenfantasies become acceptable to the ego. Humanis- then the ultimate goal was change (e.g., anxietytic therapists likewise sought to increase congru- reduction), and the overall focus of clinical inter-ence between different facets of the self, thereby ventions remained squarely on direct change.promoting a sense of self-acceptance. Althoughthe ultimate goal was change, the prevailingclinical wisdom was that targeting distressing THE GROWTH OF PSYCHOLOGICALthoughts, feelings, or behavior directly would be ACCEPTANCE IN CBTineffective at best, and possibly even counter-productive. It is perhaps ironic, then, that the field of CBT Early behavior therapists rejected the idea that currently finds itself at the forefront of a move-change required interventions focusing on pro- ment that questions the utility of such directcesses not directly related to actual presenting change strategies under certain circumstancesproblems. Instead, they directly targeted their and promotes instead the rather paradoxicalpatients’ difficulties. Behavior therapists focused idea that more pervasive and enduring improve-on modifying environmental factors thought to ments in suffering and quality of life maybe responsible for problematic behavior, broadly result from accepting, rather than attempting to 4
  26. 26. 2 • PSYCHOLOGICAL ACCEPTANCE 5 40 35 30 25 20 15 10 5 0 2000 2001 2002 2003 2004 2005 2006 2007 Publication YearFIGURE 2.1 PsychInfo Citations for Keywords ‘‘Experiential Acceptance,’’ ‘‘Psychological Acceptance,’’ or‘‘Experiential Avoidance.’’change, one’s distressing subjective experience. The recent growth of interest in these ap-This distinction between direct change efforts proaches is undeniable. For example, as illus-and psychological acceptance as a vehicle for trated in Figure 2.1, the PsychInfo databasechange has been described in various ways, reveals a steady growth in the hits of theincluding first-order versus second-order keywords experiential acceptance, its synonymchange, change in content versus context, and psychological acceptance, and experiential avoidancechange in form versus function (Hayes, 2001). (which is an antonym for the first two) from 2Regardless of terminology, a number of CBT in 2000 to 35 in 2007. Parallel increases can bemodels have emerged over the past decade that found in related databases (e.g., Medline), andhighlight efforts to accept, rather than directly in the titles of conference proceedings (e.g., the annual meeting of the Association for Behavioralchange, distressing experiences, including and Cognitive Therapies).thoughts, beliefs, feelings, memories, and sen- This increased emphasis on psychologicalsations. These approaches have not abandoned acceptance is the result of several factors (Hayes,all direct change strategies. Rather, as described 2004; Longmore & Worrell, 2007). First, anlater, they suggest that changes in some areas accumulating body of experimental researchare best facilitated by acceptance in others. It demonstrates that efforts to suppress thoughtsis worth noting that there is no hard-and-fast generally result in rebound effects in which thedistinction between traditional change-oriented frequency and intensity of thoughts increaseand acceptance-oriented models of CBT (Orsillo, upon termination of active suppression effortsRoemer, Lerner, & Tull, 2004). A key ultimate (Abramowitz, Tolin, & Street, 2001; Wenzlaffgoal of both approaches is behavior change & Wegner, 2000). Such findings suggest that(broadly writ), and both draw on technologies CBT interventions such as thought stopping,that either implicitly or explicitly seek to increase in which distressing thoughts are deliberatelypsychological acceptance. Rather, the models suppressed, might be seriously misguided.differ in the relative degree of emphasis on In fact, most CBT scholars now disavow thisacceptance versus change processes. technique (Marks, 1987). Thought suppression
  27. 27. 6 COGNITIVE BEHAVIOR THERAPYstudies (in which individuals who deliberately ago (see Dobson, 1989, for a review of thesesuppress thoughts demonstrate increased older studies). Finally, preliminary componentrebound of these thoughts relative to those control studies, in which direct cognitivewho do not engage in suppression strategies) change interventions were extracted fromhave been cited as evidence to suspect the larger CBT protocols, have generally failed toadvisability of cognitive restructuring, one support the incremental effects of such cognitiveof the most commonly used CBT techniques interventions (e.g., Dimidjian et al., 2006; Hope,(Hayes, in press). The concern is that attempting Heimberg, & Bruch, 1995; Jacobson et al., 1996).to restructure distressing thoughts may lead These observations led several psychotherapypatients to suppress them, resulting in inten- innovators to develop approaches that highlightsification and elaboration. However, it is not acceptance of distressing experiences. Suchclear that cognitive restructuring is analogous to innovations include comprehensive psycho-thought suppression (Arch & Craske, in press; therapy models such as acceptance andHofmann & Admundson, 2008). Second, some commitment therapy (ACT; Hayes, Strosahl,cognitive therapists have recently challenged & Wilson, 1999), dialectical behavior therapyon theoretical grounds the idea that directly (DBT; Linehan, 1993a), mindfulness-based stresstargeting thoughts can produce cognitive reduction (MBSR; 1990) and functional analyticor affective changes (Teasdale, 1997). Third, psychotherapy (FAP; Kohlenberg & Tsai, 1991),experimental psychopathology studies have as well as models focused on a particular clinicalfound that instructions to accept experimentally domain, such as integrative couples therapyinduced distress resulted in better outcomes (ICT; Jacobson et al., 2000), mindfulnesss-basedthan instructions to control such distress. cognitive therapy (MBCT; Coelho, Canter, &For example, acceptance-oriented instructions, Ernst, 2007; Segal, Williams, & Teasdale, 2002)relative to distraction or control-oriented instruc- for recurrent depression, and the work of leadingtions, have been shown to result in greater pain CBT theorists such as Borkovec (1994), Wellstolerance in cold pressor tasks (Hayes et al., (2000), Marlatt and colleagues (2004), and others.1999), in lower behavioral avoidance and fearresponse following exposure to CO2 enriched airamong high anxiety–sensitivity women (Eifert CONCEPTUALIZATIONS OF ACCEPTANCE& Heffner, 2003) and panic disorder patients(Levitt, Brown, Orsillo, & Barlow, 2004), and in No consensus definition of psychologicalreducing chocolate cravings in food-responsive acceptance has yet emerged, although existingindividuals (Forman, Hoffman, et al., 2007). definitions share several common themes. ButlerFourth, psychotherapy process studies often and Ciarrochi (2007) define acceptance as ‘‘ahave failed to support the theorized mechanism willingness to experience psychological eventsof cognitive mediation, raising questions about (thoughts, feelings, memories) without havingthe centrality of cognitive change as a prereq- to avoid them or let them unduly influenceuisite for changes in other areas (Longmore & behavior’’ (p. 608). These authors also note thatWorrell). Fifth, although standard CBT strategies acceptance is the mirror image of Hayes and col-have been applied to an increasing number of leagues’ (1999) concept of experiential avoidance,problems and psychological disorders over the which is defined as maladaptive attempts to alterpast 30 years, outside of a few specific areas (e.g., the form or frequency of internal experiencespanic disorder, Craske & Barlow, 2008; social even when doing so causes behavioral harm.anxiety disorder, Clark et al., 2006, Herbert Cordova (2001), writing from a behavior analyticet al., 2005) progress has slowed or even perspective, defines acceptance as ‘‘allowing, tol-stalled in many key areas. For example, it erating, embracing, experiencing, or making con-is not clear that recent studies of CBT (e.g., tact with a source of stimulation that previouslyDeRubeis et al., 2005; Dimidjian et al., 2006) for provoked escape, avoidance, or aggression’’depression produced larger effect sizes than (p. 215), and also as ‘‘a change in the behaviorstudies conducted two or even three decades evoked by a stimulus from that functioning to
  28. 28. 2 • PSYCHOLOGICAL ACCEPTANCE 7avoid, escape, or destroy to behavior functioning Likewise, the prohibition against experientialto pursue or maintain contact’’ (p. 215). avoidance in ACT is neither absolute nor These definitions share several common dogmatic, but rather pragmatic. (In fact, whilethemes. First, they specify that psychological ACT practitioners are skeptical of experientialacceptance is relevant in those situations avoidance, including many cognitive changethat evoke escape, avoidance, or aggressive strategies, their use is explicitly advised whenbehaviors designed to modify or otherwise they work without undue costs.) Second,terminate contact with a stimulus. There is a acceptance is conceptualized as an activeclass of subjective experiences (thoughts, images, process, more akin to an embracing of one’sfeelings, sensations) that are experienced as ongoing process of experiencing, rather than asunpleasant and distressing to the point at which passive resignation. Finally, consistent with theone becomes highly motivated to reduce or historical focus in CBT on change, psychologicaleliminate them through either direct mental acceptance is generally viewed as a means toefforts or through environmental modification an end rather than an end in-and-of itself. Insuch as escape or avoidance. Acceptance is fact, this last point is one of the key featuresgenerally not relevant to situations that are that distinguishes psychological acceptancenot experienced as aversive, which are usually in CBT from acceptance in certain spiritualnaturally embraced without difficulty. Second, or religious contexts, and even in popularpsychological acceptance refers primarily to the culture. Meditative practices in Eastern religiousinternal experience of distress rather than to the traditions view acceptance as part of a desiredsituations evoking this distress. In the case of a state of consciousness. Within CBT, the value ofphobia of heights, for example, acceptance refers acceptance is as a tool to reduce overall sufferingto a willingness to experience anxiety—without and especially to foster behavior change thatattempting to control or otherwise change it—in will lead to better functioning.the presence of heights, and not an acceptancethat one can never approach heights. Third,the conceptualizations of acceptance implicitly CLINICAL INTERVENTIONS TO PROMOTEchallenge the rule that overt behavior is a direct PSYCHOLOGICAL ACCEPTANCEproduct of cognition and affect, and that thelatter must therefore necessarily be changed in A number of techniques have been developedorder to produce a change in behavior. to promote psychological acceptance. Although In addition, several additional aspects of psy- comprehensive review of such techniques is wellchological acceptance emerge from the literature. beyond the scope of this chapter, we provideOn the basis of the literature on thought sup- representative examples of such strategies below.pression, experimental psychopathology, and Barlow and colleagues (1989) introducedpsychotherapy outcome and process described the technique of interoceptive exposure in theearlier, including the preliminary effectiveness context of their treatment of panic disorder.of newer CBT interventions that eschew direct Interoceptive exposure refers to the graduated,cognitive change, many acceptance-oriented systematic exposure to somatic sensationspsychotherapists have come to believe that associated with panic attacks. Various exercisesdirect efforts to suppress or otherwise change are used that reliably elicit panic-like symptoms,highly distressing internal experiences will often including cardiovascular exercises, inhalationprove ineffective, will result in unacceptable of carbon dioxide, spinning in an office chair,costs, or both (e.g., Eifert & Forsyth, 2005; breathing through a cocktail straw, and shakingSegal, Teasdale, & Williams, 2004). This is not one’s head vigorously side to side. The patientto suggest that all such efforts are doomed is instructed to notice the sensations that ariseto failure. DBT, for example, is based on the dispassionately. Although not specificallycareful, ongoing balance between acceptance framed as a technique to promote psychologicaland change and does not abandon the possibility acceptance, interoceptive exposure is consistentof direct cognitive or affective change efforts. with an acceptance focus.
  29. 29. 8 COGNITIVE BEHAVIOR THERAPY One of the most common approaches to pro- skills, emotional regulation skills, interpersonalmoting psychological acceptance is mindfulness effectiveness skills, and distress tolerancemeditation. The use of meditation was spear- skills. Each module outlines specific clinicalheaded by Jon Kabat-Zinn in the context of techniques. Mindfulness skills are generallyMBSR, which was initially introduced in 1979 taught first, as they are foundational for theas a complement to medical treatment of a vari- other skill areas. The DBT mindfulness moduleety of chronic conditions. MBSR incorporates emphasizes observing and labeling emotionalthe practice of mindfulness meditation with cer- states from a detached, nonjudgmental, accept-tain core principles and ‘‘key attitudes,’’ such as ing perspective. Patients are taught to integrateacceptance, patience, and the ‘‘beginner’s mind,’’ the ‘‘emotional mind’’ and ‘‘reasonable mind’’that is, viewing experiences as though for the into the ‘‘wise mind’’ that can inform decisionsfirst time (Kabat-Zinn, 1990). The typical for- from an informed, balanced, holistic perspective.mat through which MBSR is delivered consists A potentially unresolved issue with DBTof eight weekly classes (often with 30 or more concerns the reconciliation of experientialparticipants), and a ‘‘Day of Mindfulness,’’ a acceptance and change. DBT explicitly teachesfull-day retreat focusing on the practice of medi- a number of emotion regulation strategies, suchtation and yoga. A key technique used in MBSR is as the principle of ‘‘opposite action,’’ which‘‘sitting meditation,’’ in which participants prac- refers to attempting to change an emotionaltice nonjudgmental awareness and acceptance of state by behaving in a way that is contrary totheir thoughts and other experiences. In addi- its usual behavioral manifestation. For example,tion to meditation and yoga, participants are a phobic who approaches rather than avoidstaught various techniques designed to promote a fear-inducing stimulus is displaying themindfulness, such as the ‘‘body scan,’’ which principle of opposite action. The emphasisinvolves gradually shifting awareness through- on emotion regulation in DBT highlights theout the body, taking notice of any feelings and dialectic between acceptance and change thatsensations (Tacon, Caldera, & Ronaghan, 2004). is characteristic of the model. However, asAlthough similar to the traditional behavior ther- discussed above, there may be situations inapy technique of relaxation training, in the case which attempting to change one’s experienceof mindfulness meditation relaxation is not the only intensifies it. Thoroughgoing acceptancegoal, but rather the adoption of a nonjudgmen- of distressing thoughts or feelings may betal stance with respect to one’s experience as it precluded if one remains focused on changingoccurs in real time. Mindfulness meditation is such experiences. An obese individual sufferingalso contrasted with other meditative traditions from episodes of binge eating, for example,in which one attempts to narrow the focus of may not fully accept distressing emotionalattention to a specific area (e.g., an image or states that trigger binges, and therefore mayvocal mantra). By fostering the observation of not completely disconnect links between suchone’s experience without reactively attempting experiences and her behavior, if in the backto escape from or otherwise change it, mind- of her mind she is still struggling with tryingfulness meditation is believed to interrupt mal- to change her experience. As described below,adaptive behavioral habits and to set the context ACT takes a more radical—although arguablyfor more effective responding. more consistent—stance with respect to efforts Mindfulness meditation is also a key feature to control distressing experiences.of DBT, developed by Linehan (1993a) as a Working from a cognitive perspective, Wellscomprehensive treatment model for borderline (2000) proposes that psychopathology is relatedpersonality disorder. DBT proposes that the to problematic self-regulation of attentionalchange-oriented emphasis in traditional CBT control, resulting in rumination, increasedcan be perceived as invalidating of the expe- threat monitoring (including self-focusedrience of patients with borderline personality attention), and coping behaviors that fail todisorder. Linehan (1993b) describes modules provide corrective experiences. The roots offor teaching four key skill areas: mindfulness these self-regulatory attentional problems are
  30. 30. 2 • PSYCHOLOGICAL ACCEPTANCE 9dysfunctional metacognitive beliefs, or beliefs could simply observe his urge, and say toabout beliefs. For example, a person with himself, ‘‘I’m having the thought of shouting outgeneralized anxiety disorder might hold a right now. That’s an interesting thought.’’ Themetabelief such as ‘‘if I review things over idea is to help the patient to achieve distanceand over again it will reduce the chances of from his experience and to accept the thought assomething bad happening.’’ Wells distinguishes simply a mental event, rather than as necessarilysuch metacognitions from the conscious, reflecting anything whatsoever about his world.propositional beliefs that are the typical targets Another example derived from ACT is theof standard cognitive therapy. He suggests inter- ‘‘cards’’ exercise. In one variation of this exercise,vention efforts to target such metacognitions, the patient is instructed to carry on a con-while simultaneously accepting the stream of versation with the therapist. As she does so,one’s ongoing conscious thoughts and feelings. the therapist tosses index cards, on each ofUnlike traditional CBT approaches, such change which is written one of the patient’s typicalis not accomplished by questioning the beliefs distressing thoughts, one-by-one at the patient,directly, but by encouraging greater attentional who is then instructed either to deflect themcontrol while simultaneously encouraging a away, or to gather them and stack them neatlyheightened sense of awareness of, and an together, all while continuing the conversation.accepting stance toward, one’s thoughts as mere Needless-to-say, this is a difficult task, and themental events. As part of his metacognitive conversation is inevitably negatively impacted.therapy, Wells describes a procedure known as The exercise is then repeated, this time with thethe attention training technique (ATT), in which patient instructed simply to let the cards fallvarious sounds are presented as distractions where they may, without trying to catch or orga-while subjects remain focused on a visual nize them. Following the exercise, the therapistfixation point, accept whatever thoughts enter and patient note how much more difficult theconsciousness without struggling with them, conversation was to maintain in the first sce-and attempt to direct their attention in various nario, and the effort to gather and organize theways as directed by the therapist. ATT has cards is framed as analogous to the effort to con-been shown in preliminary studies to result in trol one’s distressing thoughts. The ACT modelchanges in distressing thoughts and symptoms, is rich with similar exercises designed to promotedespite not directly targeting them, as well as psychological acceptance.in increases in metacognitive awareness (for a Roemer and Orsillo (2002) utilize the ACTrecent review, see Wells, 2007). framework to develop an acceptance-based ACT makes use of a variety of metaphors intervention for generalized anxiety disorder.and experiential exercises in order to promote Their model draws on the work of Borkovecacceptance. A great number of such exercises (1994), who conceptualizes worry as anhave been developed, and clinical innovations avoidance method that serves to reduce thein this area continue apace. One technique has perceived likelihood of feared future events, asthe patient precede discussions of distressing well as to distract the worrier from distressingthoughts or feelings by verbally (and subse- internal anxiety. Worry, in turn, is negativelyquently subvocally) inserting the phrase ‘‘I’m reinforced by the resulting decrease in distress.having the thought [or feeling] that . . . ’’ before According to Roemer and Orsillo, by learningthoughts. For example, an individual who to accept unpleasant internal events ratherimagines that he might suddenly shout out a than struggling with them, individuals canprofanity-laced, heretical statement in church reduce their experiential avoidance of perceivedwould be highly motivated to suppress the future threats. Roemer and Orsillo’s treatmenturge to do so as well as the linked thoughts incorporates various techniques to promoteand images. Attempts to suppress thoughts mindfulness, acceptance, and behavior change.or images of such behavior would likely only For example, the ‘‘mindfulness of sound’’increase their salience and intensity, thereby exercise, borrowed from Segal and colleaguesfurther increasing distress. Instead, this person (2002), encourages patients to notice aspects of
  31. 31. 10 COGNITIVE BEHAVIOR THERAPYsound without labeling and judgment (Orsillo, noting that acceptance is rarely appropriate forRoemer, & Holowka, 2005). the former but almost always for the latter. For Marlatt and colleagues have incorpo- example, an individual suffering from depres-rated mindfulness and acceptance into their sion can distance herself from and accept feelingswork on substance abuse treatment (Leigh, of dysphoria and thoughts of worthlessness andBowen, & Marlatt, 2005; Marlatt et al., 2004; suicide, but without accepting her behavior ofWitkiewitz, Marlatt, & Walker, 2005). Marlatt’s staying in bed all day. Historically importantrelapse-prevention model involves mindful memories (e.g., one’s memories of a traumaticacceptance of urges and cravings. A key experience) are especially important to accept,intervention of their program is known as ‘‘urge as considerable research suggests that avoidantsurfing,’’ in which the patient is instructed to coping strategies are problematic for such mem-imagine a craving as an ocean wave (Larimer, ories (Folette et al., 1998; Hayes et al., 1996).Palmer, & Marlatt, 1999). Rather than allowing Likewise, one’s ongoing stream of thoughts, feel-urges to overwhelm them, patients are taught ings, and sensations also tend to be appropriatethat cravings surge to a peak relatively quickly targets for acceptance. For example, Hayes andand will then subside. By focusing on the Pankey (2003) note that a pedophile’s sexualidea that distressing emotions will eventually behavior toward children should be directly tar-subside, they are more readily tolerated while at geted for change, whereas his associated feelingstheir most intense. The patient is encouraged to and urges are unlikely to be amenable to directobserve the craving as though detached from it, change, and should therefore be accepted. It is inand to practice mindful acceptance of the urge fact precisely this decoupling of subjective expe-until it dissipates. riences from overt behavior that is at the heart of Regardless of approach, the ultimate goal of acceptance-based CBTs.each of these techniques is the promotion of It is critical to distinguish psychologicalacceptance toward one’s experience on an ongo- acceptance of a thought from belief in theing basis in real time. literal truth of that thought. Acceptance implies the willingness to experience a thought while simultaneously refraining from evaluating itsWHEN IS ACCEPTANCE RECOMMENDED, truth value. This distinction is critical whenAND WHEN IS IT LIKELY TO BE LESS EFFECTIVE? considering the patient’s personal narrative, or what Hayes et al. (1999) term the self-as-content.As noted above, efforts to exert direct control Given the powerful human drive to makeover one’s experience can be considered adaptive sense of one’s experience, we inevitablywhen they work and do not result in excessive construct narratives that tie together importantcosts. Of course, this begs the question of how historical events, and that crystallize into broadone might ascertain when direct control efforts personality descriptors. The problem with suchare likely to be effective and when psychological narratives is that once formed, they tend toacceptance is instead indicated. Several theorists be taken literally and strongly defended fromhave addressed this question, although a clear question, which can in turn lead to a narrowingconsensus has yet to emerge. Cordova (2001) of one’s behavioral repertoire. For example, asuggests that the decision is a judgment call, college student may recall academic successesmade collaboratively by the patient and ther- in school, attribute these to her intelligenceapist, on whether aversion behavior (escape, and strong work ethic, and develop an identityavoidance, or aggression toward a stimulus) is as an ‘‘exceptionally smart, hardworkingmore likely to be effective, or lead to excessive student.’’ Imagine that she then finds herselfnegative consequences, over the long term. Of in a difficult class and not understanding thecourse, this begs the question of exactly what fac- lecture material. If she holds strongly to hertors should determine such a judgment. Hayes personal narrative, she may refrain from asking(2001) distinguishes maladaptive overt behavior a question because doing so would conflictfrom acceptance of one’s subjective experiences, with her self-identity as an exceptionally bright
  32. 32. 2 • PSYCHOLOGICAL ACCEPTANCE 11student. As verbal animals, humans have all cognitive and affective control efforts are nec-evolved to seek patterns in the ongoing barrage essarily doomed to failure, which may not be theof sensory input (Shermer, 2002), and as part of case. Some experiences are neither fully volun-this process, we construct stories that weave key tary (like hand/feet movements) nor involuntarydetails of our lives into a seamless narrative. (such as heart rate). Attention is a prime example.Once constructed, there is a natural tendency In fact, a number of experiences (e.g., thoughtto believe such narratives and to defend them contents, muscle tension) are on a continuum offrom challenge. Psychological acceptance in controllability. Psychological acceptance can bethis context means accepting one’s personal understood as gentle attempts to influence suchnarrative as an inevitable product of an active, experiences where possible, while acknowledg-pattern-seeking mind without either believing ing without struggle the inevitable limitations ofor disbelieving it. this influence. Farmer and Chapman (2008) propose three Consider the case of test anxiety. As with otherprinciples in deciding if psychological accep- anxiety disorders, it is easy to appreciate howtance is indicated. First, is acceptance ‘‘justified’’? an accepting stance with respect to catastrophicA justified response is one that is warranted thoughts and anxious sensations evoked by testsby the situation, such as a fear response in the could be beneficial. However, to be successful itpresence of a phobic stimulus. If the response is not enough to accept one’s subjective distress;is justified, then acceptance is in order; if the one must also focus one’s attention in order toresponse is not justified, then one either attempts orient toward the test itself. Approaches suchto change the response or at least to change as Wells’ (2000) attentional training technique,the behavior elicited by the response (consistent in which flexible attentional control is targetedwith the DBT principle of ‘‘opposite action’’). For without attempting to change ongoing thoughtsexample, distressing thoughts about being over- or feelings, may provide a useful approach toweight are justified in an obese individual, but such cases.the same thoughts are unjustified in a woman Finally, consistent with Farmer and Chap-suffering from anorexia. Of course, determina- man’s (2008) notion of justified responses, theretion of whether a thought is justified requires at are situations in which the literal truth of aleast some degree of analysis of the truth value thought or belief is, in fact, critical to evaluate. Aof the thought, which runs the risk of interfering man with tachycardia, shortness of breath, andwith attempts to accept it. Second, is the reaction chest pains needs to know whether he is dyingor situation changeable or unchangeable? Obvi- of a heart attack or simply having a panic attack.ously, acceptance is indicated for unchangeable A woman who believes that she is being stalkedexperiences. Finally, are the patient’s responses by an ex-boyfriend must evaluate the evidenceeffective or ineffective? Effective responses are for this belief before simply accepting her feel-conceptualized as those that are consistent with ings dispassionately. In such cases, psychologicalvalued goals, whereas ineffective responses are acceptance becomes relevant after an objectiveinconsistent. When responses are ineffective in evaluation of the relevant evidence (e.g., a med-this sense, they call for acceptance. ical workup for the individual with chest pains, A common rule of thumb among acceptance- consultation with appropriate law enforcementoriented CBT clinicians is that psychological authorities for the woman who believes she isacceptance is indicated for any distressing per- being stalked). In many other cases, however,sonal experiences, such as painful memories, one may be tempted to evaluate the truth ofdisturbing thoughts, and difficult feelings or thoughts when doing so may not be necessary.sensations, as well as for personal narratives. By An individual with public speaking anxiety willcontrast, direct change efforts should be reserved almost certainly have thoughts concerning nega-for overt behaviors, that is, things involving one’s tive evaluation by the audience in anticipation ofhands, feet, mouth, and so on. Although superfi- a speech. An objective evaluation of the evidencecially appealing, such a distinction becomes more for such beliefs would not only be difficult todifficult upon closer examination. It assumes that achieve, but is not necessary. The individual can
  33. 33. 12 COGNITIVE BEHAVIOR THERAPYlearn simply to notice his catastrophic thoughts value of cognitions is clearly necessary. Althoughand associated feelings of anxiety and to give the at first glance such efforts may appear incom-speech anyway. The issue of determining when patible with experiential acceptance, acceptanceto evaluate versus when to accept distressing may actually enhance one’s efforts along thesethoughts is discussed further below. lines. Many existing acceptance-based innova- tions have not attended sufficiently to the inte- gration of change and acceptance strategies, andUNRESOLVED ISSUES AND DIRECTIONS the reconciliation of these apparently inconsis-FOR FUTURE RESEARCH tent themes. It may in fact be the case that even the mostGiven the relatively recent emphasis of staunch acceptance-oriented therapists covertlyacceptance-based therapies within CBT, there or implicitly do evaluate the validity of theirremain a number of unresolved questions patients’ thoughts, and then promote accep-and directions for future research and clinical tance only when thoughts are inaccurate. In theinnovations. First, there is a need for new case of the man with chest pains described ear-technologies to promote psychological accep- lier, for example, no acceptance-based therapisttance. Given the pervasiveness of psychological would suggest that he simply acknowledge andchange-oriented strategies in Western culture, accept the pain without first referring him for anthe notion of fully accepting one’s experience appropriate medical evaluation to rule out car-while simultaneously engaging in behavior that diac disease. We propose that the determinationis seemingly inconsistent with that experience of whether acceptance versus engagement withcan be counterintuitive. A range of clinical thoughts is indicated is best made on the strengthstrategies and techniques are needed to foster of one’s knowledge that (1) one has already sys-psychological acceptance. It is likely that there tematically evaluated a thought before, and/oris untapped clinical wisdom among both (2) one’s mind routinely emits this exact thoughtpracticing cognitive behavior therapists and without good cause. An example of a workablethose from other theoretical orientations that strategy along these lines would be to reach anwould be helpful in promoting acceptance. agreement with patients to undertake a thoroughSimilarly, the best methods of training practi- evaluation of a troubling thought once and onlytioners in acceptance-based technologies require once, after which the thought is simply noticedfurther development. Many leading innovators, and accepted without further elaboration.including Kabat-Zinn, Linehan, and Teasdale, In addition to clinical developments, thereall stress the importance of therapists cultivating remain a number of unresolved conceptualtheir own mindfulness practice (Lau & McMain, issues. For example, is acceptance best concep-2005). Likewise, Hayes incorporates various tualized as an overt behavior that can be directlyexperiential exercises in his training workshops assessed, as suggested by Cordova (2001), orwith the purpose of developing a deeper as a private experience that is only indirectlyappreciation of ACT principles. Although there reflected in overt behavior? An individual withis clear logic to the notion that such efforts will social anxiety disorder may attend a partybe helpful in therapists’ efforts to understand but may engage in a variety of covert ‘‘safetyand transmit acceptance-based strategies, the behaviors’’ that render her not fully engaged inimportance of such training strategies is not the experience. A purely behavioral assessmentknown empirically. of the topography of her behavior would erro- Second, the development of more explicit neously conclude that she was highly acceptingguidelines is needed in order to distinguish of her anxiety. The quality of one’s experiencewhen psychological acceptance is likely to be with respect to a distressing stimulus is alsohelpful, and conversely, when direct change unclear. Cordova (2001) argues that ‘‘genuine’’strategies are indicated. As discussed above, acceptance involves a ‘‘change in the stimulusthere are situations in which a certain level of function from aversive to more attractive’’ andattentional control and evaluation of the truth similarly as ‘‘ . . . change in stimulus function
  34. 34. 2 • PSYCHOLOGICAL ACCEPTANCE 13of a situation toward that which inclines the and terminological confusion (Zvolensky,person to seek or remain in contact’’ (p. 221). Feldner, Leen-Feldner, & Yartz, 2005).According to this analysis, if one remains in A review of the outcome research oncontact with an aversive stimulus without the acceptance-based CBTs is beyond the scopestimulus losing its aversive properties, one is of this chapter; several reviews of the litera-effectively in a state of hopeless resignation ture are now available (e.g., Brantley, 2005;rather than true acceptance. It is noteworthy ¨ Coelho et al., 2007; Hayes et al., 2006; Ost,that this perspective effectively requires that 2008). In general, the status of this body ofthe stimulus be experienced as less aversive evidence can be summarized as preliminaryto qualify as ‘‘genuine’’ acceptance. Yet it but promising. Acceptance-based methodsseems entirely plausible that one could learn tend to fare at least as well as traditionalto remain in psychological contact with an change-oriented approaches, although only aaversive stimulus without requiring that one’s handful of direct head-to-head comparisonsreactions to it necessarily change. For example, have been conducted to date (e.g., Forman,a patient with chronic pain may learn to accept Herbert, et al., 2007; Lappalainen et al., 2007).rather than fight his pain. This may or may not Clearly, more outcome research utilizing largerresult in a change in his pain perception, but it samples and more sophisticated methodological ¨ controls is needed (see Ost, 2008, for a detailedis not clear that the degree of perceived painshould distinguish ‘‘real’’ acceptance from mere discussion of methodological controls within published studies on ACT and DBT). Likewise,resignation. What seems important instead is much more psychotherapy process researchhis abandoning ineffective struggles with the is needed to evaluate the extent to whichpain and his simultaneously pursuing other psychological acceptance mediates changes inactivities that will enrich his life. acceptance-based models of CBT, as well as There also remains confusion about how the perhaps even in more traditional models ofconstruct of psychological acceptance differs CBT. Although initial studies are encouragingfrom related constructs such as mindfulness. (Hayes, Levin, Yadavaia, & Vilardaga, 2007),Some theorists view acceptance as a necessary much more work remains to be done.feature of mindfulness. Brown and Ryan (2003),for example, propose that mindful awarenessnecessarily involves a nonjudgmental, accepting CONCLUSIONstance toward one’s experience. However, thisperspective fails to acknowledge that acceptance The field of CBT has recently witnessed andoes not always accompany awareness, as increased interest in theoretical and techno-in the case of heightened awareness of one’s logical developments related to psychologicalphysiological arousal in panic disorder. This acceptance. Acceptance-based models of CBThas led other theorists to deconstruct the are quickly growing in popularity. Preliminaryconcept of mindfulness such that acceptance data not only support the efficacy of suchis only one aspect. For example, Herbert and approaches, but also support the conclusionCardaciotto (2005) argue that mindfulness is that changes in psychological acceptance maybest viewed bidimensionally as consisting of mediate more general changes produced by psychotherapy, although much more workongoing awareness of one’s experience and remains to be done with respect to both outcomenonjudgmental acceptance of that experience, and process. In addition, a number of theoreticaland that these two components are in fact con- and practical issues remain outstanding andceptually and empirically distinct (Cardaciotto, await further development.Herbert, Forman, Moitra, & Farrow, in press).This conceptual and terminological confusion Referencesstems in part from the fact that investigatorsare approaching these questions from diverse Abramowitz, J. S., Tolin, D. F., & Street, G. P. (2001).theoretical perspectives, resulting in conceptual Paradoxical effects of thought suppression:

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