Mindfulness and acceptance-based cognitive behavioral therapies: empirical evidence and clinical applications from a Christian perspective.

Tan, Siang-Yang

Behavior therapy can be historically viewed as consisting of three major generations or waves (Hayes, Luoma, Bond, Masuda, & Lillis, 2006): the first wave of traditional behavioral therapy: the second wave of cognitive behavioral therapy (CBT) which is now over 30 years old; and the third wave that presently consists of relatively contextualistic approaches such as Acceptance and Commitment Therapy (ACT, pronounced as one word; Hayes, Strosahl, & Wilson, 1999; Hayes & Strosahl, 2004), Mindfulness Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002), and Dialectical Behavior Therapy (DBT; Linehan, 1993a, 1993b). Contemporary CBT has therefore expanded to include such mindfulness and acceptance-based therapies as ACT, MCBT, DBT (Hayes, Follette, & Linehan, 2004; see also Roemer & Orsillo, 2009). These therapies have recently come to occupy a major place in the field of counseling and psychotherapy today (see Tan, 2011). Both their empirical evidence and clinical applications, including self-help books, for a wide range of psychological disorders, have grown significantly in the last decade or so (see Baer, 2006; Roemer & Orsillo, 2009; Shapiro & Carlson, 2009). This article will cover research into practice for ACT, MBCT, and DBT, with a Christian perspective provided.

Empirical Evidence for Mindfulness and Acceptance-Based Cognitive Behavioral Therapies: ACT, MBCT, and DBT

Before briefly reviewing the empirical evidence for the efficacy or effectiveness of ACT, MBCT, and DBT, it is important to have a clear definition of mindfulness, which has been described in various ways (see Baer, 2006; Germer, Siegel, and Fulton, 2005; Shapiro & Carlson, 2009). Bishop et al. (2004) have provided the following helpful operational definition:

   We propose a two-component model
   of mindfulness. The first component
   involves the self-regulation of attention
   so that it is maintained on immediate
   experience, thereby allowing
   for increased recognition of mental
   events in the present moment. The
   second component involves adopting
   a particular orientation that is characterized
   by curiosity, openness, and
   acceptance (p. 232).

Mindfulness and acceptance-based therapies have some spiritual roots in Zen Buddhism, but can also include similar spiritual traditions, such as Roman Catholic and Eastern Orthodox. From a broadly Christian perspective, contemplative spirituality has, for centuries, emphasized the sacrament of the present moment or self-abandonment to divine providence in every moment and every area of life, including the mundane (see de Caussade, 1989; see also Blanton, 2008). This is now often expressed in the essential spiritual task and process of "letting go and letting God" take control of the present (as well as the past and future). The Christian tradition of contemplative, meditative, or centering prayer therefore includes aspects of mindfulness and acceptance (e.g., see Benner, 2011; Finley, 2004; Ford, 2009; Foster, 2011; Keating, 2006; Merton, 1996; Pennington, 1982, 1999). However, a biblical perspective on mindfulness and acceptance-based therapies will also be appropriately critical of some aspects of these therapies (see Clinical Applications section of this article).

ACT

ACT, as developed by Steven Hayes and his colleagues, is based on relational frame theory, with six core processes or components (Hayes, Strosahl, & Wilson, 1999): (1) acceptance; (2) cognitive defusion (emphasizing flexibility in place of rigidity in thinking); (3) being present; (4) self as context focusing on a transcendent sense of self; (5) values; and (6) committed action (in accordance with one's values). ACT helps clients to accept painful experiences rather than fight to change or control or avoid unpleasant feelings. It also encourages clients to clarify what their deepest values are in life and to act or live in accordance to their values in what is called "committed action." There are many exercises and techniques that an ACT therapist can use with clients to help them experience these six core processes of therapy. One example is for clients to imagine their thoughts written on leaves falling down onto a moving stream, and then floating by, letting their thoughts simply come and go. Another example to help clients engage in cognitive defusion so they realize they are not their thoughts per se is for them to say, "I'm having the thought that I'm useless" whenever they think to themselves, "I'm useless." Excellent books are now available for effectively learning ACT, both for therapists (e.g., see Harris, 2009; Luoma, Hayes, & Walser, 2007), as well as for clients in more of a self-help format (e.g., see Hayes with Smith, 2005; Harris, 2007). There are also DVDs on how to conduct ACT with clients, known as ACT in Action by Steven C. Hayes (Oakland, CA: New Harbinger, 2008).

The empirical evidence for the effectiveness of ACT has grown significantly over the past decade or so. Hayes, Luoma, Bond, Masuda, and Lillis (2006) have summarized much of the research done up to a few years ago, focusing on available controlled studies that evaluated the effectiveness of ACT for a wider variety of client problems, including anxiety, depression, pain, work stress, smoking, diabetes management, substance use, stigma toward substance users in recovery, epilepsy, adjustment to cancer, coping with psychosis, borderline personality disorder, and trichotillomania (compulsive hair pulling). These outcome studies compared ACT with other treatments such as behavior therapy, cognitive therapy, pharmacotherapy, psychoeducation, and general treatments as usual, as well as control groups such as wait-list, no treatment and/or attention-placebo groups. The overall between group effect size found was d = .66 after treatment, and d = .65 at follow up assessment. Ost (2008) in a more recent review and meta-analysis of the third wave of behavioral therapies came to a similar conclusion about the effectiveness of ACT, based on thirteen randomized controlled trials (RCTs) which compared ACT (by itself or in combination with another intervention) with a control group or some other active treatment. These RCTs focused on depression, stress, psychotic symptoms, borderline personality disorders, opiate dependence, smoking, math anxiety, tri chotillomania, epilepsy, and diabetes. The overall effect size found in the meta-analysis by Ost was 0.68, which is a medium to large effect size, often interpreted to be clinically significant as well (see Shapiro & Carlson, 2009, pp. 71-72).

Other more recent outcome studies have been conducted on ACT for other disorders, such as obsessive-compulsive disorder (Twohig et al., 2010) and co-morbid eating pathology (Juarascio, Forman, & Herbert, 2010), with generally positive and encouraging results. However, Powers and Emmelkemp (2009) have recently concluded that ACT is more effective than control conditions but it is not superior to established treatments based on a recent meta-analytic review of ACT (Powers, Zum Vorde Sive Vording, & Emmelkemp, 2009), although Levin and Hayes (2009) disagreed with their conclusion.

The empirical evidence supporting the effectiveness of ACT for a wide range of psychological and medical conditions is therefore significant and growing, but more and better controlled outcome studies or RCTs are still needed.

MBCT

MBCT was developed by Segal, Williams, and Teasdale (2002) as an integration of CBT and Mindfulness-Based Stress Reduction (MBSR) originated by Kabat-Zinn and his colleagues in 1979 (see Kabat-Zinn, 1990). MBSR is a more general intervention that has been used to help clients manage stress and other medical conditions such as cancer and chronic pain in more effective ways. It is an intensive intervention that requires clients to learn a number of mindfulness practices, including practice meditation and gentle yoga for forty-five minutes a day, six days a week at home, using the following mindfulness techniques: the body scan (slowly attending to one's immediate experience or sensations from the feet up to the head, with attitudes of reverence, awe, kindness and acceptance without being judgmental), sitting meditation (focusing on one's breath), walking meditation (focusing on one's walking motions with the feet), gentle yoga, and informal brief daily mindfulness practice (usually focusing on one's breath) (see Shapiro & Carlson, 2009, pp. 48-51).

MBCT is usually conducted over eight weeks in small groups of up to twelve clients who have suffered from recurrent depression. It was not originally meant to be a treatment for acute major depressive episodes but to prevent the recurrence of such depression. It focuses on the body scan, sitting meditation, walking meditation, and informal daily mindfulness. A particular technique used in MBCT is the "three minute breathing space" in which clients are taught to take a minute to be mindful of what they are experiencing at the present moment, then to focus on their breathing for a minute, and finally to refocus their attention on their whole body in the remaining minute, with nonjudgmental acceptance (see Shapiro & Carlson, 2009, pp. 51-53). A very good self-help book for clients to use that includes a CD of guided meditation practices for the mindful way through depression or MBCT is now available (Williams, Teasdale, Segal, & J. Kabat-Zinn, 2007).

The empirical evidence for the effectiveness of MBCT is limited but MBCT has been found to have an additive benefit to usual care, especially for patients who have had three or more previous episodes of depression. However, more and better controlled outcome studies are needed before definitive conclusions can be made about the effectiveness of MBCT or MBCT-specific effects in the treatment of depression and its recurrence or the prevention of relapse in depression (see Coel ho, Canter, & Ernst, 2007; Williams, Russell, & Russell, 2008). Encouraging positive findings have been reported in a few more recent controlled outcome studies that concluded that: MBCT is as effective as maintenance antidepressant pharmacotherapy in offering protection against relapse/ occurrence in patients with major depression (Segal et al., 2010); MBCT is more effective than maintenance antidepressant medication in reducing residual depressive symptoms and psychiatric comorbidity and improving quality of life in depressed patients (Kuyken et al., 2008); cancer patients who received MBCT had large and significant improvements in mindfulness, depression, anxiety, and distress compared to those in a waitlist, no treatment group (Foley, Baillie, Huxter, Price, & Sinclair, 2010); MBCT decreased anxiety and depressive symptoms in a small group of bipolar patients in remission compared to a waitlist, no treatment control group, and improved anxiety in bipolar patients more than in unipolar depressed patients who also received MBCT (Williams et al., 2008). MBCT has also recently been used to treat generalized anxiety disorder, and other conditions such as insomnia, and behavioral problems and anxiety in children, but no controlled outcome studies have been done so far with these disorders (see Shapiro & Carlson, 2009, p.69).

It should be pointed out that a recent meta-analytic review of mindfulness-based therapy including MBSR and MBCT with a total of thirty nine studies and 1,140 participants reported robust effect sizes for decreasing anxiety and mood symptoms in patients who had anxiety and mood disorders (Hofmann, Sawyer, Witt, & Oh, 2010). Mindfulness based relapse prevention (patterned after MBCT) for addictive behaviors has also been developed and described in a recent clinician's guide by Bowen, Chawla, & Marlatt (2011).

DBT

Marsha Linehan (1993a, 1993b) developed DBT as a treatment for borderline personality disorder. It focuses on acceptance and mindfulness in helping clients to manage their intense emotions. The four major components of DBT are regulating affect, tolerating distress, improving interpersonal relationships, and training in mindfulness. DBT emphasizes the dialectic balancing and integration of opposing ideas, for example incorporating both acceptance and change. In the mindfulness component of DBT, there are three "states of mind" (reasonable mind that is logical and rational, emotional mind that is reactive with feelings controlling thoughts and actions, and wise mind that is the integration and balance of reasonable mind and emotional mind), and six "mindfulness skills": three "what" skills of observing, describing, and participating, and three "how" skills of non-judgmentally, one-mindfully, and effectively (see Shapiro & Carlson, 2009, p. 55).

The skills in DBT that are taught to clients require some time and practice, and DBT therefore typically lasts minimally for a year. It includes individual sessions as well as group skills training. DBT has been applied to various disorders besides borderline personality disorder and across different settings (Dimeff & Koerner, 2007), including in private practice (Marra, 2005). A helpful book for learning DBT skills for both professional therapists as well as clients or general readers is now available (McKay, Wood, & Brantley, 2007).

The empirical evidence for the effectiveness of DBT has grown in recent years. Seven randomized controlled trials (RCTs) for DBT with borderline personality disorder, and four RCTs for DBT with other diagnoses were included in a 2007 review (Lynch, Trust, Salsman, & Linehan, 2007). Another review in 2008 found thirteen RCTs of DBT, nine of which were with patients with borderline personality disorder (Ost, 2008).

It reported an average effect size of 0.58 for the DBT interventions, which is a medium-sized effect that is considered to be likely clinically significant (see Shapiro & Carlson, 2009, p.70). There is therefore a substantial number of well-controlled outcome studies or RCTs that support the clinical effectiveness of DBT with borderline personality disorder. In a more recent meta-analysis using mixed-effects modeling and including only patients with borderline personality disorder, sixteen outcome studies were identified, eight of which were RCTs of DBT. A moderate global effect and a moderate effect size for suicidal and self-injurious behaviors were found (Kleinn, Kroger, & Kosfelder, 2010), similar to the findings reported in earlier reviews. Although there are methodological problems with some of the outcome studies reviewed (Ost, 2008), overall DBT seems to be an effective treatment, especially for women with borderline personality disorder who also have suicidal behavior or substance abuse, and for patients with depression and potentially for those with eating disorders (see Shapiro & Carlson, p. 71).

Clinical Applications

Some examples of clinical applications have already been provided earlier in this article. Mindfulness-based practices have also been applied to everyday problems such as: worry and anxiety; sadness and depression; pain and stress-related problems; romance, parenting and other intimate relationships; breaking bad habits; and aging, illness, and death (R. D. Siegel, 2010). The importance of mindfulness in the therapeutic relationship or the therapist has also been emphasized (see Hick & Bien, 2008; D. J. Siegel, 2010b). Daniel J. Siegel (2010a) has defined mindfulness in a particular way as mindsight which is "a kind of focused attention that allows us to see the internal workings of our own minds. It helps us to be aware of our mental processes without being swept away by them ..." (p. xi). He has especially pointed out how mindsight or mindfulness can actually affect our brains by changing the wiring and architecture of our brains with greater neural integration (see also D. J. Siegel, 2007).

In the more traditional CBT approach, key questions often asked in cognitive restructuring of the content of specific dysfunctional or distorted thoughts include: "On what basis do you say that to yourself?; Where's the evidence for your conclusion?; Is there another way of thinking about this?; What if it is true, what does this mean to you?" A Christian CBT approach may include questions such as: "What do you think God has to say about this?; What does the Bible have to say about this?" (see Tan, 2007; 2011). This direct approach to challenging and replacing dysfunctional or unbiblical beliefs and thoughts may work for many clients, but may not be as effective for some clients, especially those who may tend to ruminate and get stuck in obsessive cognitive restructuring. However, more traditional Christian CBT for depression was found to be an empirically supported treatment that is efficacious based on a total of 18 randomized clinical trials of spiritually oriented CBT in a recent review (Hook et al., 2010). Christian devotional meditation for anxiety and Christian group CBT for marital discord were found to be possibly efficacious treatments.

A mindfulness and acceptance-based approach to CBT will encourage clients instead to step back from their actual thoughts and passively let them come and go like leaves floating on a moving stream, and not fight the content of their thoughts no matter how negative or unreasonable. Clients come to realize that they are not their thoughts per se. They are more than their thoughts which can be random and meaningless at times. Clients can also be taught to say, "I am having the thought that I am useless" rather than saying to themselves "I am useless." They are also taught to engage in mindfulness practices such as focusing on their breathing and being aware of their bodily sensations, for example by using the three minute breathing space technique from MBCT.

A Christian approach to mindfulness and acceptance-based CBT can use some of these techniques but will contextualize them within a Christian contemplative tradition of learning to be mindful of the sacrament or sacredness of the present moment, and surrendering to God and His will in "letting go and letting God" take control. Clients can be encouraged to let their thoughts come and go, especially to Jesus so that every thought is brought captive to His control (cf. 2 Cor. 10:5), rather than just passively letting them come and go like leaves going down a stream. Clients therefore learn to "watch and pray" (cf. Matt. 26:41). This also means that the content of one's thoughts is important because biblical truth is crucial in right thinking that still affects one's feelings and actions (cf. Jn. 8:32; Rom. 12:2; Phil. 4:8). Such truth includes having hope for the future because of eternal life in Christ and Heaven to come (cf. Rom. 8:18; 2 Cor. 4:17, 18). A Christian perspective on life will therefore not focus only on the present or the now, but also on the future with hope. Secular versions of mindfulness and acceptance-based cognitive behavioral therapies do not emphasize ultimate, biblical truth, and are instead based on Zen Buddhism concepts that can be problematic from a Christian, biblical perspective. However, their emphasis on a gentle, kind, and compassionate approach to life and relationships is consistent with a biblical emphasis on the primacy of agape or Christ-like love in our lives and relationships (1 Cor. 13). Such love is the fruit of the Holy Spirit and his empowering work in our lives (Gal. 5:22, 23), and not the result of self-effort on our part.

The emphasis in ACT on values deeply and meaningfully held, and committed action in accordance with one's values, is a generally good one which is affirmed in Scripture in terms of obedience and true faith that leads to deeds and action (James 1:22; 2:15), by the power of the Holy Spirit (see Zech. 4:6; Eph. 5:18; Acts 1:8).

However, from a biblical perspective, a Christian's values should be based on Scripture as God's inspired Word and eternal truth (2 Tim. 3:16), and not on relativistic, humanistic, or secular values, that may be unbiblical or anti-biblical (see Tan, 2007, 2011).

Concluding Comment

Mindfulness and acceptance-based cognitive behavioral therapies have become a significant part of contemporary CBT and counseling and psychotherapy, although there are a few critics of this development with the view that traditional CBT is not compatible with such approaches. (e.g., see Harrington & Pickles, 2009; Hoffman & Asmundson, 2008). The empirical evidence and some clinical applications of ACT, MBCT, and DBT, as well as possible applications to Christian CBT, have been covered in this article. A biblical perspective on mindfulness and acceptance-based cognitive behavioral therapies such as ACT, MBCT, and DBT has also been provided, with appropriate cautions and critique.

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Siang-Yang Tan

Graduate School of Psycholog

Fuller Theological Seminary

Please address all correspondence to Siang-Yang Tan, Ph.D., Professor of Psychology, Graduate School of Psychology, Fuller Theological Seminary, 180 N. Oakland Avenue, Pasadena, CA 91101.

Author

Siang-Yang Tan, Ph.D. (McGill University) is Professor of Psychology at the Graduate School of Psychology, Fuller Theological Seminary in Pasadena, CA, and Senior Pastor of First Evangelical Church Glendale, in Glendale, CA. He has published numerous articles and 13 books, the latest of which is Counseling and Psychotherapy: A Christian Perspective (Baker Academic, 2011).