Acceptance and Commitment Therapy for Anxiety Disorders: Three Case Studies Exemplifying a Unified Treatment Protocol

Acceptance and Commitment Therapy (ACT) is an innovative acceptance-based behavior therapy that has been applied broadly and successfully to treat a variety of clinical problems, including the anxiety disorders. Throughout treatment ACT balances acceptance and mindfulness processes with commitment and behavior change processes. As applied to anxiety disorders, ACT seeks to undermine excessive struggle with anxiety and experiential avoidance––attempts to down-regulate and control unwanted private events (thoughts, images, bodily sensations). The goal is to foster more flexible and mindful ways of relating to anxiety so individuals can pursue life goals important to them. This article describes in some detail a unified ACT protocol that can be adapted for use with persons presenting with any of the major anxiety disorders. To exemplify this approach, we present pre- and posttreatment data from three individuals with different anxiety disorders who underwent treatment over a 12-week period. The results showed positive pre- to posttreatment changes in ACT-relevant process measures (e.g., reductions in experiential avoidance, increases in acceptance and mindfulness skills), increases in quality of life, as well as significant reductions in traditional anxiety and distress measures. All three clients reported maintaining or improving on their posttreatment level of functioning.     

Cognitive Mediators of Treatment for Social Anxiety Disorder: Comparing Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy

Objective

To assess the relationship between session-by-session mediators and treatment outcomes in traditional cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for social anxiety disorder.

Method

Session-by-session changes in negative cognitions (a theorized mediator of CBT) and experiential avoidance (a theorized mediator of ACT) were assessed in 50 adult outpatients randomized to CBT (n = 25) or ACT (n = 25) for DSM-IV social anxiety disorder.

Results

Multilevel modeling analyses revealed significant nonlinear decreases in the proposed mediators in both treatments, with ACT showing steeper decline than CBT at the beginning of treatment and CBT showing steeper decline than ACT at the end of treatment. Curvature (or the nonlinear effect) of experiential avoidance during treatment significantly mediated posttreatment social anxiety symptoms and anhedonic depression in ACT, but not in CBT, with steeper decline of the Acceptance and Action Questionnaire at the beginning of treatment predicting fewer symptoms in ACT only. Curvature of negative cognitions during both treatments predicted outcome, with steeper decline of negative cognitions at the beginning of treatment predicting lower posttreatment social anxiety and depressive symptoms.

Conclusions

Rate of change in negative cognitions at the beginning of treatment is an important predictor of change across both ACT and CBT, whereas rate of change in experiential avoidance at the beginning of treatment is a mechanism specific to ACT.     

A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania

This randomized trial compared a combined Acceptance and Commitment Therapy/Habit Reversal Training (ACT/HRT) to a waitlist control in the treatment of adults with trichotillomania (TTM). Twenty-five participants (12 treatment and 13 waitlist) completed the trial. Results demonstrated a significant reduction in hair pulling severity, impairment ratings, and hairs pulled, along with significant reductions in experiential avoidance and both anxiety and depressive symptoms in the ACT/HRT group compared to the waitlist control. Reductions generally were maintained at a 3-month follow-up. Decreases in experiential avoidance and greater treatment compliance were significantly correlated with reductions in TTM severity, implying that targeting experiential avoidance may be useful in the treatment of TTM. Other implications and suggestions for future research are noted.     

Using Acceptance and Commitment Therapy to Guide Exposure-Based Interventions for Posttraumatic Stress Disorder

Exposure is considered one of the most effective interventions for PTSD. There is a large body of research for the use of imaginal and in vivo exposure in the treatment of PTSD, with prolonged exposure (PE) therapy being the most researched example. Acceptance and commitment therapy (ACT) has sometimes been called an exposure-based treatment, but how exposure is implemented in ACT for PTSD has not been well articulated. Although support for the use of ACT in PTSD treatment is limited to a handful of case studies and open trials, research suggests ACT is particularly useful in flexibly targeting avoidance behavior—arguably the most important process in the continued maintenance of PTSD symptoms. The purpose of this paper is to explore the use of exposure within ACT in PTSD treatment. Through an overview of PE and ACT, and with the use of case examples, we describe how ACT principles and techniques may inform exposure-based treatments for PTSD in order to create more flexible approaches. In addition, understanding exposure within an ACT framework may also contribute to clarifying processes of change.     

Using Acceptance and Commitment Therapy to Treat Distressed Couples: A Case Study With Two Couples

Although the field of couple therapy has made significant strides in recent years, there continues to be a need for theoretically sound and empirically supported treatments. The current case study examines whether Acceptance and Commitment Therapy (ACT), an experiential acceptance-based behavior therapy, can be effective in treating distressed couples. Although ACT has demonstrated effectiveness in treating a variety of disorders in individuals, it has not been systemically applied to the treatment of couple distress, and the current study is the first empirical examination of ACT for the treatment of couples. Two married couples participated in the study. A number of core ACT interventions were modified to treat couples in a conjoint format. Cognitive defusion exercises were used to help couples reduce their fusion with and the believability of negative thoughts and feelings related to the relationship. Mindfulness and acceptance techniques were used to help couples increase awareness of their reactions to negative relationship cycles. Finally, value-directed action was used to help partners act in ways consistent with relationship values even in the presence of unwanted thoughts and feelings. The results of this preliminary case study suggest that ACT may be effective in increasing marital adjustment and satisfaction, and in reducing interpersonal and psychological distress in couples. Future studies with larger samples and more controlled designs are needed to build on the results from this single-case study.     

神经质对青少年情绪化饮食的影响：一个有调节的中介效应模型

摘 要 为探讨神经质、青少年情绪化饮食、体验回避及自尊之间的关系,选取1000名青少年为被试,采用简式大五人格问卷、荷兰饮食行为问卷、接纳行动量表及自尊量表进行测试。结果表明：（1）神经质对青少年情绪化饮食有显著的正向影响,并间接地通过体验回避对青少年情绪化饮食产生作用;（2）自尊在体验回避对青少年情绪化饮食的影响中起显著的调节作用,具体而言,在低自尊水平下,体验回避能显著地正向预测青少年情绪化饮食,而在高自尊水平下,体验回避对青少年情绪化饮食的预测作用不显著。     

A Pilot Study: Evaluating the Effects of Defusion on Choice Making Under Negative and Positive Reinforcement Contingencies

The Psychological Record - The goal of acceptance and commitment therapy (ACT) is to help people engage in experiential avoidance less and committed action toward values more. One possible behavior...     

Long-term outcomes of Acceptance and Commitment Therapy in drug-dependent female inmates: A randomized controlled trial

The general aim of this randomized controlled trial was to test the long-term efficacy of acceptance and commitment therapy (ACT) compared to a cognitive behavioural therapy (CBT) condition in the treatment of drug abuse. Participants were 37 polydrug incarcerated females assessed with Mini International Neuropsychiatric Interview, Addiction Severity Index-6, Anxiety Sensitivity Index (ASI) and Acceptance and Action Questionnaire II at pre, post, and at 6-, 12- and 18-months follow-ups. The mixed lineal model analyses showed reductions in drug abuse, ASI levels and avoidance repertoire in both conditions, without any differences between groups. However, the percentages of mental disorders were reduced only in ACT participants. At the 18-month follow-up, ACT was better than CBT in the maintaining of abstinence rates. This data support the incubation pattern showed in previous ACT studies. To conclude, the ACT intervention seems to be an adequate treatment option for addictive behaviours and co-occurring disorders in incarcerated women.     

Psychological inflexibility in childhood and adolescence: development and evaluation of the Avoidance and Fusion Questionnaire for Youth

The authors describe the development and validation of the Avoidance and Fusion Questionnaire for Youth (AFQ-Y), a child-report measure of psychological inflexibility engendered by high levels of cognitive fusion and experiential avoidance. Consistent with the theory underlying acceptance and commitment therapy (ACT), items converged into a 17-item scale (AFQ-Y) and an 8-item short form (AFQ-Y8). A multimethod psychometric approach provides preliminary support for the reliability and validity of the AFQ-Y and AFQ-Y8. In 5 substudies, 3 samples (total N = 1369) were used to establish (a) item comprehension (n = 181), (b) initial item selection (n = 513), (c) final item reduction and development of a short form for research (n = 346), (d) comprehensive psychometric evaluation of the AFQ-Y and AFQ-Y8 (n = 329), and (e) convergent and construct validity for both versions of the AFQ-Y. Overall, results suggest that the AFQ-Y and AFQ-Y8 may be useful child-report measures of core ACT processes.     

Relapse of anxiety-related fear and avoidance: Conceptual analysis of treatment with acceptance and commitment therapy

Excessive fear and avoidance in relatively safe situations can lead to a narrowing of one's behavioral repertoire and less engagement with valued aspects of living. Ultimately, these processes can reach clinical levels, as seen in anxiety, trauma, and obsessive–compulsive disorders. Research on the basic behavioral processes underlying successful treatment with exposure therapy is growing, yet little is known about the mechanisms contributing to clinical relapse. Until recently, these mechanisms have largely been conceptualized in terms of Pavlovian return of fear, with relatively little research into operant processes. In the current paper, we briefly review translational research in anxiety disorders and the connections between fear and avoidance, focusing on recent work in the acquisition, extinction, and relapse of avoidance behavior and the generalization of this learning through arbitrary symbolic relations. We then introduce one possible treatment approach to mitigating clinical relapse, acceptance and commitment therapy (ACT), and provide a conceptual analysis for why ACT may be especially well-situated to address this issue. Finally, we end with potential directions for future research on treatment and relapse of anxiety disorders.     

Measuring Experiential Avoidance: Reliability and Validity of the Dutch 9-item Acceptance and Action Questionnaire (AAQ)

Three studies evaluated psychometric properties of the Dutch version of the 9-item Acceptance and Action Questionnaire (AAQ)—a self-report measure designed to assess experiential avoidance as conceptualized in Acceptance and Commitment Therapy (ACT). Study 1, among bereaved adults, showed that a one-factor model, with AAQ-items constituting a single dimension of experiential avoidance, fitted the data well. The internal consistency and temporal stability of the AAQ were satisfactory. In Study 2, among undergraduate students, and Study 3, among 60 outpatients, higher AAQ scores were found to be significantly associated with psychopathology, maladaptive coping strategies, and neuroticism, attesting to the validity of the measure. In support of its incremental validity, Study 3 showed that the AAQ remained significantly associated with depression and anxiety after controlling for neuroticism and thought suppression. The current studies complement prior research supporting the psychometric properties of the AAQ and the ACT conceptualization of experiential avoidance.

Letting a little nonverbal air into the room: Insights from acceptance and commitment therapy Part 1: Philosophical and theoretical underpinnings

In recent years, a new “wave” of mindfulness based Cognitive Behavior Therapies (CBT) has become popular. Such approaches include Acceptance and Commitment Therapy (ACT; Acceptance and commitment therapy: An experiential approach to behaviour change. New York: Guilford Press, 1999), Mindfulness-based Cognitive Therapy for Depression (Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford Press, 2002), and Mindfulness-based Stress Management (Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York: Dell Publishing, 1990). In contrast to traditional CBT, these approaches often minimize attempts to change the form and frequency of dysfunctional thoughts. Is there any way to integrate traditional CBT with mindfulness based CBT? To answer this question, we discuss the philosophical and theoretical underpinnings of one form of traditional CBT (Rational-Emotive and Cognitive Behavioral Therapy) and one form of mindfulness based CBT (ACT). We argue that some aspects of each therapy can be integrated. However, in order to prevent techniques from being used haphazardly or inconsistently, we suggest that the different forms of CBT need to be driven by a common philosophical orientation (e.g., functional contextualism) and theoretical orientation (e.g., Relational Frame Theory).     

A preliminary investigation of acceptance and commitment therapy as a treatment for marijuana dependence in adults

In this investigation, 3 adults who met criteria for marijuana dependence were treated using an abbreviated version of acceptance and commitment therapy (ACT). The treatment was delivered in eight weekly 90-min individual sessions. The effects of the intervention were assessed using a nonconcurrent multiple baseline across participants design. Self-reported marijuana use, confirmed through oral swabs, reached zero levels for all participants at posttreatment. At a 3-month follow-up, 1 participant was still abstinent and the other 2 were using but at a lower average level of consumption compared to baseline. Depression, anxiety, withdrawal symptoms, and general levels of experiential avoidance generally improved. This preliminary test suggests that additional development and testing of ACT for marijuana use are warranted.     

Acceptance in Cognitive Behavioral Psychotherapies: Different or the Same?

Acceptance is a key construct in both rational emotive behavior therapy (REBT) and acceptance and commitment therapy (ACT). The objectives of this study were to assess and compare the properties of ACT acceptance with those of REBT acceptance in predicting emotions. A sample of 112 subjects, comprising different educational and occupational status, completed three measures of acceptance (REBT and ACT), two of mindfulness, as well as completing depression and anxiety scales. Both ACT acceptance as process and REBT acceptance could predict significant ACT acceptance as outcome. Mindfulness as a trait also predicted the level of ACT outcome acceptance as well as the level of REBT acceptance, but mindfulness as process predicted only ACT outcome acceptance. The results show that REBT acceptance, ACT acceptance and mindfulness can explain anxiety and depression in different ways. The results show that the difference between ACT acceptance and REBT acceptance primary concern the process of acceptance, most likely due to the underlying cognitive processing. The outcome acceptance and emotional level are similar in the two conditions. Future research should employ multiple cognitive measurements.     

Acceptance and commitment therapy: Altering the verbal support for experiential avoidance

Acceptance and Commitment Therapy (ACT) is a behavior-analytically-based psychotherapy approach that attempts to undermine emotional avoidance and increase the capacity for behavior change. An overview of this approach is given, followed by several specific examples of the techniques used within ACT. In each instance the behavioral rationale of these techniques is described. A contemporary view of verbal relations provides the basis for new approaches to adult outpatient psychotherapy.     

Safety Planning Within Acceptance and Commitment Therapy

Acceptance and commitment therapy (ACT) is a contextual behavioral psychotherapy that helps clients build meaningful lives in the service of their own chosen values, rather than specifically focusing on symptom reduction or prevention of destructive behaviors. However, empowering ACT clients to navigate suicidal crises effectively is vital to ensuring the opportunity to build a life they will choose to live. Suicide safety planning is a widely used empirically supported approach to prepare clients to survive suicidal crises, and can be effectively incorporated into ACT. In this paper, we offer a contextual behavioral conceptualization of suicide as an extreme attempt to solve the problem of painful thoughts, emotions, and sensations, and provide an example of how this conceptualization and the necessity of safety planning can be introduced to clients. Use of chain analysis of suicidal behavior is introduced as a tool to inform the suicide safety plan. We describe how ACT processes can enhance safety plans and, in turn, create safety plans that will serve as means to develop skills associated with efficacious/effective ACT interventions. Finally, we discuss the ongoing evaluation and revision of the safety plan from an ACT framework.     

Acceptance and Commitment Therapy for a Heterogeneous Group of Treatment-Resistant Clients: A Treatment Development Study

Acceptance and commitment therapy (ACT) has been shown to have broad applicability to different diagnostic groups, and there are theoretical reasons to consider its use with clients with chronic mental health problems. We report an innovative treatment development evaluation of ACT for a heterogeneous group of ”treatment-resistant clients” (N = 10) who had attended a mean of 3.5 previous psychological interventions. All clients had Axis I presentations and half met diagnostic criteria for Axis II disorders. Functioning, assessed at pre- and postintervention, and at 6- and 12-month follow-up, showed improvements over time on all primary outcome measures, driven largely by significant changes occurring between baseline and 6-month follow-up. Improvements were associated with ACT processes of change. The data thus suggest that a broad range of clients who had not benefited from standard care may benefit from ACT.     

Comparing in-the-moment skill coaching effects from tailored versus non-tailored acceptance and commitment therapy mobile apps in a non-clinical sample

Mobile apps are promising for teaching how to practice psychological skills in high-risk and in vivo momentary situations, but there has been minimal research on the immediate effects of app-based skill coaching on mental health in-the-moment. This study analyzed the mobile app data in a non-clinical sample of 39 adults participating in a larger randomized controlled trial, with participants randomized to an acceptance and commitment therapy (ACT) mobile app that tailors skill coaching based on in-the-moment variables (n = 17) or an app that provides randomly selected skill coaching (n = 22). Data were collected before and after each ACT skill coaching session on proximal outcome (depression, anxiety, and engagement in meaningful activity) and ACT process variables. Multilevel models indicated significant immediate improvements on average following ACT skill coaching sessions on all proximal outcome and ACT process variables, although with relatively small effects ranging between 0.17 and 0.27 SD units change. Larger immediate pre-to-post effects from ACT coaching sessions were found for anxiety, experiential avoidance, and cognitive fusion in the tailored app versus random app condition. Overall, results suggest that an ACT app can have immediate, in-the-moment effects on psychological functioning, which may be enhanced by tailoring skills to current context.     

Processes in acceptance and commitment therapy and the rehabilitation of chronic fatigue

Acceptance and commitment therapy (ACT) has never been tested for patients with chronic fatigue. We aimed to test if a 3.5‐week ACT rehabilitation program for patients with chronic fatigue improved quality of life (QoL), fatigue, and psychological flexibility. Further, to test if improvements in QoL and fatigue were associated with improvement in psychological flexibility, and if psychological flexibility explained variance above and beyond maladaptive cognitions typically targeted in CBT for fatigue. Patients (n = 140) who had been on sick leave > 8 weeks due to chronic fatigue received a 3.5‐week non‐controlled inpatient rehabilitation program based on ACT. A physician and a psychologist examined the patients, assessing medication use and SCID‐I diagnoses. Patients completed questionnaires about somatic complaints, psychological complaints, and maladaptive cognitions before and after treatment. At post‐treatment, patients reported improved QoL (p < 0.001; g = 1.07) and less fatigue (p < 0.001; g = 1.08), but not increased psychological flexibility (p = 0.6). Changes in psychological flexibility was associated with improved QoL, but not fatigue, in hierarchical regression analyses. When adjusting for other cognitions, changes in fear‐avoidance cognitions and all‐or‐nothing thoughts, but not psychological flexibility, were associated with improved QoL and fatigue. The ACT‐based treatment improved QoL and reduced fatigue for patients with chronic fatigue with large effect sizes. Improvement was associated with a reduction in fear‐avoidance cognitions and all‐or‐nothing thoughts, but not psychological flexibility.     

Impact of acceptance and commitment therapy versus education on stigma toward people with psychological disorders

Acceptance and commitment therapy (ACT) has previously been shown to alter stigmatizing attitudes and to be relatively useful for psychologically inflexible participants. The present study is the first to bring those two findings together by comparing ACT to an education intervention for reducing stigma toward people with psychological disorders, and examining whether results differ for psychologically inflexible versus flexible individuals. A sample of college students (N =95) was randomly assigned to a 2(1)2h ACT or educational workshop. Measures were taken before and after the workshop and at a 1-month follow-up. ACT reduced mental health stigma significantly regardless of participants' pre-treatment levels of psychological flexibility, but education reduced stigma only among participants who were relatively flexible and non-avoidant to begin with. Acceptance could be an important avenue of exploration for stigma researchers.