The evolution of a fundamentally mindfulness-based treatment methodology: From DBT and ACT to MDT and beyond.

Abstract

THE EXPLICIT EFFORT TO integrate mindfulness into traditional cognitive-behavioral therapy has been one of the central issues in the so-called of cognitive-behavioral therapies (Baer, 2006). (Behavior therapy was the first wave and cognitive therapy was the second.) As summarized by Jennings, Apsche, Blossom, & Bayles (2013), these newer mindfulness-based approaches included, in published chronology, Mindfulness Based Stress Reduction (Kabat-Zinn, 1982); Acceptance and Commitment Therapy (Zettle & Hayes, 1986); Dialectical Behavior Therapy (Linehan, 1993); Mindfulness-Based Cognitive Therapy (Teasdale, Segal, & Williams, 1995); and Mode Deactivation Therapy (Apsche, Evile, & Castonguay, 2002). Of these five mindfulness-based treatments, two were developed specifically to overcome the shortcomings of Cognitive Behavioral Therapy (CBT) in meeting the needs of particular clinical populations. Marsha Linehan developed Dialectical Behavior Therapy (DBT) for women with borderline personality disorder and suicidality, while Jack Apsche developed Mode Deactivation Therapy (MDT) for conduct disordered adolescents with histories of abuse, neglect and trauma. * Dialectical behavior therapy: Applying mindfulness to borderline women Linehan (1993) found that the traditional CBT procedures for challenging the empirical and logical validity of her borderline clients' beliefs caused them to feel that their emotional pain was discounted as not real, their competency was being attacked, and they were being judged and rejected. Given their clinical characteristics of extreme emotional reactivity, sensitivity to perceived rejection, and inability to self-soothe, Linehan (1993) turned to mindfulness to better serve this population. First, she used direct skills training in meditation to help her borderline clients to learn to self-soothe, regulate their emotional reactivity and manage stress. In fact, this straight-forward training emphasis is reflected in the title of her ground-breaking book, Skills Training Manual for Treating Borderline Personality Disorder. Second, Linehan developed the process of validation. Instead of disputing dysfunctional cognitions and beliefs, she explicitly and strongly acknowledged each client's experience of emotional pain as fully real, and explicitly affirmed that each client's maladaptive and illogical actions--especially suicidality, self-injury and self-destructive behavior--were valid attempts to relieve pain and suffering (Linehan, Cochran & Kehrer, 2001). Linehan's third major innovation was the principle of radical acceptance. Radical means complete and total, while acceptance is acknowledging what is. Linehan directly encouraged her clients to allow themselves to the spontaneous experience of any and all sorts of thoughts, urges, and ideas (even negative or forbidden thoughts like suicide that would otherwise be typically suppressed). The key was empowering her clients to allow the dysfunctional thoughts to be in the present immediate moment, but without making any negative self-judgments. To accept something is not the same as judging it to be good or even tolerable. The reality is neither good nor bad, fair nor unfair. It just is. By first training her borderline clients to use mindful meditation to control emotional over-reactivity, they were better able to manage the experience of allowing and accepting negative thoughts and affect (without losing emotional control) and to stop negative self-judgments for having such thoughts. * Mode deactivation therapy: Applying mindfulness to adolescents In a similar fashion, Jack Apsche found that traditional CBT was failing with his clinical population of severe conduct disordered and aggressive adolescents with histories of abuse and trauma. By adapting Beck's (1996) theory of modes and schema therapy, Apsche argued that severely disordered youth develop habitual, dysfunctional modes as a consequence of their histories of abuse, neglect, and trauma. …