Approach to Therapy: Acceptance-Based Behaviour Therapy
Science-based approaches to therapy, like cognitive-behavioural therapy (CBT) and acceptance and commitment therapy (ACT), offer a number of strategies from which to choose. These include those that address thoughts, feelings, and behaviour. Behaviour change strategies, such as modifying one's environment, facing feared situations, reducing avoidance, and increasing engagement in values-consistent activities, have consistently been shown in scientific research to be cornerstone of effective therapy. However, these strategies are often minimised or absent from therapy. Instead, therapists tend to emphasise "coping skills" for reducing negative thoughts and feelings, like controlled breathing, muscle relaxation, positive thinking, distraction, and mindfulness techniques. Alternatively, therapy may involve unstructured conversation without a clear direction or purpose, an approach based on the misguided assumption that having a good relationship with an empathic therapist is all clients need to overcome their psychological issues.
Unfortunately, the therapy offered to many clients in the community does not take advantage of our most powerful strategies for improving lives. This is because therapists tend to "drift" from behaviour change strategies toward feel-good approaches that are less challenging but also less effective. Work with clients emphasizes "talking therapy" instead of "doing therapy." This talking therapy typically focuses on strategies for creating shorter-term comfort rather than encouraging important behavioural changes that make their lives better in the longer-term.
Why Emphasise Behaviour Change Instead of Anxiety-Reducing Coping Skills?
I do not not emphasise coping skills for controlling negative thoughts and feelings. Rather, I work with clients to live better, more specifically making behaviour changes that provide valuable learning opportunities and help them live a more full and values-consistent life, and to become willing to accept the internal experiences (thoughts, emotions, sensations) that show up along the way. Here is why:
Behaviour therapy without coping skills can work better and more quickly
Research shows that a variety of CBT approaches are effective for anxiety. These include approaches that emphasise cognitive therapy, anxiety-reducing coping skills, exposure therapy, and their combination. Importantly, exposure (behaviour) therapy alone works at least as well as therapy that combines different elements of CBT. It also has the advantage of being more straightforward, easier to deliver, and produces quicker improvement. It is also tolerated well and viewed positively by clients. Exposure therapy emphasises a single, powerful approach to overcoming anxiety and devotes the majority of the therapy to mastering it. This is different from other CBT approaches that mix and match various anxiety-reducing coping skills while devoting a few sessions to exposure.
Although coping skills can be helpful as a short-term strategy to manage anxiety, research clearly shows they are unnecessary and do not add to the effectiveness of behaviour therapies like exposure. Instead, they waste time, money, and effort, delay improvement, and reduce the amount of behaviour therapy clients receive. Given that the Australian healthcare system's Better Access program provides a rebate for only 10 therapy sessions per year, it is important that time spent in therapy is used wisely, emphasising powerful strategies and excluding those that are unnecessary, slow improvement, and take time away from what works best.
Although coping skills can be helpful as a short-term strategy to manage anxiety, research clearly shows they are unnecessary and do not add to the effectiveness of behaviour therapies like exposure. Instead, they waste time, money, and effort, delay improvement, and reduce the amount of behaviour therapy clients receive. Given that the Australian healthcare system's Better Access program provides a rebate for only 10 therapy sessions per year, it is important that time spent in therapy is used wisely, emphasising powerful strategies and excluding those that are unnecessary, slow improvement, and take time away from what works best.
coping skills miss the point that Anxiety is part of life
The use of coping skills is based on the idea that internal experiences like unwanted thoughts, emotions, memories, images, urges, doubts, and body sensations are bad and need to be controlled or eliminated in order for the person to have good "mental health." I reject this view because negative thoughts and feelings are universal and expected in light of one's history and context, especially during periods of high stress. Don't take my word for it - check out this study showing that 83% of people experience a diagnosable psychological problem by age 38! This doesn't mean that nearly everyone is "mentally ill," but rather that experiencing significant psychological distress at times is part of the human condition. The human condition also involves having a mind shaped by evolution to constantly warn us of threats, compare ourselves to others, recall upsetting memories, provide intrusive thoughts and impulses that contradict our most cherished values, and so on. This is how the human mind works and these functions cannot be turned off or effectively controlled with coping skills. Indeed, many people find that the harder they try to control their internal experiences, they more out of control they become. This reality leaves us with two choices: (a) wage a constant, unwinnable war with our unwanted internal experiences in an effort to make them go away, or (b) stop fighting and learn to live with them. Accordingly, I work with clients to become more accepting of their moment-to-moment internal experiences while directing their energy toward behaviour change in the service of living a rich, full, and meaningful life; in other words, to Get Out of Your Mind & Into Your Life (a book I often use with clients). I also work with clients to develop a more adaptive belief system, acquired principally through new life experiences courtesy of behaviour change, that helps them live a more valued life.
Coping skills can fuel anxiety
For many people, coping skills are a major part of the problem. Habitual attempts to control unwanted thoughts and feelings by suppressing them, distracting oneself from them, and avoiding or withdrawing from situations that evoke them - also known as experiential avoidance - are largely ineffective despite whatever short-term relief they provide, maintain and worsen distress over time, and reduce quality of life as people withdraw from important pursuits and relationships. They can also worsen depression and anxiety as people gradually come to realise that they are not living life in accordance with their values. Therapists who emphasise the use of coping skills (e.g., diaphragmatic breathing, muscle relaxation, distraction, replacing negative thoughts with positive thoughts, incorrectly applied mindfulness techniques) may contribute to this experiential avoidance agenda by providing clients with more tools for attempting to control negative thoughts and feelings. Psychological struggles are often fuelled by the combination of an unwillingness to have negative internal experiences and habitual efforts to cope them away that ironically intensify them. From this perspective, the problem isn't that people are insufficiently skilled in the use of coping skills for controlling their internal experiences, but the belief that such coping skills are necessary in the first place.
Coping skills can make therapy less effective
Therapy works best when it is delivered without the concurrent use of coping skills. This approach involves encouraging clients to fully engage in important behaviours, without using coping skills to control negative thoughts and feelings along the way, in order to (a) learn important lessons, such as discovering that distress is tolerable and that important actions can be successfully performed even when one is distressed, and (b) pursue goals that move them toward valued life directions, such as having better quality relationships and regularly engaging in activities that provide a sense of accomplishment or purpose, and (c) become willing to live a full and values-consistent life while accepting rather than controlling the internal experiences that show up along the way. I aim to help clients learn that coping skills are unnecessary in order to prevent catastrophe, tolerate distress, function adequately, and pursue important life directions.
In contrast, when therapy emphasizes coping skills, clients are taught that it is necessary to control negative thoughts and feelings in order to fully live their life. Clients are encouraged to become skilled "copers" who habitually battle negative thoughts and feelings with "skills" for controlling them. The mental energy needed to fight this internal war, which can never be won, can make it difficult to be in the present moment and fully engage with life. This approach is also a recipe for trouble in situations where coping skills are unavailable or ineffective. Rather than working with clients to become skilled at controlling negative thoughts and feelings when they occur, I focus on helping them live better (according to their own vision of what this means) while building acceptance of the internal experiences that are an inevitable product of their life experience.
In contrast, when therapy emphasizes coping skills, clients are taught that it is necessary to control negative thoughts and feelings in order to fully live their life. Clients are encouraged to become skilled "copers" who habitually battle negative thoughts and feelings with "skills" for controlling them. The mental energy needed to fight this internal war, which can never be won, can make it difficult to be in the present moment and fully engage with life. This approach is also a recipe for trouble in situations where coping skills are unavailable or ineffective. Rather than working with clients to become skilled at controlling negative thoughts and feelings when they occur, I focus on helping them live better (according to their own vision of what this means) while building acceptance of the internal experiences that are an inevitable product of their life experience.
Coping skills ARE FOR THE therapist, not the client
Our research shows that therapists who emphasise the use of coping skills do so to manage their own discomfort with their clients' distress. Many therapists are concerned that their clients will be unable to tolerate the discomfort associated with making challenging but empowering behavioural changes (e.g., facing feared situations) and believe it is unethical to subject their clients to temporary distress even if it is in their best long-term interests. They view their clients as fragile and see their role as protecting clients from their own anxiety with coping skills intended to suppress it. Our research shows that many therapists are anxious themselves, and that their discomfort with anxiety leads them to deliver therapy in an unnecessarily cautious manner in a misguided effort to spare clients from intolerable distress. These concerns lead therapists to focus on short-term anxiety management strategies rather than encouraging clients to make important but temporarily uncomfortable behavioural changes that might improve their lives in the longer-term. I reject these ideas. I view my clients as resilient and experienced "anxiety tolerators" and use exposure therapy to build distress tolerance and acceptance of thoughts and feelings so clients can fully pursue living a valued life, even when they feel distressed. Life is meant to be lived, not coped with!