In this blog, I continue my journey down the developmental history of cognitive-behavioral therapy. My purpose is to place current approaches in context and to help readers see how our understandings have changed over time. With this in mind, and to ensure readers get the most out of this series, I highly encourage readers to read the 3 parts in succession.
The Third Wave
Rather than bringing about psychological change through disputation, affirmation and control of thoughts and emotions, the third wave of behavior therapies emphasize techniques employing mindfulness and acceptance. This constellation of therapies integrates the basics of traditional cognitive-behavioral therapies (e.g., CBT and REBT) with concepts derived from Existentialism, Eastern thought, and Hellenistic philosophy. Whereas CBT and REBT focus on alleviating presenting symptoms and relying on behavioral strategies to correct dysfunctional beliefs, third wave therapies target more meta-cognitive processes (thinking about ones thinking), with an emphasis on working toward broader life goals. The most notable and utilized of these are Dialectical Behavior Therapy (DBT; Linehan, 1993), Mindfulness Based Stress Reduction (MBSR; Kabat-Zinn, 1979 ) and Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999). Seen as more eclectic, this group of therapies are utilized to treat a great variety of psychological and medical conditions including; anxiety, depression and other mood disorders, personality disorders, eating and addiction disorders, schizophrenia, pain management, as well as life transitions and everyday challenges.
Dialectal Behavior Therapy (DBT)
Like REBT and CBT, Dialectal Behavior Therapy (DBT) is a highly researched, evidence-based intervention belonging to the family of cognitive-behavioral therapies. Developed by American psychologist Marsha Linehan during the late 1970’s and early 1980’s, DBT was the outgrowth of Linehan’s search for a modality to treat chronically suicidal women and those struggling with borderline personality disorder (BPD). Individuals diagnosed with BPD frequently suffer from abandonment fears, excessive emotional responses, feelings of emptiness, unstable relationships, and sometimes during the most acute phases, a detachment from reality. Initially trained as a behaviorist, and having tried CBT, Linehan found CBT’s focus on “distortions” in thinking to be too stressful and invalidating for her target population. Like REBT and CBT, DBT is directive and change-oriented, but places greater emphasis on behavioral interventions. Working with what is viewed as an emotionally volatile and behaviorally impulsive population, the core goals of DBT are the development of Mindfulness, Emotional Regulation, Distress Tolerance, and Interpersonal Effectiveness. There is a strong focus on validation, self-acceptance, de-escalation of highly charged emotional states, and balancing learning acceptance-based strategies with the need for behavior change. DBT’s focus on the concept of “dialectics” (the idea that two opposing viewpoints or emotions can both be valid and experienced at the same time), has lent it to being very effective and widely used in group therapy.
Mindfulness Based Stress Reduction (MBSR)
Developed by Jon Kabat-Zinn in the 1970’s, MBSR was the outgrowth of his decades-long dive into the study of Buddhism and meditation. In 1979 Kabat-Zinn opened the Mindfulness-Based Stress Reduction Clinic at the University of Massachusetts Medical School, and then in 1995, the Center for Mindfulness in Medicine, Health Care, and Society. Kabat-Zinn has integrated many forms of mindfulness practice and teachings into MBSR, but the program is considered secular in nature and devoid of any theological components. The meditation practiced utilized by MBSR is Vipassana meditation. Vipassana meditation often referred to as “insight” meditation, is the oldest of Buddhist meditation practices.Offered as an 8-week course of intensive education, training and practice the program seeks to help patients cope with stress, pain, and illness. MBSR’s goalsis for the practitioner to increasingly develop an awareness of the activity of our mind, how it ruminates, clings and avoids. Another goal is to
cultivate ones ability to accept all that shows up in our lives (internally and externally) and with this, in the parlance of Rogerian psychology, unconditional positive regard first for ourselves and then others. In addition to meditation, MBSR utilizes an array of mindfulness cultivating practices such as yoga, Zen, and progressive muscle relaxation. According to their website, MBSR is now offered in over 700 hospitals and medical centers around the world.
Acceptance and Commitment Therapy (ACT)
Developed by Stephen C. Hayes in the 1980’s, Acceptance and Commitment Therapy (ACT) was the outgrowth of Hayes’ efforts to deal with his history of panic disorder. ACT is one of the fastest growing, evidence-based psychotherapeutic interventions being used today. ACT gets its name from one of its core messages: Accept what is outside your personal control and commit to taking action that enriches your life. From an ACT perspective, painful events and difficult challenges are an unavoidable part of our human experience. However, we increase our suffering when we rigidly adhere to unworkable behaviors in an effort to avoid, get rid of, and control painful experiences (e.g., thoughts, emotions, urges, sensations, and memories) that arise during challenging times in our lives. Additionally, ACT views humans as being predisposed (a function of our evolutionary neurobiology) to worrying about having enough resources to sustain ourselves, not being good enough, being unprepared, and not fitting-in with our social group. In prehistoric times these worries were about physical safety, food, shelter, and warmth, but for those of us fortunate to live in today’s first world societies, these existential needs are often conflated with things like wealth, status, and physical attributes.
ACT’s main goal is to help people handle the pain and stress of everyday life by increasing their psychological flexibility. That is, rather than working at controlling, eliminating, and avoiding painful thoughts and emotions, an ACT therapist works with the client to learn new ways to relate to their painful experiences. Instead of getting better at avoiding, clients learn to lean-in to their discomfort. With an attitude of openness and curiosity the client works to accept the present moment, and instead of struggling against it, make it their ally rather than their enemy. Core concepts in ACT are acceptance, being present, developing your observing-self (that part of you that can notice your own thinking), unhooking from thoughts, and taking committed action to live by one’s values.
There are other cognitive-behavioral oriented therapies than the ones I have covered here. If this blog has piqued your interest in any of the above-covered therapeutic interventions, I highly recommend you spend some time browsing the internet, as there is a great deal written about all of these. With this said, I urge you to always check the sources of the information you access to insure they come from bona fide sources such as the APA(American Psychological Association, NIH (National Institutes of Health), esteemed universities, and respected scientific journals (obviously a quick read of Wikipedia wouldn’t do any harm).
Namaste
