Therapists and counsellors of different orientations use cognitive-behavioural and mindfulness approaches to inform and guide their practice with clients. In this essay, I will examine similarities and differences in their accounts of the origins of distress, the goals of therapy, the role of the therapist and the kinds of therapeutic interventions that follow. While these perspectives vary in their respective understandings of fear and sadness, the present analysis highlights similarities in the way therapists work with people. It also shows the essentially complementary nature of their core techniques. On this basis, I will argue the relative merits and utility of each form of therapy as part of an integrative approach to working with fear and sadness.
Salkovskis (2010) describes how contemporary cognitive-behavioural therapy (CBT) combines elements from both behavioural and cognitive theories. As a result, the roots of distress are understood in behaviourist terms (e.g. as lack of positive reinforcement or ‘learned helplessness’ (Seligman et al, 1975)) in conjunction with Beck’s cognitive theory of emotion (Beck et al, 1976). Salkovskis (2010) concludes that, in prioritising meaning over behaviour, Beck has increased the scope of CBT to include depression, anxiety and the full range of mental health problems. Such problems are seen from a cognitive viewpoint; meanings that events or experiences have for the person concerned arise in the conscious and non-conscious. These meanings form the basis of interpretations and reactions to events and situations, so that emotional disorders are understood to be a result of the person becoming ‘stuck’ in a negative spiral of incidents, appraisals and responses.
In contrast, mindfulness explains the roots of distress in Buddhist terms, as an aspect of inevitable human suffering (Barker, 2010). The assumption is that people are driven to strive for safety and to satisfy their desires in ways that can only ever lead to further suffering. Based on the ‘four noble truths’ (Batchelor 1997, p.11), the mindfulness approach assumes the need to pay attention to suffering in order to see how distress is rooted in craving. It is the ‘letting-go’ of craving and, therefore, suffering that brings peace – a practice that must be fostered until it becomes effortless. Unlike the CBT, this understanding of fear and sadness has no place for diagnostic categories such as depression or anxiety and presents no sense of distress as an individual or unique experience. Rather, it is the universality of human suffering that is emphasized and addressed, with no distinction made between specific emotions such as fear or sadness (Barker, 2010).
These different approaches lead to diverse understandings of the role of therapy. In CBT, the therapist works to develop a shared understanding of the client’s problems through careful listening and negotiation (Barker, 2010). Using diagnostic categories as a guide, the therapist identifies a focus of concern such as panic disorder, obsessive-compulsive disorder or post-traumatic stress. In the process of therapy, new modes of understanding are jointly explored in order to open up alternative ways for the client to make sense of his/her problems – either through discovering the fears underlying their safety-seeking and avoidance behaviour, or by uprooting current interpretations/appraisals. It is a therapeutic approach that is both change- and future-oriented.
The mindfulness approach, on the other hand, emphasises the client’s experience of the present moment and how to engender an awareness and acceptance of the moment. This is achieved through breathing techniques and other kinds of meditation practice. The goal is to be present with whatever thoughts/sensations are there for the client and to facilitate awareness of the flow of thoughts as they come and go – rather than get drawn into the ‘psychological quicksand’ (Hayes, 2005, p.27) of memories, inner dialogues and visions of the future.
From a mindfulness perspective, any attempt to avoid or distract ourselves from anxiety, fear or other difficult feelings is bound to fail in the long-term. For these therapists, the solution is not to control our distress, but to acknowledge and accept whatever we are feeling in this moment. Through becoming ‘spaciously aware’ (Barker, 2010, p.176) we are said to gain insight into the fact that any feeling is necessarily only part of our fleeting, minute-by-minute, experience. As Hayes (2005) suggests, the alternative to explaining or making-sense of our feelings is simply to be with them and notice what happens when we do that. Unlike CBT, focusing on future-focused change is problematic for this approach. Hanh (1988) stresses how we can only have peace if we find it in the present moment. Unless we can be fully in this moment, we remain vulnerable to the tyranny of automatic thought processes (Williams et al, 2007).
Interestingly, both CBT and mindfulness approaches recognize and target the imposition of automatic thoughts on our everyday responses and mood states. But, while CBT works to change the content of seemingly automatic/habitual interpretations and appraisals, mindfulness targets the very process of automatic thinking in itself. The aim is to transcend the craving, grasping and worrying that dislocates us from the here-and-now and keeps us focused on the past or the future. Not surprisingly, different (though sometimes overlapping) techniques are used to achieve these distinct therapeutic aims.
In CBT, building rapport and forming a therapeutic alliance is the first goal. The therapist uses techniques of empathic listening, responding and summarising to discover the ‘original motivation’ (Barker, 2010, p.157) for the client’s response and sets/agrees appropriate therapeutic goals. This is done with respect for the client’s current understanding (Theory A or the present belief system) and the parallel beliefs that present an alternative to where the client is now (Theory B). Client and therapist count as ‘two experts in a room’ (Barker, p.160) who jointly engage in techniques of structured discussion, information gathering and behavioural experiments. As well as talking, therapy can include exercises and activities that test certain aspects of the client’s experience and help him/her uncover the beliefs or thoughts associated with a problem or experience he/she has brought to therapy.
On the other hand, mindfulness techniques focus more on breathing and meditation (Williams, 2007). Batchelor (1997), for instance, proposes a mindfulness meditation that involves turning attention inwards to bodily sensations and feelings and then gradually allowing the mind to settle on the inward and outward flow of the breath. As Barker (2010) points out, the role of counsellors/therapists is to teach the practice of mindfulness to clients through guidance and co-meditating with them. Germer et al (2005) highlight the advantages of mindfulness for therapists themselves, while Hanh (1991) lists other, more active, techniques that can be used to anchor the person in the present moment such as yoga, playing a musical instrument, cooking, walking and writing.
A common element in both CBT and mindfulness approaches is the emphasis on generalizing therapeutic insights and practice beyond the therapy/meditation room to the client’s everyday circumstances and way of being. CBT can involve homework that is agreed between the therapist and client at the end of each session and is designed to continue the process of discovery, understanding and change initiated in therapy. Similarly, it seems that the point of meditation is to stimulate mindfulness in ordinary life. Hanh (1991) argues the case for building ‘mindful space’ (p.184) into such daily routines as eating or washing-up.
While these two therapeutic approaches are different, there appear to be no fundamental tensions or conflicts between them. Despite understanding the roots of fear and sadness in different ways, one technique (e.g. CBT) does not seem to rule out integration with the other (e.g. meditation). Barker (2010) points out that most of the texts bringing mindfulness and counselling together come from CB therapists. This is considered by some to be the ‘third wave’ (Barker, 2010, p.173) in cognitive-behavioural therapy. An example of this kind of integration would be Hayes’ (2005) ACT therapy that combines acceptance of the here-and-now with a commitment to being mindful of, and living by, core values.
Which approach I am most drawn to? I am most drawn to a creative and appropriate (for the particular client and the issues he/she brings to therapy) blend of the two. At the same time, I see the advantages of CBT for clients who are seriously debilitated by fear-based anxiety disorders. The strategic, respectful and change-oriented viewpoint of CBT (facilitated via the all-important therapeutic alliance) offers a clear structure and method for working with such a client. An example would be the case of Dora (Barker, 2010, Section 3.4) and her struggles with panic disorder and agoraphobia. On the other hand, I might be drawn to mindfulness techniques in cases of more generalized human suffering, such as that of Nancy (Barker, 2010, Section 8.4) where accepting and giving space to difficult feelings is likely to offer a way forward. Whatever the context, therapists should know their limits and only attempt to make use of one or other approach (or an integrated blend of both) if they have the training and skill to do so. Ethical practice is essential in all cases, as is an empathic and respectful attitude from the therapist towards the client.
To sum up, this analysis has shown how CBT and mindfulness approaches work from separate sets of assumptions about the nature and origins of fear and sadness. As a result, each perspective has developed its own view of the role of therapy and its own interventions in distress. Each has merits and limitations, with CBT seeming to me to be strongest when it comes to dealing with cases where there is a clear focus of concern and mindfulness more appropriate for non-specific or generalised suffering. Even so, no fundamental contradictions or tensions have been found, leading to an argument that where applicable, these approaches can be combined in an integrative approach to therapy.
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Williams M., Teasdale J., Segal Z. and Kabat-Zinn J. (2007) The mindful way through depression: Freeing yourself from chronic unhappiness. New York: The Guilford Press.