Behavioral Medicine has developed through three generations of Behavior Therapy. In the first generation, learning lab metaphors were the dominant paradigms, with applications of contingency management continuing today in such areas behavior management with behaviors associated with dementia (Lundervold et. al.,1992) and application of classical conditioning in desensitization preparing for stressful medical procedures (Burish and Bradley,1983). The second generation was significantly influenced by the cognitive revolution in psychology and led to the dominance of Cognitive Behavior Therapy (CBT) in clinical training programs and to applications in Behavioral Medicine in coping with pain (Thorn, 2004), managing chronic illness (White, 2001) and a wide variety symptoms and syndromes. The third generation, or as Steven Hayes has called it, the third wave of behavior therapy, has introduced new conceptualizations and newer therapies including:

o       Acceptance and Commitment Therapy or ACT (Hayes, Strosahl and Wilson, 1999)

o       Dialectical Behavior Therapy or DBT (Linehan, 1993)

o       Mindfulness-based Cognitive Therapy or MBCT (Segal, Williams and Teasdale, 2002)

The research of David Barlow (2002) was a bridge between the second and third generations. He found that anxiety and panic were ubiquitous and common elements in most of the emotional disorders, including depression. He suggested that control was a central issue and common both to those who fit in the DSM categories and those who do not. Control is a central issue with many patients in Long Term Care (LTC). His formulation encompasses stress and permits an understanding of why, in the real world, we find a mix of anxiety and depression rather than the neat categories that DSM committees say we should find. That kind of mix is very common in LTC. Above all he found in 30 years of research that interoceptive cues, or experience itself, must be the focus of treatment for classical anxiety disorders. Patterns of avoidance of aversive internal experiences had to be brought into the treatment equation.

In the months to come we will explore applications of ACT, DBT and MBCT to health related problems. We will begin the series with ACT.

ACT, or Acceptance and Commitment Therapy (Hayes, Strosahl and Wilson, 1999), was developed by Steven C. Hayes, a student of Barlow’s, and a collaborator with Marsha Linehan and others in development of third generation alternatives. ACT is pronounced as ‘act’ and not as A-C-T. Hayes (Hayes et. al. 1999) suggests the foundation for ACT is in behavior analysis and the basic concept on which it is built is what he calls functional contextualism. It is defined as the view that psychological events involve a set of ongoing interactions between whole organisms and historically and situationally defined contexts. Analysis emphasizes the functions of events in context and Hayes believes that the way we use and abuse language is a major source of suffering. However, it is less the literal content of cognitions than the functions of cognitions that are matters of concern. He ties the methods to what he calls Relational Frame Theory (RFT). The theory is beyond the scope of this article. An in depth presentation of the theory in book form was published by Plenum Press in 2001 (Hayes et. al. 2001). Also there is a tutorial on RFT at Hayes’ web site: http://www.contextualpsychology.org

In ACT, as in DBT, the patient is encouraged to become passionately interested in the pursuit of life according their own values rather than seeking insightful formulations about distal cause of feelings and behavior. The goal is psychological flexibility as opposed to the sort of rigidity that one finds in many emotional illnesses and in response to the stress of illness in LTC. Hayes and Stosahl (2004) define ACT this way:

“ACT is a therapy approach that uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce psychological flexibility.” (Hayes and Strosahl, 2004, p. 13)

Hayes argues that evolution has made us acutely sensitive to aversive events, since many such events have survival value. Language amplifies aversive qualities and serves to create a pattern of generalization that may have once helped with survival but now amplifies and extends psychological pain and suffering. We can become less concerned with here-and-now experiences and more preoccupied with internal evaluations of threats that have taken place and threats that may be part of our future. To put it another way we become occupied with avoiding negative emotional experiences. The desire for experiential avoidance enslaves language and psychological flexibility only becomes possible by addressing that avoidance and defusing language habits that perpetuate suffering. Seniors in LTC experiencing the suffering of acute and chronic illnesses risk the perpetuation of negative emotions through just such rigidity even though the may not qualify as fitting in one of the DSM categories.

Creating greater psychological flexibility involves these six changes by the patient under the guidance of the therapist:

1. Establishing psychological acceptance skills
2. Establishing cognitive diffusion skills
3. Distinguishing self-as-context from the conceptualized self
4. Contacting the present moment
5. Distinguishing choice from reasoned action
6. Committed behavioral persistence and change linked to chosen values

In our culture we are taught early to try to control our emotions. We are not supposed to be afraid, or to be in pain or to be anxious. We are not supposed to have certain thoughts, and if we do we should control them. To make a key point I usually tell patients to stop immediately thinking about an elephant. They cannot. A useful method used by ACT therapists to make the point and to illustrate acceptance is to give them a pair of Chinese handcuffs like we all played with as children. Tell them to get loose and the harder they pull the tighter the grasp on their fingers. We can channel emotions if we are aware of them and we can change the language habits that perpetuate them but we cannot control them as such. They are part of our natural wiring and as such should be accepted as part of us and part of the richness of living.

In ACT cognitive diffusion and mindfulness techniques go hand in hand. The classic diffusion technique involves repeating a word infused with negative emotion over and over again until the word loses its conditioned emotional meaning. ACT therapists use a variety of exercises to ‘deliteralize’ language associated with the problem presentation. For example, the name of the patient’s illness (e.g. cancer) may be the focus of diffusion. Talking about the meaning of the word by identifying associations and then repeating the word until it becomes a sound that evokes little meaning. Mindfulness exercises are powerful diffusion tools. The goal is to learn to look at thoughts rather than through thoughts. Mindfulness exercises and then daily practice to develop skills help to create a skill in directing attention that can be used to defuse thoughts of their conditioned negative emotional meaning.

In ACT acceptance means more than just tolerance. It is the active nonjudgmental embracing of experience in the here and now. ACT therapists make a distinction between passive acceptance, which involves giving up, and active acceptance which is done with compassion for oneself. There are four steps:

o       Acknowledgement of the feeling

o       Acceptance of the situation as it is

o       Identifying the source of the feeling

o       Respond with forgiveness and compassion

The philosophy of acceptance is defined well in the Serenity Prayer. We need not accept the things we can really change. But we must learn to identify those beyond our capacity for control. Patience is the handmaiden of acceptance. There are a wide variety of exercises to promote acceptance. We will examine those in months to come.

ACT therapists often ask: “What do you want your life to stand for?” That probes the area of personal values which is central to the approach. Exercises include asking what the patient would like to have said at their funeral. Once values are clarified action goals are set and homework is based on such a plan of action. Values in the following areas should be explored:

• Family
• Personal development and education
• Intimate relations
• Recreation
• Parenting or nurturing
• Spirituality
• Social life
• Community life
• Work
• Physical self-care and wellness

The commitment in ACT is to action each and every day guided by values. ACT involves both acceptance of things out of the realm of control and change when it is possible and improves the quality of life. Georg Eifert (Eifert et. al., 2005) summarizes the three key steps as:

• Accept thoughts and feelings
• Choose directions
• Take action

In the coming months we will examine the application of ACT to coping with chronic illness and pain. Then we will explore applications of DBT and MBCT.

References

Barlow, D.H. (2002) Anxiety and Its Disorders, Guilford Press.

Burish, T.G. and Bradley, L.A. (Eds) (1983) Coping With Chronic Disease: Research and Applications, Academic Press.

Eifert, G.H. and Forsyth, J. P. (2005) Acceptance and Commitment Therapy for Anxiety Disorders, New Harbinger Publications.

Hayes, S.C., Barnes-Holmes, D. and Roche, B., (Eds) (2001) Relational Frames Theory, Plenum Press.

Hayes, S.C. and Stosahl, K.D. (2004) A Practical Guide to Acceptance and Commitment Therapy, Springer Press.

Hayes, S.C., Strosahl, K.D. and Wilson, K.G. (1999) Mindfulness and Acceptance, Guilford Press.

Linehan, M.M. (1993) Cognitive-behavioral treatment of borderline personality disorder, Guilford Press.

Lundervold, D.A., and Lewin, L.M., (1992) Behavior Analysis and Therapy in Nursing Homes, Charles C. Thomas.

Segal, Z.V., Williams, J.M. and Teasdale, J.D. (2001) Mindfulness-based cognitive therapy for depression, Guilford Press.

Thorn, B.E. (2004) Cognitive Therapy for Chronic Pain,  Guilford Press.

White, C.A., (2001) Cognitive Behavior Therapy for Chronic Medical Problems,  John Wiley and Sons.