Cognitive change techniques are often considered incompatible with mindfulness and acceptance based therapies. In these approaches, clients are encouraged to distance themselves from sticky thoughts rather than changing their form and content. While there is no doubt that therapeutic techniques employed in mindfulness and acceptance approaches are different than traditional cognitive therapy techniques, it is worth looking more closely at what therapists do to promote distancing from thoughts. When therapists invite clients to look at their thoughts as if they were clouds in the sky, or to mentally step back from these thoughts, are they not encouraging clients to think differently about their thoughts, after all?
Relational frame theory (RFT) is a contextual behavioral approach to language and cognition that allows therapists to integrate cognitive change strategies into mindfulness and acceptance based approaches. From an RFT perspective, there are 4 main principles to follow in order to help clients change their way of thinking, while avoiding the pitfalls of traditional cognitive change techniques (e.g. paradoxical effects of thought suppression, fruitless debates about reality, pathologizing certain thoughts and their thinkers). Here are these 4 principles:
#1 Target the context, not the thought
Thinking is a behavior, and like other behaviors, you can shape it. In order to do that, it is crucial to understand that a behavior is a not a concrete thing that you can alter directly, but an interaction between an organism and an environment. You need to target the antecedents and consequences of the behavior you are trying to shape. Imagine a client who is lacking motivation to engage in actions that could actually improve his life. He might be thinking for example, “I am too lazy to do it”. The therapist might increase his motivation by shaping his ability to connect the action to some meaningful purpose. She could ask for example, “When you imagine coming back next week and telling me how the past week went, what would you like to tell me you were able to accomplish? What would be meaningful, as you reflect back on the past week?” Here, the therapist uses an antecedent (the question) that makes thinking in terms of meaningful purpose more likely. Motivation is not directly modified by an intervention inside the client. It is activated by an alteration of the context. When you shape clients’ thinking (and other behaviors), always ask yourself: in what ways can I alter the context? What impact will this alteration have on the client’s way of thinking?
#2 Work by addition and integration, not by subtraction
Unlearning is not a psychological process. There are behaviors we learn not to do anymore, but they don’t disappear from our repertoires. We just don’t do them anymore. We can decide not to ever go back to a disappointing restaurant. That doesn’t mean we unlearn to go to that restaurant but simply that we learned not to do that, and we have good control over that action. The problem with thinking is that we have less control on this behavior than on other behaviors. It’s impossible to decide not to ever think of a painful memory again, and actually completely refrain from doing it. The symbolic relations that connect our thoughts with each other requires that we accept that thoughts can always come back, even if we don’t want to have them. So, when shaping clients’ thinking, assume that what they are thinking now will never completely disappear. Drop the strategy of removing or substituting any thought and instead, approach cognitive change as an additive and integrative process. Ask yourself, what useful thoughts could be added to the client’s repertoire? What thoughts might make sense of less useful thoughts while opening the client to new perspectives and more flexible responses? A typical example of integrative strategy to change cognition is to have clients reformulate a thought by saying, “I have the thought that…” Doing so puts the original thought in a broader context and creates some distance with its content, which undermines the influence of the thought over the client’s behavior.
#3 Encourage pragmatic thinking, not objective truth
One of the main pitfalls of cognitive change is to get stuck in the search for essential, objective truth. No thought is true or wrong out of context. Even the thought “I better kill myself” might be true in some contexts, for some people at least, if it means for example escaping the horrible pain associated with a deadly and untreatable disease. From an RFT perspective, thinking is better guided by pragmatism than essentialism. What matters is to develop ways of thinking that are useful. Instead of exploring how true a thought might be, therapists using RFT prefer considering the utility of this thought in a given context. Imagine a client saying, “I am the shyest person in the world. I will never be able to make friends. There is no point in even trying”. Even though this thought sounds like an overstatement, questioning its accuracy in terms of objective truth is likely to feel invalidating and to increase the client’s belief that what he is thinking is true. Instead, focusing on the utility of this thought in the context of wanting to make friends will redirect the client’s attention to what he can do to improve his life. The therapist might ask, “When you have this thought, what do you do next? And then what happens? Does that help you get closer to making friends, or farther away?” Other ways of making functional sense may also consist of normalizing responses, for example by establishing emotions as normal reactions, or by understanding that ineffective behaviors have been selected by past contingencies.
#4 Work experientially rather than didactically
Cognitions can create powerful insensitivities to important elements of our experience. Once we start thinking in a certain way, we tend to see things that confirm this way of thinking while ignoring other things that contradict it. From an RFT perspective, the main job of therapists is to help clients be more in touch with their own experience, so they can adapt their responses to the context in most effective ways. Giving good advice can be helpful, as when doing psycho-education about symptoms of a panic attack. But what is even more helpful is to teach clients how to learn from their own experience. This way, they acquire skills they can apply to any issue. If they are able to observe what they do and track the antecedents and consequences of what they do, they can adjust their responses moment by moment in the most adaptive way. Thus, instead of telling clients what to do or what to observe, experiential therapists prefer evoking observation of a variety of experiences. They ask a lot of questions that orient the client to useful contingencies (antecedent-behavior-consequence) such as, “What were you feeling then?” “What did you do next?” “And then what happened?” When shaping clients’ thinking, create a context that evokes their observation and encourage them to draw their own conclusions. Ask questions that lead them to explore various ways of thinking. Even when you think you know better, consider the possibility that the client might come to a different conclusion that is just as valid as yours, or perhaps even more.
- Don’t miss our training event in San Francisco on April 23-24. Mastering the Clinical Conversation: An Experiential Approach to Cognitive Change.
- Learn more about using RFT to do cognitive change in Mastering the Clinical Conversation: Language as Intervention.