Further delineating the applicability of acceptance and change to private responses: The example of Dialectical Behavior Therapy.

In the last decade, empirical support has emerged for therapies emphasizing mindfulness and acceptance. Increasingly, clinicians are integrating these strategies into clinical packages that have traditionally focused on change and control of cognitive content. The authors suggest that a mindfulness/acceptance approach is grounded in a set of basic assumptions that are not compatible with strategies that focus on change and control of private responses. The authors illustrate this point using the example of Dialectical Behavior Therapy (DBT). Inclusion of cognitive change strategies with mindfulness to address cognitive content creates a contradiction that is theoretically unworkable and experientially confusing. The authors describe a form of DBT in which cognitive change strategies are replaced with the principles and practices of Acceptance and Commitment Therapy (ACT) as an approach to private responses, and cognitive content in particular. Keywords: Dialectical Behavior Therapy, DBT, Acceptance and Commitment Therapy, ACT, mindfulness, acceptance. ********** Several fields of science (e.g., physics and neuroscience) have moved beyond mechanistic and mentalistic paradigms to explain everything from the basic components of the universe to the functioning of the "mind." These changes have begun to influence the discipline of behavioral sciences as well, having influenced what has been heralded as the "third wave" in cognitive-behavioral therapy (Hayes in Hayes, Follette, & Linehan, 2004). Our thinking has been expanded beyond the limitations of the current cognitive approach (Hayes, Stroshal, Wilson, 1999) to include mindfulness and acceptance as important aspects of a complete treatment strategy for various distressing states. While a number of key figures, including Marsha Linehan, Steven Hayes, Neil Jacobson, and Robert Kohlenberg, have focused on acceptance and mindfulness in their work for several decades, only in the past ten years has there been wide-spread consideration within the cognitive-behavioral tradition of mindfulness and acceptance as important aspects of a complete treatment strategy for various distressing states. Consideration of philosophical assumptions is important when clinicians attempt to integrate new strategies into traditional treatment packages, in order to avoid confusion at the level of theory and experience (Hayes, Strosahl, & Wilson, 1999). We suggest that while the movement toward integrating acceptance and mindfulness into traditional cognitive-behavioral practices is a step in the right direction, it is also important to think critically about the compatibility of the basic assumptions implicit within these various approaches. To illustrate this point, we will use the example of Dialectical Behavior Therapy (DBT), both because of our dedication to this therapy and because it is one of the earliest examples of the attempt to integrate acceptance and change strategies into a coherent treatment package. As its name suggests, DBT is grounded in a dialectical perspective on reality and experience. That is, the world is in constant flux and ever changing, and individuals are continually in transition. An individual's current knowledge sets the occasion for his or her next act, and the consequences of that action refines his or her knowledge of self, others, and the world. This never-ending cyclical relationship between what the individual knows and what he or she does leads to successive approximations toward or away from reality. DBT identifies and attempts to address a meaningful dialectic of human experience, however, by including strategies aimed at changing or controlling the content of private experience, it generates a contradiction that is both theoretically and experientially unnecessary and which may limit the effectiveness of this treatment. While strategies for changing and controlling private experience may not appear to be a major emphasis in DBT, they are presented as interventions both in the individual therapy and skills group. …