Cognitive Defusion versus Cognitive Restructuring in the Treatment of Negative Self-Referential Thoughts: An Investigation of Process and Outcome

Within traditional cognitive therapy, cognitive restructuring is often used to challenge the veracity of dysfunctional thoughts. In contrast, acceptance and commitment therapy (ACT) uses " cognitive defusion" techniques to change the function of negative thoughts rather than modify their content. Previous research has shown that a cognitive defusion technique known as the "milk exercise" ( rapidly repeating a self-referential, one-word thought such as "fat") reduces the discomfort and believability associated with negative thoughts. This study sought to replicate and extend these findings by comparing the impact of cognitive defusion with that of cognitive restructuring in a sample of participants distressed by negative thoughts about their body shape. Participants received a detailed rationale and training followed by instructions to practice the assigned technique as homework for 1 week. Results indicated that both cognitive techniques produced substantial improvements that generalized well beyond the specific thoughts targeted for treatment. Clear differences in treatment process and the course of improvement were evident. Findings are discussed in the context of theoretical and practical similarities and differences between these two approaches. Keywords: cognitive therapy; cognitive restructuring; acceptance and commitment therapy; cognitive defusion Cognitive models of psychopathology (e.g., Beck, 1976) posit that dysfunctional cognitions directly contribute to negative emotions. Accordingly, a common technique in traditional cognitive behavioral therapy (CBT) is cognitive restructuring, in which the therapist and patient collaboratively identify irrational or maladaptive thoughts and challenge their veracity using strategies such as logical disputation, Socratic questioning, and behavioral experiments (Hofmann & Asmundson, 2008). The goal of this process is to encourage patients to think in more accurate and adaptive ways, which facilitate effective problem solving and living a more satisfying life (Beck, Rush, Shaw, & Emery, 1979). CBT is a highly effective treatment for a wide range of mental disorders (Butler, Chapman, Forman, & Beck, 2006). CBT consists of various techniques, however, and the specific contribution of cognitive restructuring to the overall efficacy of CBT has recently come under scrutiny. In their review of treatment studies for anxiety and depression, Longmore and Worrell (2007) concluded that cognitive interventions do not consistently provide added value to behavioral interventions. Cognitive restructuring has also been criticized on theoretical grounds by proponents of mindfulness and acceptance-based approaches such as acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999). For example, Eifert and Forsyth (2005) characterize the process of challenging dysfunctional thoughts as engaging patients in an attempt to "master" and " control" their thoughts. These authors suggest that cognitive restructuring aims to "teach clients to become better suppressors and avoiders of their unwanted thoughts" (p. 39), thereby arming them with a potentially unworkable strategy to avoid experiencing negative emotions. Cognitive therapists have vigorously disputed the notion that cognitive restructuring encourages the suppression and avoidance of negative thoughts and emphasize the contradiction between the negative depiction of cognitive restructuring by ACT proponents and the observation that cognitive therapy is "the most clearly established effective psychotherapy that exists" (Leahy, 2008, p. 149). Nevertheless, a cardinal feature of "third wave" approaches (Hayes, 2004) is their marked departure from traditional CBT approaches toward negative thoughts. Rather than directly challenge the content (e.g., accuracy) of negative thoughts, these methods emphasize changing the function of thoughts by encouraging patients to adopt a different awareness of and relationship to thoughts (Segal, Teasdale, & Williams, 2004). …