In a recent blog, I discussed how Acceptance and Commitment Therapy (ACT) can help a patient create a willingness approach (acceptance) to unpleasant thoughts, feelings and physical sensations (1, 2). Note: acceptance is rarely a word to use with directly with patients or loosely in the clinic.

An important core process in the ACT model for pain is cognitive defusion.  This process helps create a willingness approach and loosen the struggle with difficult thoughts, feelings or physical sensations. The outcome are behaviors directed toward more meaningful activities, goals and well being.

Act for Pain: Do Words Equal Actions?

Cognitive defusion (cognitive distancing or “deliteralization”) is one of the six core processes of ACT that underpin what is known as Psychological Flexibility (3). Cognitive defusion seeks to counteract cognitive fusion or getting caught up (fused) in thinking and allowing thoughts to direct one’s behavior. This process is normal and adequate to handle many tasks and interactions. However, it works in aversive ways when thoughts function as barriers to actions and behaviors that help pursuing meaningful goals and values.

Cognitive defusion seeks to loosen the struggle with automatic pattern of labeling, categorizing, dissecting, comparing and judging what we see and experience by changing our relationship with our own thoughts. This means:

• Looking at thoughts, rather than from thoughts.
• Noticing thoughts, rather than being caught up in thoughts.
• Seeing thoughts as what they are, not as what they seem to be
• Creating some distance from negative thoughts.
• Being more mindful; observing our thoughts instead of being carried away by them.
• Gently questioning our thoughts, and recognize that they don’t often represent reality nor are absolute, unchangeable truths.

The aim of Cognitive Defusion is NOT to feel better or to get rid of unwanted thoughts, feelings and physical sensations. Rather, the aim is to reduce the influence of unhelpful thoughts upon behavior, to facilitate being psychologically present and engaged in experience and to facilitate awareness of language processes, in order to enhance psychological flexibility.

Act for Pain: Noticing the Mind to Change Behavior

Defusion techniques can be odd, and may make clients feel invalidated if not introduced and executed properly. Therefore, establishing trust and empathy with the client is very important before engaging in these types of exercises. The goal is creating a context in therapy where thoughts are viewed from a different perspective and in different ways (4).

The Association for Contextual Behavioral Science lists many defusion techniques.

Some seek to expose difficult thoughts as a prelude to meaningful action:

• Physicalizing: Label the physical dimensions of thoughts
• Experiential seeking: Openly seek out more material, especially if it is difficult
• Put them out there: Sit next to the client and put each thought and experience out in front of you both as an object
• Sound it out/sing it out: Say difficult thoughts very, very slowly/sing them

Some attempt to put distance between thoughts and self:

• “The Mind”: Treat “the mind” as an external event; almost as a separate person.
• “I’m having the thought that…”: Include category labels in descriptions of private events.
• Open mindfulness: Watching thoughts as external objects without use or involvement.
• Just noticing: Use the language of observation (e.g., noticing) when talking about thoughts

Some question thoughts’ pre-assigned meaning:

• Titchener’s technique: rapid word-repetition (e.g., “milk, milk, milk”) to denaturalize meaning.
• Polarities: Strengthen the evaluative component of a thought and watch it pull its opposite.
• Thoughts are not causes: “Is it possible to think that thought, as a thought, AND still do  X?”
• Think the opposite: Engage in behavior while trying to command the opposite.
• Description vs Evaluation: Realizing that objective description is grounded in reality, but evaluation is subjective (virtually anything can be evaluated negatively).

Check out HOW PERSPECTIVE TAKING IN ACT CHANGES CHRONIC PAIN

Some try to stress the relative and imperfect nature of thoughts:

• Focused mindfulness: Direct attention to nonliteral dimensions of experience.
• Strange loops: Point out a literal paradox inherent in normal thinking.

Some seek to shake things up when the client surrenders to his own thoughts:

• Who is in charge here?: Treat thoughts as bullies; use colorful language
• And what is that in the service of?: Step out of content and ask this question.
• OK, you are right. Now what?: Take “right” as a given and focus on action.

All these techniques ultimately seek to “see thoughts as what they are, not as what they say they are” in order to release the grip that negative thoughts have on behavior. They teach paying attention to the process by which language configures those thoughts, rather than focusing on the content of such thoughts; this allows for different conscious articulations of ideas and situations, changing the weight they have as conditioners of actions and behaviors.

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Seeing Through Thoughts to Values  

In several ways, cognitive defusion techniques connect with another core principle of ACT, self-as-context, or the ability to observe objectively our own thoughts, feelings, and emotions (the ‘observing self’) (5). By exercising this ability, it is possible to evaluate and weigh things from different angles (‘flexible perspective-taking’) and choose behavior patterns that align with one’s values and well being.

Interested in learning more about ACT for pain? ACT-informed pain practice is beneficial for physical therapists, occupational therapists, psychologists, social workers, counselors, physicians, nurses and wellness professionals who work with clients that live with pain.

Click here to learn more about ACT for Pain and training for practitioners!

REFERENCES:

1- Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes, and outcomes. Behaviour research and therapy, 44(1), 1-25.

2- Deacon, B. J., Fawzy, T. I., Lickel, J. J., & Wolitzky-Taylor, K. B. (2011). Cognitive defusion versus cognitive restructuring in the treatment of negative self-referential thoughts: An investigation of process and outcome. Journal of Cognitive Psychotherapy, 25(3), 218-232.

3-Blackledge, J. T. (2007). Disrupting verbal processes: Cognitive defusion in acceptance and commitment therapy and other mindfulness-based psychotherapies. The Psychological Record, 57(4), 555-576.

4 Healy, H. A., Barnes-Holmes, Y., Barnes-Holmes, D., Keogh, C., Luciano, C., & Wilson, K. (2008). An experimental test of a cognitive defusion exercise: Coping with negative and positive self-statements. The Psychological Record, 58(4), 623-640.

5- Ayduk, O., & Kross, E. (2010). From a distance: implications of spontaneous self-distancing for adaptive self-reflection. Journal of personality and social psychology, 98(5), 809-29.