Entangled with illness: How cognitive fusion is linked to poor health in chronic conditions

I am excited and proud to present Dr. Ines Trindade, a Clinical Psychologist and Research Scientist, based at Coimbra University in Portugal. Every once in a while, a young researcher comes along whose work makes you sit up and take notice. Like, really take notice; to the extent that you very much look forward to seeing what study they conduct and publish next. Ines Trindade is one of those people. Ines and her colleagues at Coimbra are at the cutting edge of applying Acceptance and Commitment Therapy based concepts and principles to real world issues that will affect most of us at some point in our lives, chronic illness. Enjoy this wonderful thoughtful and learned blog – Dr. Ian Tyndall, University of Chichester, UK

I am grateful to Dr Ian Tyndall for his kind invitation for me to write this blog. Ian asked me to write about how the way cognitive fusion (i.e., getting “fused” or entangled with our internal experiences) impacts on mental health in chronic conditions. My PhD studies have in part focused on this, particularly in the context of inflammatory bowel disease and cancer. These chronic conditions, and a lot of others (such as chronic autoimmune, cardiovascular, metabolic, musculoskeletal, or respiratory diseases), have detrimental effects on many aspects of patients’ lives. What is more, they are not rare. Not even close to uncommon. The World Health Organization indicates that, in 2018, more than one third of the European population over 15 have at least one chronic illness. The prolonged, uncertain, and intermittent course of chronic conditions, their associated life-long (and at times severe and life-threatening) symptomatology, and patients’ need for permanent treatment and medical surveillance, are linked with functional impairment, disability, and mental health problems. This emotional cost is often overlooked in the usual care of chronic health conditions, which usually almost exclusively involves, in a dangerous alignment with outdated mind-body dualism, the physical dimension of the disease. This is particularly bewildering if we consider (and we should) the psychological suffering patients go through and the substantial amount of scientific evidence on the positive effects of psychotherapeutic interventions, such as those based on contextual behavioral science, on the alleviation of that suffering.

Acceptance and Commitment Therapy (ACT), rooted in functional contextualism, proposes that human suffering largely results from efforts to control/avoid unwanted internal experiences (such as sensations, thoughts, or emotions), to the extent that adaptive functioning gets restricted. It is conceptualized that individuals may attempt to control internal experiences when fused with them, in a process central to ACT’s model of psychopathology called cognitive fusion. Due to our verbal learning history, we tend to experience thoughts as literal interpretations of reality which should be responded to. When we learn a verbal language and are taught that words refer to real “things” in the world, these verbal stimuli will hold particular power. This is why humans tend to believe in, and become fused with, thoughts. In a state of cognitive fusion, a thought can look like the utter truth, a command, or a rule that has to be followed. As we assess thoughts as negative and get entangled with them, the less willing and available we are to experience them. Experiential avoidance is thus founded upon cognitive fusion. If someone buys into the thought “I probably have cancer and will die from it”, this thought can take over behavior and lead to avoidance of preventive health examinations.

Cognitive defusion in turn is the process through which we see thoughts as subjective and temporary products of the mind that do not need to be responded to (when defused we see thoughts as what they are, not as what they say they are). Defusion techniques aim to deliteralize language and modify the maladaptive functions of thoughts without altering their content and frequency. Rather than buying into the thought “I must conceal my illness from others”, one can, for instance, thank the mind for this product, put a label on the thought (“thank you mind for this evaluation/comment/command/etc”), repeat the thought out loud until only its sound remains, just notice the thought, or treat it as an externally observed event by giving it a shape, size, colour, speed, or form. These techniques enable engagement in values-driven behavior even if this would mean, for example, disclosure about your illness symptomatology to others.

In recent published studies from my PhD thesis we have examined cognitive fusion’s longitudinal impact on the evolution of mental and physical health in inflammatory bowel disease (IBD) patients. These studies demonstrated that some patients tend get more fused with internal experiences than others and that this pattern tends to be stable over time (i.e., if a person presents with high levels of cognitive fusion, it is likely that he or she will maintain high levels of fusion over time). The major finding was that both IBD-related physical symptomatology and cognitive fusion impacted on the initial levels of self-reported psychological and physical health but only cognitive fusion significantly influenced their evolution over a course of 18 months. Patients presenting higher levels of cognitive fusion reported low psychological health and physical health that tended to decrease over time through the effects of this verbal process. Overall, these findings corroborated other studies on other chronic health conditions that had showed the association between cognitive fusion and poor mental health.

Fusion’s impact on psychological health may be related to the link between this process and lack of committed action. If someone gets fused with thoughts such as “No one can know about my condition or they’ll think less of me” or “I can’t go out tonight or people will think something’s wrong with me” this person may avoid behavior that would be valued and meaningful (e.g., having safe and close connections with others). Lack of commitment with values driven behavior can lead to the perception that life does not have a purpose or meaning. Cognitive fusion’s effects on physical health can be similarly explained. Fusion with disease-related thoughts (e.g., “It won’t make no difference if I take this medication”; “This medical test is too scary for me, I won’t handle it”) may dominate illness behavior. Fusion with such thoughts could lead to avoidance patterns that could interfere with adherence to taking prescribed medication, undergoing medical treatments, or going to medical appointments. What is more, fusion with thoughts relating to the negative aspects of experiencing pain may lead to pain avoidance strategies that will paradoxically cause increased pain. Further, the detrimental effects that cognitive fusion seems to have on physical health may also relate to the known self-perpetuating cycle that exists between depression symptoms and inflammation, given that cognitive fusion leads to negative affect and the further occurrence of negative internal events, and eventually, as our studies also empirically demonstrated, to depression symptomatology.

For these reasons, the development and application in the context of chronic illness of psychotherapeutic interventions that promote cognitive defusion seem to be of upmost importance. As therapists and researchers, we should aim to disseminate this knowledge and sensibility. As patients, we should ask or look for additional and complementary (to the treatment of physical aspects of illness) science-based sources of help if we feel we would benefit from them; soldier on, for together we stand.