MODULE 5 -OTHER COGNITIVE BEHAVIOR THERAPIES

ACCEPTANCE AND COMMITMENT THERAPY

ACT gets its name from one of its core messages: accept what is out of your personal control,
and commit to taking action that enriches your life. The aim of ACT is to help us create a rich,
full, and meaningful life, while accepting the pain that life inevitably brings. ACT does this by
teaching us psychological skills to handle painful thoughts and feelings effectively, in such a way
that they have much less impact and influence—these are known as mindfulness skills; and
helping us to clarify what’s truly important and meaningful to us—that is, clarify our values—
and use that knowledge to guide, inspire, and motivate us to set goals and take action that
enriches our life.
Steven C. Hayes developed Acceptance and Commitment Therapy in 1982 in order to create a
mixed approach which integrates both cognitive and behavioral therapy.

ACT view of mindfulness

Acceptance and Commitment Therapy is a powerful mindfulness-based therapy (and coaching
model) which currently leads the field in terms of research, application and results.
Mindfulness is a mental state of awareness, focus and openness – which allows you to engage
fully in what you are doing at any moment. In a state of mindfulness, difficult thoughts and
feelings have much less impact and influence over you – so it is hugely useful for everything
from full-blown psychiatric illness to enhancing athletic or business performance. In many
models of coaching and therapy, mindfulness is taught primarily via meditation. However, in
ACT, meditation is seen as only one way amongst hundreds of learning these skills – and this is a
good thing, because most people do not like meditating! ACT gives you a vast range of tools to
learn mindfulness skills – many of which require only a few minutes to master.
ACT breaks mindfulness skills down into 3 categories:
1) Defusion: distancing from, and letting go of, unhelpful thoughts, beliefs and memories
2) Acceptance: making room for painful feelings, urges and sensations, and allowing them to
come and go without a struggle
3) Contact with the present moment: engaging fully with your here-and-now experience, with
an attitude of openness and curiosity

Six core therapeutic process of ACT

The six core therapeutic processes in ACT are:
1. Contacting the Present Moment (Be Here Now)
Contacting the present moment means being psychologically present: consciously connecting
with and engaging in whatever is happening in this moment. Humans find it very hard to stay
present. Like other humans, we know how easy it is to get caught up in our thoughts and lose
touch with the world around us. Contacting the present moment means flexibly bringing our
awareness to either the physical world around us or the psychological world within us, or to
both simultaneously. It also means consciously paying attention to our here-and-now
experience instead of drifting off into our thoughts or operating on “automatic pilot.”

2. Defusion (Watch Your Thinking)

Defusion means learning to “step back” and separate or detach from our thoughts, images, and
memories. Instead of getting caught up in our thoughts or being pushed around by them, we let
them come and go as if they were just cars driving past outside our house. We step back and
watch our thinking instead of getting tangled up in it. We see our thoughts for what they are—
nothing more or less than words or pictures. We hold them lightly instead of clutching them
tightly.

3. Acceptance (Open Up)

Acceptance means opening up and making room for painful feelings, sensations, urges, and
emotions. Instead of fighting them, resisting them, running from them, or getting overwhelmed
by them, we open up to them and let them be. (Note: This doesn’t mean liking them or wanting
them. It simply means making room for them!)

THE ACT HEXAFLEX

4. Self-as-Context (Pure Awareness)

In everyday language, we talk about the “mind” without recognizing that there are two distinct
elements to it: the thinking self and the observing self. We’re all very familiar with the thinking
self that part of us which is always thinking—generating thoughts, beliefs, memories,
judgments, fantasies, plans, and so on. But most people are unfamiliar with the observing self:
the aspect of us that is aware of whatever we’re thinking, feeling, sensing, or doing in any
moment. Another term for it is “pure awareness.” In ACT, the technical term is self-as-context.
For example, as you go through life, your body changes, your thoughts change, your feelings
change, your roles change, but the “you” that’s able to notice or observe all those things never
changes. It’s the same “you” that’s been there your whole life. With clients, we generally refer
to it as “the observing self” rather than use the technical term “self-as-context.”

5. Values (Know What Matters)

Values are desired qualities of ongoing action. In other words, they describe how we want to
behave on an ongoing basis. Clarifying values is an essential step in creating a meaningful life. In
ACT, we often refer to values as “chosen life directions.” We commonly compare values to a
compass because they give us direction and guide our ongoing journey.

6. Committed Action (Do What It Takes)

Committed action means taking effective action, guided by our values. It’s all well and good to
know our values, but it’s only via ongoing values-congruent action that life becomes rich, full,
and meaningful. Values-guided action gives rise to a wide range of thoughts and feelings, both
pleasant and unpleasant, both pleasurable and painful. So committed action means “doing what
it takes” to live by our values even if that brings up pain and discomfort.
  Psychological Flexibility: A Six-Faceted Diamond
Keep in mind that the six core processes of ACT aren’t separate processes. To help therapists
and clients learn and apply the ACT model—it’s more useful to think of them as six facets of one
diamond. And the diamond itself is psychological flexibility.
Psychological flexibility is the ability to be in the present moment with full awareness and
openness to our experience, and to take action guided by our values. Put more simply, it’s the
ability to “be present, open up, and do what matters.” Technically speaking, the primary aim of
ACT is to increase psychological flexibility. The greater our ability to be fully conscious, to be
open to our experience, and to act on our values, the greater our quality of life because we can
respond far more effectively to the problems and challenges life inevitably brings. Furthermore,
through engaging fully in our life and allowing our values to guide us, we develop a sense of
meaning and purpose, and we experience a sense of vitality.

The ACT acronym

A = Accept your thoughts and feelings, and be present.
C = Choose a valued direction.
T = Take action.

Duration and Delivery of ACT

ACT can be delivered in many different ways:
a) long-term therapy – for example, for borderline personality disorder: forty 2-hour sessions.
b) medium-term therapy – for example, for chronic pain: eight hours in total
c) brief therapy – for example, for schizophrenia: only four 1-hour sessions
d) ultra-brief therapy – for example, Kirk Strosahl’s work in primary care medical settings, where
ACT can be highly effective even in one or two twenty to thirty-minute sessions.
 DIALECTICAL BEHAVIOR THERAPY
The “D” means “dialectical.” A dialectic is a synthesis or integration of opposites. In DBT,
dialectical strategies help both the therapist and the client get unstuck from extreme positions. 
The “B” stands for “behavioral.” DBT requires a behavioral approach. This means that we assess
the situations and target behaviors that are relevant to our clients’ goals in order to figure out
how to solve the problems in their lives.
DBT is a cognitive-behavioral treatment developed by Marsha Linehan in the 1980s to treat
people with borderline personality disorder. 
Dr. Linehan made three major assumptions when organizing the principles of her approach to
psychotherapy:

 Multiple foundations: The approach had its basis in the foundations of philosophy and
science.
 Change is inevitable: The approach assumes that truth and reality constantly evolve.
 Integration: Everything is connected with everything else. The one major constant in the
universe is that change is inevitable and that even what appear to be totally opposing points of
view can be integrated.

DBT presumes a capability and motivational deficit model of borderline personality disorder.
Linehan hypothesised that, as a consequence of a biological vulnerability transacting with
invalidating environments, clients develop deficits in key self-management skills (e.g. emotion
regulation, interpersonal effectiveness, distress tolerance) and in sustaining motivation to
change. Each function of the treatment addresses some aspect of these capability and
motivational deficits. For example, DBT programmes devote an entire modality of treatment to
skill acquisition; most commonly skills training groups fulfill this function. Without sustained
attention to the motivational factors that interfere in changing behavior and the effective
utilization of new skills, skills’ training alone is unlikely to be effective. DBT individual
psychotherapy is the most common modality addressing motivational problems. The DBT
therapist, through repeated behavioral and solution analyses reaches a comprehensive
understanding of the motivational difficulties of the client and implements strategies to
ameliorate them.
DBT programmes have five functions designed to comprehensively address the problems of
clients with a borderline diagnosis.

Techniques used
 Incorporating the concept of mindfulness: the concept of mindfulness refers to the
ability to give one’s undivided attention to what is happening in the moment in a
nonjudgmental manner and experiencing the moment as it occurs. For individuals with
distressing problems, it is often important for them to suspend their expectations and
biases in order to understand others.
 Tolerating stress/distress: This technique is related to the mindfulness approach.
Individuals frequently come to therapy attempting to change stressful or distressing
circumstances (e.g., loss of a loved one, a traumatic experience, etc.). In some cases,
such change is impossible. DBT endeavors to assist clients to accept such inevitabilities
in a nonjudgmental and non-evaluative fashion. This allows them to accept more
positive approaches and take more positive actions to address issues they can control.
 Emotional regulation: Many clients who are originally referred for DBT experience very
extreme and intense emotional states (e.g., actively suicidal clients or clients with
borderline personality disorder). DBT attempts to identify emotions, reducing one’s
vulnerability to reactive behaviors that may occur as a result of emotional states,
increasing mindfulness, identifying obstacles to changing emotions, learning to take
opposite actions, and/or applying stress management for stress/distress tolerance.
MINDFULNESS BASED COGNITIVE THERAPY - developed by Jon Kabat-Zinn
Mindfulness-Based Cognitive Therapy (MBCT) is a relatively new form of therapy that takes
features from both mindfulness techniques and cognitive therapy.
Mindfulness can be described as being in the present moment and being aware of one’s body,
thoughts, surroundings and feelings. It has roots in Buddhist traditions and has increasingly
been adapted for use in therapy. Mindfulness can increase concentration levels, and can help
both mental and physical conditions including obsessive compulsive disorders, anxiety, and
prevention of relapse in depression and drug addiction. Significant research supports the use
of MBSR in significantly helping patients with chronic pain, hypertension, heart disease,
cancer, and gastrointestinal disorders, as well as for psychological problems.

Unlike cognitive therapy, the mindfulness approach makes no attempt to change the content of
negative thinking. Rather it encourages participants to change their relationship to their own
thoughts, feelings and body sensations, so that they have an opportunity to discover that these
are fleeting events in the mind and the body which they can choose to engage with – or not.
That is, repeated practice in noticing, observing with interest and compassion, and decentring
helps participants to realise that their thoughts, emotions and sensations are just thoughts,
emotions and sensations, rather than ‘truth’ or ‘me’.

MBCT exercises and techniques

The most popular course of MBCT treatment was developed by Jon Kabat-Zinn. This treatment
is an 8-week group-based therapy program created to help clients cope with both mental and
physical symptoms. Groups meet once a week for two hours and complete homework outside
of class for six days a week. Homework includes meditation practice, audio-guided mindfulness
exercises, and techniques like the three-minute breathing space.
1. Three-Minute Breathing Space
The three-minute breathing space is a quick exercise that is undertaken in three steps:
 The first minute is spent on answering the question, “how am I doing right now?” while
focusing on the feelings, thoughts, and sensations that arise and trying to give these words
and phrases.
 The second minute is spent on keeping awareness on the breath.
 The last minute is used for an expansion of attention from solely focusing on the breath,
to feeling physical sensations and how they affect the rest of the body.

2. Body Scan
The Body Scan exercise begins with the participants lying on their backs with their palms facing
up and their feet falling slightly apart. This exercise can also be done by participants sitting on a
comfortable chair with their feet resting on the floor.
The facilitator asks the participants to lie very still for the duration of the exercise, and move
deliberately and with awareness if it becomes necessary to adjust their position.
Next, the facilitator begins guiding participants through the Body Scan. Participants begin by
bringing awareness to the breath, noticing the rhythm, and the experience of breathing in and
expelling out. The facilitator explains that participants should not try to change the way they are
breathing, just hold gentle awareness on the breath.
The facilitator guides attention to the body next: how it feels, the texture of clothing against the
skin, the contours of the surface on which the body is resting, the temperature of the body and
the environment.

Participants are instructed to bring their awareness to the parts of the body that are tingling,
sore, or feeling particularly heavy or light. The facilitator asks the participants to note any areas
of their body where they don’t feel any sensations at all or, conversely, areas that are
hypersensitive.

3. Mindfulness Stretching
Mindfulness can be practiced in many situations throughout the day, including exercise.
However, rushing straight to the exercise can be a missed opportunity to prepare both mind and
body for physical exertion.
Stretching before a workout is important for several reasons, including (Crain):
 It’s a natural and instinctive movement for humans.
 Regular stretching improves flexibility and range of motion.
 Stretching improves and increases circulation by bringing a rush of oxygen to the
muscles.
 It feels good to stretch!

4. Proprioceptive Neuromuscular Facilitation (PNF)

PNF is a set of guidelines rather than a specific technique. This type of stretching is based on
four principles:
(1) avoid pain in your stretches, 
(2) stretch slowly to avoid injury, 
(3) exercise caution when stretching, and make sure to stretch the correct muscle, and 
(4) stretch carefully to avoid affecting other muscles or joints

5. Yoga Poses
There are several yoga poses that facilitate mindful stretching, and these four are recommended
in particular:
 Gomukhasana:
 Side to side neck stretch:
 Pigeon Pose:
 The Scorpion:

6. Daily Mindfulness
Sometimes the most simple exercises can be the most helpful. In the case of MBCT, this is
especially true. Practicing mindfulness throughout the day is the best way to make sure it is
woven into your life.
Mindful Showering
While showering, direct your attention to the temperature of the water as it hits your body, the
feel of the spray, the smell of the shampoo, and the sensation of lathered soap against your
skin. If your mind begins to wander, a common problem during showers, gently bring it back to
the present with thoughts about what you are seeing, hearing, smelling, and feeling.
Mindfully Brushing Your Teeth
Similar to mindful showering, bring your awareness to the sensations evoked by the feel of the
brush.

Mindful Eating
helpful tip that has not yet been mentioned is to turn off any distractions, like the computer, TV,
radio, and smartphone, and allowing all of your senses to focus on.

INTERPERSONAL THERAPY
Interpersonal Psychotherapy (IPT is a time-limited, interpersonally focused, psychodynamically
informed psychotherapy that has the goals of symptom relief and improving interpersonal
functioning. IPT is concerned with the ‘interpersonal context’—the relational factors that
predispose, precipitate and perpetuate the patient’s distress. Within IPT interpersonal
relationships are the focus of therapeutic attention as the means to bring about change, with
the aim of helping patients to improve their interpersonal relationships or change their
expectations about them.

The structure of IPT

There are five distinct phases in the IPT approach:
1. The initial assessment for IPT suitability
The ‘assessment phase’ of IPT determines whether the patient is a suitable candidate for IPT.
Non-specific issues are considered such as suitability for any psychological intervention,
motivation for change, ego strength, adequacy on non-psychological treatments, and so forth.

2. The initial sessions

The initial sessions of IPT include a number of specific tasks. The primary goals are to develop an
interpersonal formulation, which is a detailed hypothesis about why the patient is having
interpersonal difficulties, and to gauge the patient’s social support in general. Intrinsic to this
process is the development of an Interpersonal Inventory (IPI).
The IPI functions as the main structural component of this process with a specific focus of the
patient and therapist on:
a. current relationships
b. the history of the patient’s current problems as applied to that relationship
c. information that is relevant to the process of resolving the problem area, for example
attachment style, communication style, and patterns of interaction
d. setting appropriate treatment goals.

3. The middle sessions

In the middle sessions of IPT the therapist and patient address one or more of the four IPT
problem areas using key IPT techniques. Whilst working on these issues the therapist is mindful
of the patient’s attachment style and communication style. In general, after identifying specific
problems during the assessment and initial phases, the therapist gathers more information
about the specific problem area(s). Both patient and therapist then work to develop solutions to
the problem, such as improving the patient’s communication skills or modifying his or her
expectations about a dispute.

4. Concluding acute treatment and maintenance treatment

The specific goals at the conclusion of treatment are to foster the patient’s independent
functioning and to enhance his or her sense of competence. Ideally, IPT teaches patients new
communication skills, helps them to develop insight into how they communicate their needs,
and helps them to establish more
functional social support networks, all in the service of improving interpersonal functioning.
The IPT problem areas
• grief,
• interpersonal disputes (role disputes),
• role transitions,
• interpersonal sensitivity (interpersonal deficits).
Techniques
There are a number of specific techniques that are central to the success of IPT, although not
unique to IPT.
1. The therapeutic relationship
A basic tenet of IPT is that all interventions should be therapeutic and should enhance the
alliance. Of course, the IPT therapist needs to draw boundaries when necessary and to be active
and directive as required, as it is a structured therapy. There is effectively a balance between
activity and active listening. The therapeutic relationship can be used in IPT as a means to gather
information, and as a means of attending to the patient’s attachment needs and helping them to
experience a successful relationship. The therapist can use the relationship indirectly as a means
to bring about therapeutic change, for example modeling different communication patterns.

2. Encouragement of affect
This technique is used to help patients express, understand and manage affect. According to
Stuart and Robertson (2003, 125) there are several goals regarding the use of affect in IPT:
a. to assist the patient to recognize his or her immediate affect;
b. to assist the patient to communicate his or her affect more effectively to others;
c. to facilitate the patient’s recognition of affect that may have been suppressed, or that
the patient may find painful to acknowledge. Of particular importance is the therapist’s
attention to and facilitation of ‘process affect’—affect displayed during the conduct of
therapy—as opposed to ‘content affect’—affect about past events or interactions
outside of the therapeutic relationship.

3. Communication analysis
Disordered communication is hypothesised to be a primary reason for interpersonal problems.
In particular, the therapist is attuned to ambiguous and indirect verbal and non-verbal
communication that could be changed to more direct, less ambiguous verbal communication.
Communication analysis often leads on to other techniques such as problem solving and role-
play. In terms of change the therapist may also serve as a role model for communication. The
overall goals of communication analysis according to Stuart and Robertson (2003) are:
• identify communication patterns and responses elicited from others;
• identify the client’s contribution to communication problems;
• motivate the client to communicate more effectively;
• learn new and more effective skills.
SOLUTION FOCUSED THERAPY
8) Presupposing change
When clients are focused on changing the negative aspects (or problems) in their lives,
positive changes can often be overlooked, minimized or discounted due to the ongoing
presence of the problem. The solution focused approach challenges counsellors to be attentive
to positive changes (however small) that occur in their clients’ lives. Questions that presuppose
change can be useful in assisting clients to recognise such changes. Questions such as, “What’s
different, or
better since I saw you last time?” This question invites clients to consider the possibility that
change (perhaps positive change) has recently occurred in their lives.

Applications
Solution focused counsellors are more concerned with solutions than how or why a problem
originated. For this reason, solution focused practice has a broad application. The solution
focused approach can be brief due to its focus on ‘what works’ and its emphasis on action as
a significant factor in change. This makes it an approach that can be well integrated into the
typically fast-paced lifestyle of the contemporary client.
As such, solution focused therapy has been successfully applied to a variety of client concerns,
including drug and alcohol abuse, depression, relationship difficulties, relationship
breakdown, eating disorders, anger management, communication difficulties and crisis
intervention to name but a few. In addition, solution focused approaches have been effectively
applied to a vast array of client groups, including children, families, couples and mandated
clients.