8 Psychotherapy8.2 Cognitive behavioural therapies
8.2.3 Mindfulness, compassion and acceptance
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Written by Resident Doctor Committee · Published
New in the 2027 syllabus
The College added this topic for exams from January 2027.
Third-wave approaches
Third-wave therapies look at the function of thoughts and feelings (what they do for the person) and the context in which they occur. Rather than disputing the content of every thought, they often change the person's relationship to their thoughts and feelings.
Mindfulness means paying deliberate attention to present experience with an open, non-judgemental attitude. It is not thought suppression, and it does not require the person to relax.
Decentring means recognising thoughts as mental events. The person stops treating them as facts or as the whole of who they are.
Acceptance and commitment therapy
Acceptance and commitment therapy (ACT) aims to increase psychological flexibility. This means acting in line with values the person has chosen, while making room for difficult internal experiences such as painful thoughts, feelings and sensations.
Experiential avoidance is the effort to control or escape internal discomfort. It becomes a problem when these efforts keep stopping the person from doing what they value.
ACT works through six processes:
Process | What the patient practises |
|---|---|
Acceptance | Letting uncomfortable experience be there without automatically struggling against it |
Cognitive defusion | Noticing a thought without obeying it literally |
Present-moment awareness | Bringing attention back to what is happening now |
Self-as-context | Observing experience from a perspective that stays constant |
Values | Choosing the qualities that give action its direction |
Committed action | Taking practical steps guided by those values |
Two points are easily misunderstood:
Acceptance applies to internal experience. It does not mean tolerating abuse or giving up on changing external circumstances.
Values are ongoing directions, such as being a caring parent. Goals are actions that can be completed.
Compassion-focused therapy
Compassion-focused therapy (CFT) was developed by Paul Gilbert. It targets shame and harsh self-criticism. It does this by building the person's capacity to respond to suffering with understanding and helpful action.
CFT uses a three-system model of emotion, which distinguishes:
threat and protection
drive and resource seeking
soothing and affiliation.
Compassionate practice can include imagery, developing a supportive inner voice, and attention to posture or breathing. Some people find soothing threatening at first. When this happens, the practice is adapted.
Mindfulness-based cognitive therapy
Mindfulness-based cognitive therapy (MBCT) combines mindfulness practice with a cognitive understanding of recurrent depression and the warning signs of relapse.
Relapse prevention: group MBCT can be used for people at higher risk of relapse once their depression is in remission. The choice depends on the person's preference and previous treatment.
Treatment choice depends on the condition. Evidence for one third-wave therapy cannot automatically be applied to another.
Adverse responses, such as increased distress or dissociation, need review and the practice should be adapted. Do not simply tell the person to persist regardless.