Cognitive defusion for reducing distressing thoughts in adults with autism

https://doi.org/10.1016/j.rasd.2018.12.005Get rights and content

Highlights

  • Participants with autism reported elevated levels of cognitive fusion.

  • Cognitive fusion was related to greater psychological distress in both groups.

  • Cognitive defusion and active distraction were similarly beneficial for both groups.

  • Participants reported finding both interventions useful and easy to understand.

Abstract

Background

Cognitive fusion occurs when people over-identify with their thoughts, leading to a strong emotional response and a narrowed behavioral repertoire. Cognitive defusion (CD) is a technique used in acceptance and commitment therapy (ACT) to teach people how to pay attention to the process of thinking, thereby reducing the negative effect of over-identification and allowing people to behave in more adaptive ways. CD has been widely studied in neurotypical (NT) samples, but there is little research on cognitive fusion and related interventions for people diagnosed with autism (AS).

Method

Sixty-eight adult participants (AS group n = 27; NT group n = 41) answered questionnaires measuring psychological distress and dispositional levels of cognitive fusion. In a lab setting, participants next identified a personal distressing thought, then were randomized into a brief (5-minute) cognitive defusion technique or an equally-brief active distraction technique. Before and after the intervention, participants completed measures assessing the believability of their distressing thought and how much discomfort the thought caused.

Results

The AS group reported higher overall trait levels of cognitive fusion than the NT group. Cognitive fusion was moderately- to strongly-related with psychological distress in both participant groups. The brief interventions worked equally well in immediately reducing thought believability and thought discomfort for AS and NT groups.

Conclusions

The current study provides support for cognitive fusion as a contributing factor to the psychological distress experienced by people with AS, and that a brief intervention technique can effectively reduce fusion at least in an immediate context. More work is needed to explore the specific short-term and long-term efficacy for interventions aimed to reduce cognitive fusion.

Introduction

Adults diagnosed with autism (AS) experience elevated levels of psychiatric concern, and there is an urgent need to discover or adapt effective interventions for reducing cognitive and emotional distress (Buck et al., 2014; Joshi et al., 2013; Lugnegård, Hallerbäck, & Gillberg, 2011). In particular, adults with autism are frequently affected by high levels of inflexibility and rigidity, which are related to core symptoms of autism such an insistence on sameness and restricted/repetitive behaviors (RRBs), and also to associated symptoms of anxiety (Boulter, Freeston, South, & Rodgers, 2014; Rodgers, Glod, Connolly, & McConachie, 2012; Wigham, Rodgers, South, McConachie, & Freeston, 2015). Treatment approaches that directly address inflexibility may be especially helpful for adults with autism (Mazefsky & White, 2014; Rodgers, Herrema, Honey, & Freeston, 2018).

Mindfulness and acceptance based interventions (MABIs) have been quickly gaining traction as effective and empirically supported transdiagnostic treatments for depression, anxiety, and other psychiatric concerns (A-Tjak et al., 2015; Kuyken et al., 2015; Vøllestad, Nielsen, & Nielsen, 2012). Theoretically, MABIs train explicit skills which encourage simple observation and increased tolerance of uncomfortable rigid thoughts and behaviors, rather than trying to change them; and encourage more adaptive, flexible behavioral responses. Two widely used MABIS are Mindfulness Based Stress Reduction (MBSR; Kabat-Zinn, 1990) and Mindfulness Based Cognitive Therapy (MBCT; Williams, Teasdale, Segal, & Kabat-Zinn, 2007), both of which are often, but not necessarily, conducted in a group format and utilize various structured exercises. While there is much overlap between these two intervention packages, MBSR was originally developed for chronic illness and stress and emphasizes nonjudgmental awareness of the body (e.g. body scan, mindful yoga). MBCT was originally developed to treat depression and prevent relapse, and interventions tend to focus on assisting people in coping with dysfunctional cognitions. There is a small but growing body of literature showing that modified MBSR and MBCT interventions are both feasible and helpful in treating anxiety and mood disorders in AS samples (de Bruin, Blom, Smit, van Steensel, & Bogels, 2015; Kiep, Spek, & Hoeben, 2014; Sizoo & Kuiper, 2017; Spek, van Ham, & Nyklíček, 2013).

Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 2011) is a transdiagnostic MABI used in group or individual therapy aimed specifically at increasing psychological flexibility, or the ability to effectively change or persist in one’s behavior in the service of living a meaningful life and accomplishing one’s goals. Unlike other MABIS, the aim of ACT is not symptom improvement per say. Rather, ACT assists people in recognizing the negative effects of avoidance in their life, while providing tools to make meaningful life changes (e.g. identification of and commitment to one’s values). There has been one study exploring the use of ACT for people with AS. Pahnke, Lundgren, Hursti, and Hirvikoski, (2014) conducted a pilot study examining a six-week ACT skills training group with teens and young adults administered as part of a weekly classroom curriculum compared to a wait-list control. At post-test, both teacher and self-report measures showed that students in the ACT group displayed significantly lower stress, hyperactivity, and emotional distress. Further, student self-report showed an increase in behaviors which were considered pro-social. Moreover, results were maintained at a two-month follow-up. Importantly, students had overall high satisfaction with the ACT treatment, with 93% reporting “high or very high” satisfaction (Pahnke et al., 2014).

Relational Frame Theory (RFT) is an evidence-based theory of cognition and language that underlies ACT. RFT researchers highlight the unique human ability to learn how to relate to any concept or idea in arbitrary ways (even if one has no direct experience with that stimuli). Furthermore, when people learn to associate two or more concepts (e.g., learning that a “cat” is a type of “animal”), we can learn novel responses to those concepts without ever having directly experienced them (this is called arbitrarily derived stimulus responses). For example, if a child develops a fear of dogs after being bitten, and the same child is later told that a “cat” is similar to a “dog” (i.e. both being house pets), the child may become scared of cats without ever having had direct experience with a cat. While this type of associative learning serves important survival functions, over-identification with these learned associations (coined “Cognitive Fusion” in ACT), can also lead to an unnecessarily narrowed behavioral repertoire (e.g., avoidance of all cats) and heightened distress (Blackledge, 2015; Törneke, Barnes-Holmes, & Hayes, 2010). In fact, empirical evidence from work with neurotypical samples has strongly associated greater cognitive fusion with increased psychological distress and behavioral inflexibility (Bardeen & Fergus, 2016; Berghoff, Forsyth, Ritzert, & Sheppard, 2014; Fergus, 2015; Gillanders et al., 2014; Herzberg et al., 2012).

ACT’s answer to cognitive fusion is teaching people cognitive defusion (CD) skills (Hayes et al., 2011). At its core, CD aims to reduce the impact of these arbitrarily derived stimulus functions by teaching people to challenge conventions of language in order to relate to their thoughts in less rigid ways. From a RFT perspective, people can learn strategies to recognize times when they are over-identifying with thoughts that restrict their behavior, thereby increasing their behavioral repetoire and allowing them to choose more helpful behaviors (Blackledge, 2015). CD has been shown to be one psychologically active component of ACT (Levin, Hildebrandt, Lillis, & Hayes, 2012). The most widely studied CD intervention is semantic satiation, first proposed by Titchener (1916) and often referred to as “Titchener’s repetition.” Semantic satiation involves a person saying a painful or distressing thought out loud, repeatedly, as quickly as possible. Eventually, the meaning associated with the thought is lost, and people begin to learn that they attach arbitrary meaning to their thoughts.

Some of the strongest research supporting semantic satiation as an effective defusion strategy comes from a series of studies conducted by Masuda, Hayes, Sackett, and Twohig, 2004, 2009, Masuda, Feinstein, Wendell, & Sheehan, 2010; Masuda, Twohig et al., 2010). In the first study, Masuda et al. (2004) had participants come up with two negative self-referential thoughts and turn them into single words (e.g., “fat”). The participants then rated the thoughts on a scale of 0–100 regarding the amount of emotional discomfort the words cause them, and separately regarding the believability of the words. Using an alternating treatment design, the investigators found that the semantic satiation exercise was more successful in reducing thought believability and emotional discomfort than a distraction group and a thought control group. A parametric analysis to determine the “dose” of semantic satiation suggested two distinct processes that occur at different times: emotional discomfort begins diminishing between 3 and 10 s after the beginning of a satiation exercises, and thought believability diminishes between 20 and 30 s after starting (Masuda et al., 2009). These results have been replicated multiple times using group design studies, where semantic satiation has been shown to effectively alleviate emotional discomfort and believability of fearful or distressing thoughts compared to active and inactive control groups (Deacon, Fawzy, Lickel, & Wolitzky-Taylor, 2011; Mandavia et al., 2015; Masuda, Feinstein et al., 2010; Masuda, Twohig et al., 2010; Ritzert, Forsyth, Berghoff, Barnes-Holmes, & Nicholson, 2015). Deacon et al. (2011) provided evidence that a semantic satiation exercise was as effective in reducing distress and believability as a cognitive restructuring technique, which is a well-established cognitive behavioral therapy (CBT) treatment for distressing thoughts. They also found that positive effects persisted at a 1-week follow-up.

It has yet to be determined to what extent people with AS are fused with their thoughts, but frequent rigidity in AS could be related to a tendency for people to believe their thoughts to a much greater degree than neurotypical people. If this were the case, cognitive fusion would lead them to react aversively to distressing thoughts, which would engender increased anxiety and an urge to behave in restricted and repetitive ways to cope with the anxiety. Preliminary evidence for this can be seen in a recent study showing that non-acceptance of internal experience (including thoughts and feelings), in addition to alexithymia (inability to describe emotions), largely mediated the relationship between autism symptoms and anxiety (Maisel et al., 2016). If people with AS tend to be more fused with their cognitions, defusion could be especially helpful in treating comorbid distress. In fact, a recent study utilizing two defusion techniques in verbal children diagnosed with AS suggested that, when combined with exposure therapy, defusion is quite helpful in reducing RRBs and other problematic behaviors (Eilers & Hayes, 2015). To date, however, there has been little other research concerning the use of defusion in AS samples. Our goals for this study were to understand the extent of cognitive fusion in AS, and the relationship between cognitive fusion and symptoms of emotional/cognitive distress; and to examine the effectiveness of a brief cognitive defusion exercise alongside another active distraction condition.

  • 1)

    Characterize the relationship between cognitive fusion (increased believability and taking thoughts literally) and psychiatric concerns in adults with AS. We hypothesize similar or stronger associations between cognitive fusion and anxiety, depression and stress in the AS compared to the NT group.

  • 2)

    Compare the effectiveness and feasibility of two very brief interventions for reducing cognitive fusion in AS and NT participants. While both techniques have shown efficacy in previous studies with neurotypical samples, we hypothesize an interaction in that the cognitive defusion condition will be more effective than distraction for the AS group.

Section snippets

Participants

Participants were 17 years or older. IQ for all participants was in the average range or above (>80) as measured by the Wechsler Abbreviated Scale of Intelligence, 2nd Edition (WASI-2; Wechsler, 2011). Participants in the AS group were recruited from existing research databases, referrals from a university counseling center, and flyers posted at a local intensive services program for adults with developmental disabilities. Diagnosis of AS according to DSM-5 criteria was made a clinician (author

Sample characteristics and dispositional group differences

As seen in Table 1, the only significant between-groups difference in demographics was for age, where the AS group was slightly older than the NT group. In line with data from previous studies, the AS group reported significantly more autism symptoms, anxiety, depression, and stress. As hypothesized, the AS group reported significantly more cognitive fusion than the NT group. Differences were also examined between conditions. There were no significant differences between the NT group assigned

Intervention effects

The most important finding of the current study showed that a brief cognitive defusion technique and a brief active distraction technique were similarly effective in immediately reducing thought believability and thought discomfort in both groups with moderate to large effect sizes. This finding extends a body of research from neurotypical adults, showing the utility of semantic satiation and active distraction interventions to a sample of adults with autism who have average cognitive and

Implications

Our data indicate that both defusion and distraction tasks may be clinically indicated for managing distressing thoughts in AS individuals, at least in-the-moment during therapy sessions. Specifically, we have shown that people with AS and understand the rationale of defusion and benefit from experiential practice. After such initial interventions, clinicians could proceed by engaging in more extensive interventions aimed at reducing the impact of negative thoughts and increasing behavioral

Conflicts of interest

All authors declare that there are no conflicts of interest.

Acknowledgements

No external funding supported this study.

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