Acceptance and commitment therapy as a treatment for anxiety and depression: A review.

Acceptance and commitment therapy (ACT) is a modern form of cognitive behavioral therapy based on a distinct philosophy (functional contextualism) and basic science of cognition (relational frame theory). This article reviews the core features of ACT’s theoretical model of psychopathology and treatment as well as its therapeutic approach. It then provides a systematic review of randomized controlled trials (RCTs) evaluating ACT for depression and anxiety disorders. Summarizing across a total of 36 RCTs, ACT appears to be more efficacious than waitlist conditions and treatment-as-usual, with largely equivalent effects relative to traditional cognitive behavioral therapy. Evidence from several trials also indicate that ACT treatment outcomes are mediated through increases in psychological flexibility, its theorized process of change. Acceptance and commitment therapy (ACT)1 is part of a larger research approach called Contextual Behavioral Sciences (CBS). Those with a CBS focus to their work generally adhere to a behavior-analytic theoretical orientation, and as such have a strong interest in the basic science that informs the techniques used in therapy. Behavior analysis traditionally focused on the use or contingency management procedures to modify overt actions, and did not have a conceptualization of the role of cognition other than it being another form of behavior that was reinforced by the verbal community.2 This differs from CBS in that, the most active line of basic research is a behavioral account of language and cognition called relational frame theory (RFT).3 RFT has been an active line of research since the 1970’s when it was called stimulus equivalence.4 Since that time, RFT research has expanded and provides a method to study language and cognition, and inform behavioral interventions. To put it simply, ACT as described in this paper, is modern behavior analysis applied to clinical issues including anxiety and depression. This manuscript will review the foundations of ACT, its theoretical model of psychopathology and treatment, and the empirical evidence for ACT as a treatment of anxiety and depressive disorders

Sexual Orientation Intrusive Thoughts and Well-Being: The Mediating Role of Psychological Inflexibility

Sexual orientation intrusive thoughts are a debilitating form of obsessive compulsive disorder (OCD). The present study aimed to elucidate how psychological inflexibility and dysfunctional beliefs may impact the relationships of sexual orientation intrusive thoughts and obsessive-compulsive (OC) symptoms with well-being. A total of 181 undergraduate students completed measures of sexual orientation intrusive thoughts, OC symptoms, psychological inflexibility, dysfunctional beliefs, and well-being. Results indicated positive correlations between psychological inflexibility, sexual orientation intrusive thoughts, dysfunctional beliefs, and OC symptoms, along with negative correlations between well-being and sexual orientation intrusive thoughts, OC symptoms, dysfunctional beliefs and psychological inflexibility. Psychological inflexibility acted as a mediator between sexual orientation intrusive thoughts and well-being, and between OC symptoms and well-being. Dysfunctional beliefs were not a significant mediator. These results suggest that psychological inflexibility may partially explain the association between OC symptoms and well-being, pointing towards the need for future research on the impact of psychological inflexibility on well-being in the context of OC symptoms

Merging Acceptance and Commitment Therapy with Exposure Exercises to Treat Social Anxiety in a Teen

Social anxiety disorder (SAD) often develops during teenager years, and it is important to conceptualize developmentally appropriate interventions. Exposure therapy framed from a perspective of acceptance and commitment therapy (ACT) shows promise for decreasing pathology and increasing wellbeing. This case illustrates the process through which exposure therapy was integrated with ACT to elicit meaningful outcomes in a case of SAD with a 16-year-old female. Treatment outcomes assessed included engagement in values-based activities as well as assessments of depression, social anxiety, separation anxiety, generalized anxiety, experiential avoidance, and contextually targeted school-based wellbeing. Intervention centered on learning ACT principles through relatable metaphors and experiential exercises and practicing them with values-guided social exposures. This integration resulted in increased engagement in socially meaningful experiences over time as well as associated changes in treatment outcomes. Treatment implications, guidelines, and recommendations are presented, including the need for skill-focused treatments, identifying deficits in psychological flexibility, and maintaining a compassionate yet growth-oriented course of treatment

ACT-Enhanced Behavior Therapy for a Hispanic Adult With Trichotillomania: A Case Report

Trichotillomania, also known as Hair-Pulling Disorder, is characterized by recurrent pulling out of one’s hair over brief episodes or sustained periods of time and results in hair loss. ACT-enhanced behavior therapy (A-EBT) has been shown to be an effective approach in the treatment of trichotillomania by promoting psychological flexibility around hair pulling urges and teaching stimulus control and habit reversal training. However, there is limited support of A-EBT for clients with an ethnic minority identity. This case report focuses on an adult, Hispanic female client, Luna (pseudonym), who received eight sessions of A-EBT for the treatment of trichotillomania. At post-treatment, Luna showed significant improvements in number of hairs pulled, trichotillomania specific psychological flexibility, depression and anxiety. Luna’s case highlights barriers to care such as potential resistance in seeking mental health services, the influence of family members’ beliefs on receiving mental health services, and the limited access to specialized treatment of trichotillomania

Examining Processes of Change in an Online Acceptance and Commitment Therapy Dismantling Trial with Distressed College Students

This secondary analysis examined the processes of change from a randomized dismantling trial evaluating the Open (i.e., cognitive defusion, acceptance) and Engaged (i.e., values, committed action) components of acceptance and commitment therapy (ACT). Analyses were conducted with 161 distressed college students randomly assigned to a full online ACT program (Full n=40), online ACT targeting the Open components (Open n=41) or targeting the Engaged components (Engaged n=39), or a waitlist condition (Waitlist n=41). The intervention occurred over six weeks followed by a post-treatment assessment with mental health symptoms as the primary outcome. Consistent with predictions, pre- to post-treatment improvements in global psychological inflexibility, cognitive fusion, acceptance, values, and committed action all predicted pre- to post-treatment improvements in mental health, with most processes continuing to independently predict improvements when included in a single model. The relations between changes in psychological flexibility and mental health were generally equivalent between conditions. Each psychological flexibility process separately mediated improvements in mental health for Engaged versus waitlist and Full versus waitlist conditions. However, global inflexibility, committed action, and values progress did not mediate effects for Open versus waitlist. Overall, results indicate a range of acceptance, defusion, values, and committed action processes are functionally relevant for outcomes with the Engaged components of ACT and Full ACT, but values, committed action, and global psychological inflexibility processes may be more weakly related to the effects of the Open components of ACT alone

A Randomized Trial of Acceptance and Commitment Therapy and Traditional Cognitive-Behavioral Therapy Self-Help Books for Social Anxiety

Background: Self-help resources such as books may help meet critical mental health needs in college students, but there is insufficient evidence on whether and how such books work. This randomized trial compared acceptance and commitment therapy (ACT) and traditional cognitive behavior therapy (tCBT) self-help books for social anxiety, a common concern with notable barriers to treatment seeking. Methods: A sample of college students (n = 102) with social anxiety was randomly assigned to use one of the two self-help books over eight weeks. Results: Improvements were observed in both conditions across all outcomes (social anxiety, general well-being, and social functioning) as well as potential processes of change (cognitive fusion, appraisals of social concerns, and progress toward personal values). Few differences were observed between conditions. Changes in general cognitive fusion consistently predicted outcomes at posttreatment, and anxiety-specific cognitive fusion and concern about negative social interactions also predicted some later outcomes. Conclusions: Use of self-help books to address social anxiety in college students is promising, and addressing cognitive fusion appears to be important

Acceptance and Commitment Therapy for a Child With Misophonia: A Case Study

Misophonia, a condition involving hypersensitivity, anger, and/or disgust in response to specific noises (e.g., chewing, tapping), is highly underresearched in children. Several case studies point towards the utility of cognitive behavioral therapy and related treatments (e.g., acceptance and commitment therapy [ACT]). ACT presents a particularly promising option, as it focuses on building psychological flexibility in response to difficult internal experiences, rather than trying to remove or change them (e.g., responding effectively to irritation provoked by chewing). The present case study describes “Kelly” (pseudonym), a 12-year-old girl with moderately severe misophonia symptoms, who received a 16-session course of ACT for misophonia. At post-treatment, Kelly reported a decline to the mild range of misophonia, as well as re-engagement in activities that were important to her and clinically significant reductions in depressive symptoms. These results suggest that ACT may be an appropriate treatment for children with misophonia; however, much more research is warranted

Examining Processes of Change for Acceptance and Commitment Therapy and Cognitive Behavioral Therapy Self-Help Books With Depressed College Students

Given the prevalence of depression, it is worthwhile to consider a variety of treatment approaches to reach as many sufferers as possible, including highly accessible formats such as self-help books. Books based in acceptance and commitment therapy (ACT) and cognitive behavioral therapy (CBT) propose to treat depression through distinct processes of change, though the degree to which these treatments are distinguishable in this format is unclear. Furthermore, it is possible that some individuals may respond better to therapeutic processes from one approach over the other based on personal preferences. We tested the effects of ACT and CBT self-help books on processes of change in a sample of 139 depressed college students in which some participants were given a choice of treatment and others were randomized. Cognitive fusion, which improved better in the ACT group, was the only process of change that distinguished the two treatments. Additionally, early improvements in cognitive fusion were associated with less depression-related stigma at posttreatment. Lastly, randomization, instead of choosing a treatment, led to greater improvements in almost all processes of change. We discuss how these findings inform personalized care, tangible differences between ACT and CBT, and effective practices for treating depression at large scale

Beyond Acceptance and Commitment Therapy: Process-Based Therapy

This article describes process-based therapy (PBT) as a natural evolution toward more effective and efficient mental healthcare. Using acceptance and commitment therapy as an example of an early prototype of PBT, this paper explicates the broader features of PBT and the shift in mindset researchers and clinicians will need to take to fully embrace PBT with respect to assessment, conceptualization, and intervention. In addition, the paper enumerates challenges to implementing the PBT model and proposes recommendations for circumventing these challenges in the areas of theory development, research methodology, and clinical practice. Finally, we make the argument shifting to PBT is the logical next step for our field

Evaluating the Effects of Guided Coaching Calls on Engagement and Outcomes for Online Acceptance and Commitment Therapy

Previous research indicates mixed results for guided support with interventions. The current secondary analysis evaluated the effects of phone coaching from a dismantling trial of online acceptance and commitment therapy (ACT) in a sample of 136 distressed college students randomized to one of three versions of an ACT website. Participants were randomized to receive email prompts alone (non-coaching condition) or email plus phone coaching (coaching condition). Results indicated no differences between the coaching and non-coaching conditions on program engagement, program satisfaction, mental health outcomes, and almost all psychological flexibility processes. However, participants in the coaching condition reported stronger pre- to posttreatment improvements in psychological inflexibility than the non-coaching condition. This effect was moderated by ACT component condition, with larger pre- to posttreatment effects from coaching on psychological inflexibility in the values/committed action condition and weaker improvements from coaching in the acceptance/defusion condition. Overall, results indicate online self-guided ACT interventions with email prompts are sufficient for addressing college student mental health and that phone coaching provided minimal additional benefit