The basic conceptualisation of human experience offered by this book is that distress arises from our relationship with our own internal experience. The remedy goes beyond (and could be seen as contrary to) the traditional cognitive therapy approach of disentangling the client from the thoughts, questioning them and replacing them with more realistic and helpful ones.
Mindfulness- & Acceptance-Based Behavioral Therapies in Practice
By L. Roemer and S.M. Orsillo, 2008. ISBN 9781593859978. Guilford Press. 244 pages.
This book is aimed at therapists or other mental health professionals who are looking for an understanding of mindfulness and acceptance based practices, either out of interest in one of the fastest growing fields in therapy or out of a desire to integrate them into their own work.
I found Mindfulness- & Acceptance-Based Behavioral Therapies in Practice, the fruit of fourteen years of collaborative work and scientific research by the authors, strong and insightful both on theory and practice. The book includes an abundance of useful and reproducible handouts, which form an integral part of mindfulness and acceptance therapy: both self-monitoring forms (e.g., an anxiety awareness sheet) and psycho-educational materials (e.g., an explanation of the function of emotions). It also provides an enlightening overview of the similarities and differences between the initially bewildering array of approaches within the “family”: acceptance and commitment therapy (ACT), mindfulness based cognitive therapy (MBCT), mindfulness based relapse prevention (MBRP), dialectical behaviour therapy (DBT) and of course the original cognitive therapy (CT).
The authors describe their own approach, drawing on techniques from all the above schools. A comprehensive guide is given to assessment, case conceptualisation, and the treatment itself. Guidance is given to the therapist regarding how to educate the client about the model of human functioning used, use mindfulness exercises within and between sessions, support the client with homework tasks such as self monitoring and stream of consciousness writing, and establish a strong, collaborative, compassionate therapeutic alliance. Other important elements in guiding the client towards behavioural change are the monitoring of progress, prevention of relapse and finally the termination of therapy. Finally, there is a chapter on cultural considerations. The presentation of the therapy process itself is engaging, interspersed with transcripts and especially detailed potential therapist responses to particular situations.
The basic conceptualisation of human experience presented is that distress arises from our relationship with our own internal experience, and more specifically, our tendencies to avoid unpleasant emotions/thoughts, and an habitual experience of fusion with our own thoughts and feelings. The remedy goes beyond (and could be seen as contrary to) the traditional CT approach of disentangling the client from the thoughts, questioning them and replacing them with more realistic and helpful ones. The remedy is, in fact, the opposite of changing thoughts. It involves mindfulness, to use Kabat-Zinn’s definition: “an open-hearted, moment-to-moment, non judgemental awareness” (p. 2) of thoughts and emotions, a kind of pragmatic “being with” them, because they are already here, and because being with what is actually here leads us to be aware of the transience of thoughts and emotions, whereas fighting them off tends to strengthen and maintain them.
In a similar vein, the mainstay of the approach to behavioural change is not reversing the problem, or working towards a goal such as not having the problem, or “changing” oneself, but uncovering and articulating what the client’s underlying values are, and increasing behaviours which are consistent expressions of those values. While goals can be motivating, “they can also engender feelings of discontent and hopelessness and promote nonacceptance of the present moment. In contrast, values are present-centered and encourage ongoing participation and engagement in meaningful activities.” (p. 143)
The book is very scientifically oriented — it includes, for example, several tables presenting in an accessible way the make up, sample size, comparison, length, findings and limitations of many of the randomised controlled trials which have been conducted to test the efficacy of therapies in the mindfulness school for various specific groups, e.g. substance-related and eating disorders and psychotic disorders. The evidence base for particular elements in therapy is the guiding principle for the authors at all times. While I personally found this theoretical framework’s ultimate valuing of what can be tested and what has been tested a little stifling to the spontaneity, depth and unpredictability of client work, I also found that discussions of the therapy process itself within the book were always mindful of individual difference, and different possibilities.
The book amply fulfils its aims to provide a comprehensive, informative, theoretically rigorous and practical guide to mindfulness and acceptance based work. But I was left with a few questions, some about human nature, and character disorders — e.g. whether the radical acceptance of the client’s values, whatever they may be, is really possible — and some about the nature of the self. The mindfulness practices used in therapy lead to a realisation that one is not one’s thoughts, emotions, etc. The authors suggest that those for whom this raises questions along the lines of “who am I, then?” should be referred to Buddhist sources. This seems to me to be a bit of a cop out, both from the point of view of the presentation of mindfulness techniques as unhooked from religious context and applicable to people of all faiths, and from the point of view of the existential reality experienced by the client which seems to me to belong squarely within the therapy arena. My last question is related to cultural contexts — the chapter devoted to the subject failed to convince me that there was not a possible agenda in the therapy along the lines of “find your own real individual values”, which would deny the reality of someone from a more collective culture who might hold their deepest value to be a sense of oneness with the values of others.
These are my own questions, and the book will both answer and raise many more for others. I encourage all mental health practitioners to read it.
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