Lynn Mollick Addresses NJ-ACT on Acceptance and Mindfulness for Anxiety
By Lynn Mollick
Cognitive Behavior Therapy developed in three sequential stages, sometimes described as three waves. The First Wave emphasized behavioral interventions such as relaxation, systematic desensitization, skill training, and exposure. The Second Wave built on the First and added cognitive techniques based on logic, disputation, and evaluating the evidence. Anxiety reduction was the goal of both waves.
CBT’s Third Wave is based on the idea that attempts to reduce anxiety symptoms increase anxiety. The goal of Third Wave CBT is acceptance of anxiety. Steven Hayes’ Acceptance & Commitment Therapy (ACT) is the most prominent Third Wave Treatment.
In her September 24, 2017 presentation for NJ-ACT, Dr. Lynn Mollick explained that techniques from the First, Second, and Third Waves all change the three critical cognitions that cause and maintain anxiety:
1. The belief that anxiety is intolerable,
2. The belief that anxiety is interminable, and
3. The belief that anxiety is dangerous.
Acceptance & Commitment Therapy (ACT) for Anxiety
ACT utilizes four types of interventions:
1. Pursuing valued goals in spite of anxiety;
2. De-fusing from problematic thoughts and feelings; making them less important;
3. Self-compassion — accepting negative thoughts and feelings as “just thoughts” and “just feelings”; and
4. Mindfulness — non-judgmental awareness of present experience.
Being mindful of the present reduces worry about the future and rumination about the past. Reducing worry and rumination diminishes physiological anxiety. The fundamental reason for teaching mindfulness to anxious patients is to help them develop a skill they can use in their daily lives.
“In-the-moment” mindfulness means being constantly aware of the present – what you can see, hear, feel, etc. Two examples of “in the moment” mindfulness are mindful eating and mindful showering.
Mindfulness exercises. In Third Wave CBT, there are two basic mindfulness protocols — Kabat-Zinn’s Mindfulness-Based Stress Reduction (MBSR) and Eifert & Forsyth’s Acceptance & Commitment Therapy (ACT) for anxiety disorders.
Mindfulness-Based Stress Reduction (MBSR)
MBSR has been widely disseminated. Variations appear in many empirically validated CBT programs, e.g. Mindfulness-Based Cognitive Therapy, Mindfulness- and Acceptance-Based Behavior Therapy, Mindfulness-Based Relapse Prevention.
The two basic exercises in MBSR are:
1. The Body Scan – noticing physical sensations throughout the body; and
2. Breath Awareness – attending to sensations of breathing.
The goal of both exercises is non-judgmental present-focused awareness. MBSR encourages patients to bring the same accepting attitude into daily activities so that they can eat, shower, vacuum, wash dishes, or perform all daily activities mindfully.
Other exercises build on the Body Scan and Breath Awareness:
3. Mindfulness of Thoughts and Feelings — non-judgmental awareness of whatever passes through awareness; and
4. Inviting in a Difficulty (aka Befriending Difficult Feelings or Mindfulness of Difficult Feelings) – asking patients to intentionally experience distressing thoughts and feelings so they learn to accept them without judgment or alarm.
MBSR is a Third Wave approach because it teaches acceptance of all emotional experience. On the other hand, MBSR might be considered Second Wave because it explicitly seeks to reduce anxiety.
Eifert & Forsyth’s ACT approach:
Because ACT rejects any attempts to escape, avoid, or diminish anxiety and other emotional experiences, Eifert & Forsyth do not teach the Body Scan and Breath Awareness. Here is the Eifort & Forsyth protocol:
1. Centering. The protocol begins with Centering — mindful awareness of present experience: sounds in the room, sensations of sitting in a chair, pleasant and unpleasant thoughts and feelings. Eifert & Forsyth assign Centering for homework after the first session, and they suggest beginning every therapy session with this exercise.
2. Awareness of Thoughts and Feelings.
3. Awareness of Anxiety.
4. Feeling Experience Enriches Living (FEEL). This is Eifert & Forsythe’s name for interoceptive exposure, intentionally creating physical anxiety symptoms – for example spinning around in a swivel chair to create feelings of dizziness. FEEL is a way to “get better at feeling” instead of “feeling better.” Eifert & Forsyth also explain that the purpose of FEEL is neither habituation nor extinction of anxiety. The purpose of FEEL is to have “a life worth living” in spite of emotional distress.
ACT therapists ask patients to rate their “willingness” to undertake FEEL exercises on a scale of 1 to 10. Willingness of 7 or higher suggests that patients are ready to attempt a more intense FEEL exercise.
Initially patients should practice FEEL in the therapist’s office. Later they should practice at home. Finally, patients utilize FEEL in situations that trigger their symptoms.
Eifert & Forsyth’s approach is firmly Third Wave because it makes no attempt to reduce anxiety symptoms. Nonetheless, patients eventually learn that anxiety is not intolerable, not interminable, and not dangerous.
Panic patients experience a distressing emotion, usually anxiety, and respond with negative assessments of the distressing emotion: “My anxiety is intolerable, interminable, and dangerous because it will make me pass out, have a heart attack, go crazy, or somehow make a fool of myself.” As a result of these appraisals, the patient tries to avoid, escape, diminish, or suppress the distressing emotion.
Because anxiety reduction is reinforcing, the pattern perpetuates itself. Patients begin to avoid situations where panic attacks might occur.
Acceptance techniques often helpful for Panic Disorder include:
1. “In-the-moment” body scan. During a panic attack, notice sensations that occur. Start at the top of the head and proceed down the body to the feet. Repeat until the attack has passed or is no longer troublesome.
2. Russ Harris’ mindful STOP:
Slow down breathing; slowly stretch, press fingers together or push feet into the floor.
Take notice (with curiosity) of present thoughts and feelings-
what your 5 senses take in, where you are, what you’re doing
Open up and make room for your thoughts and feelings; allow them to flow through you; use any de-fusion technique you like
Pursue values and let them guide what you do next
3. F-A-F-L. Claire Weekes’ (1976) instruction to face it, accept it, float through it, and let time pass.
4. Diaphragmatic breathing (Barlow). Use to help patients experience and get through panic
attacks until they pass, not to reduce or avoid anxiety.
5. FEEL. (Eifert & Forsyth) After doing interoceptive exposure for panic symptoms in the office and at home, do it in avoided situations that promote patients’ values.
Obsessive Compulsive Disorder (OCD)
OCD begins when a person experiences unwanted thoughts and feelings. The patient interprets these thoughts and feelings as intolerable, interminable or dangerous. The patient then performs a compulsion to escape, avoid, or diminish the unwanted thought or feeling. Later, the patient avoids situations where the unwanted thoughts and feelings might occur.
Because OCD patients give too much importance to their obsessive thoughts and feelings, de-fusion is helpful:
1. Language modifications. “I’m having the thought that I left the oven turned on,” or “I’m having the feeling that my hands are dirty.“ This modification creates distance and makes the thought or feeling seem less important.
2. Metaphors. Treat an obsessive thought as though it were something else, for example:
a) Skunk in the living room. You wouldn’t want to shoo it away with a broom. It would be better to wait for it to walk out the door.
b) Jerk at a party. You wouldn’t want to argue with the jerk or demand that the jerk leave. It’s better to enjoy the party and pay no attention to the jerk.
3. Imagery. Turn the obsession and its consequences into a movie that you watch on a screen.
4. Mindfulness enables OCD patients to observe distressing thoughts and feelings, and to take a less emotional perspective on them.
5. Thought labeling means giving a label (a name) to each kind of thought that interferes with present-focused awareness. For example, if a health anxiety patient’s mindfulness exercise is interrupted by a thought of having a serious illness, the patient could label that thought “health worry,” and then return to the mindfulness exercise. This teaches OCD patients to respond to intrusive thoughts without alarm, by “doing nothing.” They learn to see their obsessions as “just OCD thoughts,” a useful skill for overcoming OCD. Thought labeling can be added to any mindfulness exercise.
Post-Traumatic Stress Disorder
In PTSD, patients re-experience their trauma in dreams and flashbacks. They use numbing, escape, and avoidance to diminish terrifying thoughts, memories, and feelings.
Since memories are “just thoughts” and “just feelings,” mindfulness practice can help PTSD patients take a different perspective on their thoughts and feelings. The mindful body scan can teach PTSD patients to experience trauma memories as small bits of sensation. Modifications to mindfulness exercises may be needed with PTSD patients:
1. Keep eyes open instead of shut.
2. Focus outside the body, for example with mindfulness of sounds,
before focusing on the surface of the body.
3. Add images of safety.
4. Practice in the office first and prepare for dissociation and de-realization. Dissociation and de-realization are “just feelings.”
5. Use a hierarchy for Inviting In a Difficulty (imaginal exposure),
and repeat each scene many times.
PTSD patients often do not accept themselves; they view themselves as damaged. ACT provides the following acceptance techniques:
1. Self as context. (Think “container” instead of “context.”) Positive and negative thoughts and feelings exist within the self (context/container). The self is inherently neutral or good and cannot be damaged.
2. Metaphors. For example, “The Chessboard.” Black pieces are negative evaluations; white pieces are positive evaluations. Sometimes one color is winning the game; other times the other color is winning. The patient is the chess board where the game takes place. (This is another example of “self as context.”)
3. Self-compassion. Write a description of each of these aspects of yourself: your best self, your struggling self, your self as a friend/parent/other part of your identity. Meditate on what each of these would say to you. When you are finished with each, say “I am holding this image of myself gently. It is soft, like a feather. But it is not me.”
Social Anxiety Disorder (SAD)
SAD patients’ behavior is controlled by their expectations that others will evaluate them negatively. Since others’ evaluations can never be known, exposure will not provide information to correct these expectations of criticism. Therefore, exposure is not particularly effective for SAD patients. These patients firmly believe their expectations. De-fusion helps them take a new perspective and establish some distance from their expectations of social rejection.
1. Make subtle language changes:
a) Express thoughts as thoughts, not facts. “I’m having the thought that they think I’m an idiot” instead of “They think I’m an idiot.”
b) Substitute “and” for because. For example: “I felt anxious and I left the party” instead of “I left the party because I was anxious.” You don’t have to leave parties because you’re anxious. When you feel anxious at parties, you can remain and continue to feel anxious.
2. Objectify anxious thoughts. “Thank you mind for reminding me to worry about what people think of me,” or, “There goes my mind telling me that I can’t tolerate having sweaty palms.”
3. Metaphors. Think of yourself as a bus journeying in a valued direction. Unfortunately, you have many unruly passengers that are trying to get you off course. The unruly passengers are your various social fears. Name them.
4. Name the thinking error of each of each of your dysfunctional thought without disputing the thought. “I’m fortune telling.” “I’m jumping to conclusions.”
5. Adrian Wells’ Attention Focus Training can help SAD patients distance from the many thoughts that preoccupy them in social situations and can help them focus on the present.