Thursday, March 31, 2011

Open, Aware, and Active: Contextual Approaches as an Emerging Trend in the Behavioral and Cognitive Therapies

In recent post, I wrote about how Dr. Steven Hayes coined the term "third wave" to describe the recent crop of mindfulness and acceptance-based treatments. In a new paper, Dr. Hayes and his colleagues at the University of Nevada-Reno explore this notion further.

The article examines the theoretical underpinnings of the current generation of mindfulness and acceptance-based psychotherapies, and at the published empirical data supporting the theory. This article provides a fantastic overview of the current state and development of many of these treatments.

Towards the end of article, Hayes and colleagues suggest abandoning the term "third wave" in favor of what they call "contextual cognitive behavioral therapy" or contextual CBT. According to the authors, contextual CBT differs from traditional CBT in several important ways:

1. Contextual CBT emphasizes changing the context and function of psychological events (e.g., thoughts, emotions, physical sensation) rather than the content, accuracy, and frequency. For example, a contextual CBT therapist is more interest in changing how someone relates to self-critical thinking than in changing the thoughts themselves.

2. Contextual CBT focuses more on what the authors call a "transdiagnostic approach to mental health." What this means is that, rather than treat specific diagnoses (e.g., generalized anxiety disorder), contextual CBT therapists focus more on processes (e.g., emotion regulation).

3. Contexutal CBT therapists are encouraged to apply these methods to themselves. For example, leaders of Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy groups are encouraged--even required--to maintain their own mindfulness practices.

4. Contextual CBT is less about throwing away techinques and interventions from other treatments than in taking what is useful and applying it in ways that are consistent with the theories underlying contextual CBT.

5. In their final distinction, the authors suggest contextual CBT is being applied to a much broader and deeper range of problems within the human conditions, such as spirituality and values. (The authors admit that this point is more of a "judgment call" than an accepted fact.)

I highly recommend this article for readers of Scientific Mindfulness. It's a great review article for much of what we write about in this blog.

To download a copy of the article, click on the full citation below:

Hayes, S.C., Villatte, M., Levin, M., & Hildebrandt, M. (2011). Open, Aware, and Active: Contextual Approaches as an Emerging Trend in the Behavioral and Cognitive Therapies. Annual Review of Clinical Psychology, 7, 141-168.

Wednesday, March 23, 2011

The Strange Powers of the Placebo Effect

This video isn't about mindfulness specifically, but I think it's a wonderful illustration of one of the reasons why scientific research is so important. Without controlled studies, it's hard to discern active treatments from placebo because placebo by itself can an effective treatment. It's important to assess whether treatments work for the reasons we think they work; otherwise, we can become lost in a sea of pseudoscientific cures. (If you're interested, click here for a blog post I did about pseudoscience in psychotherapy.)

Wednesday, March 16, 2011

In Memory of Alan Marlatt's Passing

For those of you who haven't heard, University of Washington professor and researcher Dr. G. Alan Marlatt passed away from melanoma on Monday (3/14/2011). He was 69. My understanding is that the diagnosis was unexpected, and Dr. Marlatt was told he had only days left to live. By report, he passed away in the company of his family.

I've previously talked about Dr. Marlatt's work with Mindfulness-Based Relapse Prevention here in Scientific Mindfulness. Dr. Marlatt has a 30-year history practicing mindfulness and meditation. He started by with Transcendental Meditation hoping it would help lower his blood pressure (it did), and eventually began exploring different Buddhist meditative traditions.

Even if Dr. Marlatt had never incorporated mindfulness into his research, he would be well-known for his other contributions to the study of addictions and substance abuse. He is well-known for his work on harm reduction: the notion that some people who don't want to give up alcohol entirely may learn to drink moderately. He made significant contributions towards understanding relapse.

I had a few brushes with Alan in my career. Early on in my graduate studies, I emailed him a question about problems with alcohol abuse in Buddhist teachers. Not only did he respond, but he suggested we talk about by phone! He was extremely kind and supportive during our brief chat. A year or two later, he was the discussant at a symposium I participated in. I introduced myself again but felt too shy to make an effort at engaging him, as there were others calling for his attention. Everyone I've spoken with about Alan has commented on his kindness and gentleness, an impression I shared.

Alan Marlatt will be missed. We've lost an exceptional researcher, a great contributor towards understanding mindfulness and acceptance-based treatments, and a wonderful man.

Time has a brief article on Dr. Marlatt. To check it out, click here.

For those interested in knowing more about him, Dr. Marlatt wrote a very touching portrait of his history with mindfuless that's worth tracking down:

Marlatt, G. A. (2006). Mindfulness Meditation: Reflections from a Personal Journey. Current Psychology, 25(3), 155-172.

Friday, March 11, 2011

Psychology Today: Bringing ACT to Sierra Leone

In a blog post today on the Psychology Today website, Dr. D.J. Moran, author of ACT in Practice, writes of a recent trip to war-torn Sierra Leone with two other psychologists. Together, they taught two workshops on Acceptance and Commitment Therapy (ACT) to local mental health practitioners. Dr. Moran writes:

In January 2011, my colleagues Beate Ebert and JoAnne Dahl and I set out to present two workshops in evidence-based behavior therapy and Acceptance and Commitment Therapy (ACT).  Beate is a dedicated psychologist and the founder of Commit + Act, the non-governmental agency that planned this trip.  JoAnne has extensive understanding of using ACT with the chronic pain population, but also has experience with bringing ACT to populations that have limited access to mental health care.  Our first five (5) day workshop was in Freetown, S.L. and the second three (3) day workshop was in Serabu, S.L..  Each workshop had over 30 mental health practitioners in attendance.   They were very eager to hear how they could address Post-Traumatic Stress Disorder with behavior therapy and ACT.

Dr. Moran offers a touching sketch of their efforts to bring an evidence-based mindfulness and acceptance-based treatment to therapists in a country that has witnessed unimaginable horror. I can't do it justice to through summary; to read the full post, click here.

Thursday, March 10, 2011

How Does Mindfulness-Based Cognitive Therapy Work?

Mindfulness-Based Cognitive Therapy (MBCT) has demonstrated it reduces depressive relapse in those with three or more depressive episodes across several studies now. But why--what changes occur in MBCT that reduce relapse? The theory behind MBCT suggests increased mindfulness leads to reduced chance of relapse; however, treatments may be effective for reasons having little to do with why we think they're effective.

A recent article by Kuyken and colleagues examines processes of change in MBCT in order to assess the theory behind underlying it. The researchers used what are called mediational analyses. Mediational analyses look at whether changes in one factor (e.g., mindfulness) lead to changes in another (e.g. lower depression).

The authors used data from a previous study (Kuyken et al., 2008) in which 123 people with 3 or more depressive episodes who were currently prescribed antidepressant medication were randomly assigned to either 8-weeks of MBCT or were placed on a wait list. Those in the MBCT condition were weaned off their medication while those not assigned to MBCT remained on their meds. Participants were assessed every 3 months up to a 15 month follow-up. (In the original study, there was no difference in rate of relapse between MBCT and antidepressant meds; however, people in MBCT exhibited fewer depressive symptoms by the 15-month follow-up.)

Results of this study suggest increases in mindfulness and self-compassion mediated the effect of MBCT on depressive symptoms at follow-up. Researchers also looked at what they called cognitive reactivity. Cognitive reactivity was defined as changes in depressive thinking before and after a short piece of "sad" music (i.e., Prokofiev).

Curiously, people who participated in MBCT exhibited greater cognitive reactivity than those who remained on antidepressant medication. Here's the interesting part, though: whereas cognitive reactivity was associated with poorer outcome for people taking antidepressants, participation in MBCT appears to erase this relationship. Said another way, for people who participated in MBCT, cognitive reactivity no longer appeared to impact depressive symptoms. This reminds me of the Mindfulness-Based Relapse Prevention study in which the researchers found the relationship between depression and relapse appeared to disappear for those who participated in the program.

These results of the current study offer further evidence that mindfulness doesn't change patterns of thinking so much as it changes how people relate to thinking. Additionally, this is another study showing the useful in self-compassion in understanding mechanisms of change in mindfulness based treatments. (For another study indicating the importance of self-compassion, click here.)

As with any study, there are limitations. Mediational analyses don't definitively tell us that particular variables lead to change. However, the results largely supported the hypotheses of the researchers, offering additional evidence in support of the theory.

To download a copy of the article, click on the full citation below:

Kuyken, W., Watkins, E., Holden, E., White, K., Taylor, R.S. et al. (2010). How Does Mindfulness-Based Cognitive Therapy Work? Behaviour Research and Therapy, 48, 1105-1113.

Friday, March 4, 2011

The U.S. Government Lists Acceptance and Commitment Therapy as an Evidence-Based Treatment

This is exciting news within the Acceptance and Commitment Therapy (ACT) community! The Substance Abuse and Mental Health Services Administration (SAMHSA), a major department within the U.S. government, now lists ACT as an empirically supported treatment. This is part of its National Registry of Evidence-based Programs and Practices (NREPP).

ACT received high scores across a number of different dimensions, including quality of research and efforts at dissemination (e.g., getting ACT out there to professional and the public). This is a great victory for mindfulness and acceptance-based treatments, and for ACT in particular!

Read about it yourself here.

Thursday, March 3, 2011

Investigating the Similarities and Differences Between Practitioners of Second- and Third-Wave Cognitive Behavioral Therapies

In 2004, Dr. Steven Hayes published an influential paper in which he coined the term "third wave." Third wave refers to the mindfulness and acceptance-based cognitive behavioral therapies we focus on in Scientific Mindfulness: Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT), among others.

In calling these third wave treatments, Dr. Hayes distinguished them from the first wave of treatments that came out of behaviorism, and from the second wave of therapies that came out of cognitive therapy. Traditional cognitive behavioral therapy (CBT), which focuses on changing maladaptive thoughts, is a second wave treatment. The mindfulness and acceptance-based treatments of the third wave differ from the second wave, according to Dr. Hayes, in their focus on changing how people relate to thinking, not the thoughts themselves. (You can download a copy of this seminal article at the bottom of this post.)

A group of researchers affiliated with Brown University took some data from a larger study to examine similarities and differences between second and third wave therapists. Out of a sample of 176 clinicians who completed an Internet survey, 55 identified as second wave and 33 identified as third wave. The terms second and third wave weren't actually used in the Internet survey: rather, therapists who identified as "cognitive or cognitive behavioral" (i.e., second wave) or "acceptance-based behavioral/cognitive" (i.e., third wave) were included in the two categories.

In general, the researchers found that second and third wavers are more similar than different. For example, both were equally likely to endorse using social skills training and homework. The main differences the authors found were related to techniques and treatment strategies. Second wavers were more likely to use traditional cognitive techniques such as cognitive restructuring and relaxation training; by contrast, third wavers were--as you might imagine--more likely to use mindfulness and acceptance techniques.

Curiously, third wavers were also more likely to report using existential/humanistic and family systems techniques. The authors offers explanations for these findings. For one, they suggest the emphasis in values clarification in ACT may explain the endorsement of existential/humanistic techniques. This is a reasonable assumption but, by no means, an clear-cut interpretation. What seems a little more far afield is the authors' suggestion that the endorsement of family systems techniques reflects a greater inclusiveness in the use of techniques by third wavers. Again, this assumption is not unreasonable, but it seems like a stretch in the absence of any additional data. That said, I don't know how to explain these findings either!

What I found most interesting is that third wavers reported greater use of exposure. Exposure is a decades old behavioral intervention that has been widely successful in treating anxiety disorders (e.g., anxiety, phobias, obsessive-compulsive disorder, and posttraumatic stress disorder). In my view, exposure is an extremely useful intervention when appropriate applied. As it's also been incorporated into traditional CBT and interpreted according to cognitive models, I find it really interesting that second wavers are significant less likely to use exposure than third wavers because it is frequently a component of empirically-supported CBT treatments for anxiety disorders.

The authors conclude both second and third wavers emphasize evidence-based practice. Where they differ is that, although third wavers use both first and second wave interventions, they are less likely to use traditional cognitive techniques (e.g., cognitive restructuring). One important potential bias the authors note is that, as they recruited from an ACT listserv, among other listservs, ACT therapists may be over-represented in their sample compared to other third wave therapies such as DBT and MBCT. Consequently, the results may be more reflective of ACT therapists than to the broader community of third wave therapists.

The full citations are below. Only members of ACBS can download the main article I covered. However, everyone can click on the second citation to download a copy of Dr. Hayes seminal 2004 article:

Brown, L.A., Gaudiano, B.A., & Miller, I.W., (2011). Investigating the Similarities and Differences Between Practitioners of Second- and Third-Wave Cognitive Behavioral Therapies. Behavior Modification, 35(2), 187-200.

Hayes, S.C. (2004). Acceptance and Commitment Therapy, Relational Frame Theory, and the Third Wave of Behavior Therapy. Behavior Therapy, 35, 639-665.