Acceptance & Commitment Therapy for Anxiety Disorders

Chapter 1

What Is ACT?

The purpose of life is not to be happy—but to matter, to be productive, to be useful, to have it make some difference that you have lived at all.

—Leo Rosten

Where We Have Been

Over the last forty years, behavior therapy has led the field in the development of empirically derived and time-limited psychological interventions to assist those suffering from anxiety- and fear-related problems. Most of these interventions now exist in the form of manuals and have been remarkably successful. Yet, all is not well. Despite some impressive short-term gains, we are still far from producing overwhelming success rates in terms of long-term recovery and prevention of relapse. Indeed, many time-limited cognitive behavioral interventions for anxiety-related disorders appear to produce equally time-limited treatment gains (Foa & Kozak, 1997a). And, despite numerous theoretical and conceptual advances in understanding the etiology and maintenance of anxiety-related disorders, we still lack agreement on the critical variables that may be involved, and do not yet agree on how best to approach the problem (Rapee, 1996).

Cognitive Behavioral Views of Anxiety Disorders

The result has been a growing literature of conflicting and unrelated findings, numerous disagreements and controversies, and a proliferation of disorder-specific mini theories and models that implicate so many different variables and processes that it is difficult to make any meaningful sense out of them (e.g., Barlow, 2002; Beck & Emery, 1985; Lang, 1993). This state of affairs is somewhat frustrating given that the anxiety disorders represent one of the more homogeneous diagnostic categories. Finally, despite refinements in our current diagnostic system (Diagnostic and Statistical Manual of Mental Disorders-IV-TR; American Psychiatric Association, 2000)—a system that has become ever more atheoretical, symptom-based, and categorical in nature—our field is still undecided about how best to classify and assess the problems in living that are grouped under the anxiety disorders, with diagnostic reliability often taking precedence over validity (Brown & Barlow, 2002). What is certain is that anxiety and fear-related problems are ubiquitous in human affairs. They often represent the main concerns of clients seeking outpatient psychotherapy and help from primary care physicians. What is more uncertain is whether cognitive behavioral therapies are addressing the real problem of anxiety and fear in the most useful fashion possible.

Most texts on the anxiety disorders describe etiological, theoretical, and treatment differences for each anxiety disorder consistent with the DSM-IV-TR—a system that classifies disorders and anxiety subtypes based on symptoms defined topographically and structurally rather than functionally or dimensionally. Using the DSM system as a bedrock for conceptual and treatment development is problematic for a number of reasons, but two stand out. First, the DSM tells us little about processes involved in how individuals come to have the symptoms they do. Second, the DSM does not address how those symptoms and associated problems in living can be effectively influenced in therapy. Despite such concerns, the DSM is widely used as a road map for thinking about psychopathology and has greatly influenced how we all think about anxiety disorders. For instance, it has become customary, if not mandatory, for behavior therapists to approach the anxiety disorders as discrete diagnostic entities, with each having its own separate etiologies and assessment and treatment strategies. As a result, the bigger picture is lost. Readers of standard chapters, texts, and treatment manuals on the anxiety disorders can easily be left with the false impression that the anxiety disorders are more different from one another than they really are.

Clearly, there is considerable overlap across the anxiety disorders. Such overlap, in turn, suggests that common behavioral processes are involved in the development, maintenance, and treatment of anxiety disorders. Perhaps if we were to come to grips with the common processes involved in how anxiety-related problems develop and are maintained, we might be in a better position to produce more impactful and meaningful behavior changes with our treatments and alleviate a wider range of human suffering. This is the more general aim of this book.

Cognitive Behavioral Therapies for Anxiety

For better or for worse, cognitive behavioral therapies (CBT) have become the treatments of choice for the anxiety disorders. Such treatments focus heavily on symptom alleviation as a therapeutic goal, are matched to specific DSM-defined anxiety disorders, and are set within a mastery and control framework. Such treatments imply several things.

First, they suggest that the “symptoms” are the problem. This perspective, by the way, is similar to how clients tend to view their problems (at least early on in therapy). In this sense, CBT therapists and clients appear to be in agreement that symptoms of anxiety cause impairment and suffering. If this were the whole story, then an obvious treatment strategy would be to target the symptoms. Yet there is usually a more important life to be lived behind the symptoms. It is this aspect of living that is of deep concern to clients, as it is to most human beings. In the past, traditional CBT has not paid sufficient attention to this and, as a consequence, may have missed important aspects of a person’s life situation. It is for this reason that acceptance-based approaches put living front and center on the therapeutic stage—as we show in this book.

Second, we must provide a more process-oriented answer to the question: What are the so-called symptoms of anxiety a sign of? If we refer to the problem responses that our clients seek treatment for as symptoms of anxiety, then we must explain what the disorder is. Calling the disorder “anxiety” sounds reasonable, but is not a viable solution. A problem response (symptom) cannot define a disorder and be a symptom of the disorder at the same time (Williams, 2004). The alternative we suggest in this book is to go after the processes that turn normal anxiety into the often life-shattering problems we refer to as anxiety disorders and then target those processes during treatment.

Third, the strategy of matching treatments to different anxiety disorders suggests that the anxiety disorders are truly distinct, and thus warrant different approaches for each. This issue alone is interesting and certainly deserves more comment than space would allow for here. Most therapists, however, are quick to point out the high degree of functional and symptom overlap across the presumably different anxiety disorders. Similar treatment technologies work for different anxiety disorders (e.g., exposure, cognitive restructuring, relaxation). This is a further indication that the disorders are more similar than they have been made out to be. It is interesting that this perspective has actually been gaining ground in CBT, too. For instance, David Barlow has recently proposed a unified treatment protocol and modular approach directed at the core features of all anxiety and related emotional disorders with the goal of condensing the existing various versions of CBT to one strategic approach that targets those core features (Barlow, Allen, & Choate, 2004).

Finally, virtually all cognitive behavioral treatments are cast within a mastery and symptom control framework. The chief therapeutic goal of such interventions is to teach clients more effective ways to gain control over their anxiety, fear, and related symptoms. Again, this is precisely what clients have come to expect from therapy, and a posture that most clients are all too familiar with by the time they enter therapy. That is, clients have tried this or that to master and control their anxiety and fear, often without much success. Now, they expect therapists to provide them with new, “better,” gold-plated strategies to do essentially more of the same, hoping that such strategies will be more workable than those they have tried in the past. As we will suggest, this mastery and control agenda is unnecessary and may even be counterproductive. Thoughts and emotions need not be managed to live a valued and meaningful life. Human experience tells us as much. Management and control of our internal private world is not a necessary prerequisite for living a meaningful life.

If this all sounds like a slam against cognitive behavioral therapies, it is not. Rather, our intent is to suggest ways that we can improve upon existing CBT interventions while retaining those components of CBT that have clearly proven effective, such as exposure exercises and strategies to counteract avoidance behavior. Helping clients to improve their life situations, however, may require that we rethink the mastery and control change agenda within standard cognitive behavioral therapies for anxiety disorders.

Before proceeding, we would like to challenge you to put aside for a moment some of the following commonly held assumptions about anxiety: (a) anxiety is bad; (b) anxiety is the cause of human suffering and life problems; and (c) our task as therapists is to help clients “get rid of,” “control,” “replace,” or “eliminate” disturbing feelings or irrational thoughts, memories, and urges associated with anxiety and fear. In place of these assumptions, we offer a different view of anxiety and fear and their treatment and, hence, of psychological health.

Where We Are Going

The treatment approach described in this book is based on Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999). Acceptance and Commitment Therapy (ACT) is a relatively new third-wave behavior therapy. It goes after various forms of experiential and emotional avoidance that keep people stuck and suffering. The basic goal of ACT is to help the client become better at living a full, rich, and meaningful life, rather than becoming better at feeling good (i.e., being symptom free) in an attempt to have such a life.

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy is a unique behavior therapy approach that aims to address human concerns about anxiety and fear in a mindful, compassionate way, while encouraging people to pursue what really matters to them. In a nutshell, ACT is about helping clients to do three things: accept themselves and others with compassion, choose valued directions for their lives, and commit to action that leads them in those directions. ACT teaches clients that it is okay to have whatever unwanted thoughts and feelings their minds and bodies come up with. Rather than struggling with these thoughts and feeling, clients learn new ways of relating to them as experiences to be had.

ACT has two major goals: (1) fostering acceptance of unwanted thoughts and feelings whose occurrence or disappearance clients cannot control, and (2) commitment and action toward living a life that they value. This is why ACT is about acceptance and it is about change at the same time. Applied to anxiety disorders, clients learn to accept and live with their unwanted thoughts, worries, bodily sensations, and other feelings and take charge and move their lives in directions that they value.

ACT is not just short for Acceptance and Commitment Therapy. The ACT acronym also nicely captures the three core steps or themes of this approach—Accept thoughts and feelings, Choose directions, and Take action:

1.            Accept Thoughts and Feelings: Accept and embrace thoughts and feelings, particularly the unwanted ones (anxiety, pain, guilt, inadequacy). The idea is for clients to accept what they already have anyway and end their struggle with unwanted thoughts and feelings by not attempting to eliminate or change them, by not acting upon them, and by ultimately letting them go. Through various mindfulness exercises clients learn to live with their critical, evaluative mind.

2.            Choose Directions: This step is about helping clients to choose directions for their lives by identifying and focusing on what “really matters” and what they value in life (“What do you want your life to stand for?”). It is about helping clients to discover what is truly important to them and then making an important choice. It is about choosing to go forward in directions that are uniquely theirs and accepting what is inside them, what comes with them, and what accompanies them along the way.

3.            Take Action: This step is about committed action and involves taking steps toward realizing valued life goals. It is about making a commitment to action and changing what can be changed. The therapist encourages clients to behave in ways that move them forward in the direction of their chosen values. In this stage of ACT, clients learn that there is a difference between them as a person, the thoughts and feelings they have about themselves, and what they do with their lives. We will describe this process in detail as it is fundamental to ACT work, regardless of the clinical presenting problem.

The philosophy of ACT is somewhat similar to the serenity creed that many people love: Accept with serenity what you cannot change, have the courage to change what you can, and develop the wisdom to know the difference.Most people find that it is much easier to agree with the serenity creed than to do what it says. The reason is that often people simply do not know what they can change and what they cannot change. As a result, they do not know how to apply this profound statement in their daily lives and become frustrated with it. ACT teaches people to put the serenity creed into action.

ACT accepts the ubiquity of human suffering and does not seek to reduce pain or to produce a particular positive feeling. It is not about producing quick fixes or using culturally sanctioned feel-good formulas and methods to reduce suffering. ACT seeks instead to reduce suffering by increasing people’s vitality and ability to do what they want to do with their lives. This is what the ACT approach is all about: Accept and have what there is to be had (anxiety, anger, joy, memories, the whole package) while also staying committed to doing what needs to be done to live a fulfilled, rich life guided by chosen values. People can choose to do things they enjoy and value regardless of what it is that they think or feel. Anxiety need not stand in the way of doing. If anxious clients start to move down this path, they are likely to feel more anxiety at first. Eventually they will probably feel more enjoyment and less pain and anxiety. If that happens, it is considered a welcome by-product of therapy—it is not an explicit goal of ACT.

An ACT Approach to Anxiety Disorders

CBT approaches to anxiety disorders have rightly focused on helping clients confront rather than avoid situations and stimuli that have been associated with anxiety. More recently, however, clinical researchers have begun to focus on a more general type of avoidance called experiential avoidance. Experiential avoidance refers to an individual’s attempts and efforts to avoid, suppress, or otherwise alter the form of negatively evaluated private events such as bodily sensations, emotions, thoughts, worries, and memories (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). According to this view, when persons with agoraphobia avoid public places, they are not avoiding the places per se. What they are really avoiding is experiencing their thoughts and emotions associated with panic in such places (Forsyth, 2000; Friman, Hayes, & Wilson, 1998). Similarly, when people with obsessive-compulsive disorder avoid touching a doorknob that might have germs on it, they are not doing so to avoid being contaminated. What they are doing is avoiding the negative affect associated with touching the doorknob. In other words, in all these cases of phobic avoidance, people are avoiding their own psychological and emotional experiences.

This type of avoidance is at the core of all anxiety disorders. For instance, individuals with specific phobias do not really avoid snakes, elevators, or airplanes per se. They avoid experiencing paniclike responses in the presence of these stimuli (Forsyth & Eifert, 1996). Likewise, combat veterans with post-traumatic stress disorder do not avoid the sound of helicopters simply because they are afraid of them. They avoid the intense negative affect that is associated with that sound and its potential to remind them of past traumas that they wish not to think about. We therefore agree with the notion that the core issue in anxiety disorders is a fear of fear (Chambless & Graceley, 1989) or, more generally, a fear of negative affect. This is certainly part of the problem, but not the complete story. In fact, we would add to and rephrase fear-of-fear notions to read: The core issue in anxiety disorders is a fear of fear and doing everything possible to avoid experiencing the fear. The primary function of such experiential avoidance is to control or minimize the impact of aversive experiences. In fact, this avoidance tendency (not wanting to have the fear) is what drives fear of fear. Without avoidance, there would be no reason to fear the experience of fear.

Rigid and inflexible patterns of emotional and experiential avoidance are common to all anxiety disorders and function to make anxiety and fear problematic for anxious clients. Within ACT, such avoidance is viewed as a core toxic process driving “disordered” experiences of anxiety and fear. This is why experiential avoidance is one of the most important explicit treatment targets. ACT is not about helping clients to control or manage their anxiety, only to leave them stuck with lingering fears and concerns, such as “When is anxiety going to come back?” This prolongs the client’s struggle and effectively sets up a relapse trap for them. Instead, ACT attempts to teach clients to approach fear and anxiety more fundamentally, more deeply, and in a different way. Specifically, an ACT approach to anxiety disorders is designed to teach clients the following:

1.            Rigid and inflexible attempts to control, reduce, and avoid experiencing anxiety are the problem, not a solution.

2.            Acceptance (as opposed to struggle) is a viable alternative agenda when faced with anxiety responses and the circumstances that occasion such responses.

3.            Practice mindful acceptance and willingness when experiencing aversive bodily sensations, thoughts, and feelings during anxiety and other emotional states, regardless of whether they occur spontaneously or are elicited during exposure exercises. The goal here is not to help clients to feel good (i.e., be anxiety free), but to become good at feeling a full range of private experiences (i.e., thoughts, memories, emotions, bodily sensations) for what they are.

4.            Client concern about overcoming anxiety has resulted in a restricted life and a great deal of suffering. Thus, clients are encouraged to take a hard look at their lives. In the process, they are encouraged to identify their own values while committing to put those values into freely chosen action. This will invariably result in what CBT manuals usually refer to as naturalistic exposure exercises. Yet, unlike typical CBT approaches, the primary goal is not to extinguish and reduce anxiety. The goal is to help clients live a valued life. ACT-style exposure, therefore, is always done in the service of client values and life goals, not as a means to reduce or get a handle on symptoms. Though symptom alleviation may come about via the exercises contained in part 3 of this book, it is not an explicit focus nor a requirement for living life as a complete, fully functioning, capable human being.

Building upon these and other core ACT concepts, this book provides an alternative mastery of experiencing context for the exposure-type interventions that lie at the core of virtually all cognitive behavioral interventions for persons suffering from anxiety disorders. The ultimate therapeutic prize within ACT is to help the client live a full, rich, and meaningful life. Any exercise that facilitates movement in such directions is considered worthwhile.

How to Use This Book

This book explores and describes ways to integrate the most successful components of traditional cognitive behavioral therapy within an Acceptance and Commitment Therapy framework. It is not meant to replace texts and manuals focusing on conventional CBT interventions. Most CBT texts provide comprehensive accounts of the current conceptual and research-based knowledge on the causes and assessment of anxiety disorders (Barlow, 2001, 2002; Craske & Barlow, 2000). These books also give clinicians detailed session-by-session instructions on how to conduct CBT for the various anxiety disorders. We summarize CBT approaches and review their efficacy in chapters 2 and 3 in enough detail so that you know where we are coming from and where we are going.

A word of caution, however, on how not to use this book. Please do not move to the treatment guidelines in part 3 without first reading part 2. There are several reasons we recommend against doing so that will become clearer to you as you read on. An increasing number of conference presentations, journal articles, professional books, and self-help books have focused on acceptance and mindfulness notions. Such topics, in turn, are becoming ever more popular in clinical science and practice. The tide is shifting. Many researchers and clinicians are curious about what this shift may offer them and the clients with whom they work. Though the basic ideas are certainly old, they are new in the field of psychology. Yet, the rapid dissemination of such notions has raced ahead of the practical, how-to translation. The underlying theory, rationale, and practical technology have not been disseminated in an easily understood and useable form. Acceptance- and mindfulness-based approaches remain somewhat shrouded in mystery for this very reason. This is unfortunate and a problem we hope to begin to remedy with this book. This book is, at its core, about describing and applying acceptance- and mindfulness-based notions to understanding and treating anxiety disorders. It represents our best effort to translate the underlying framework and technology. Our intention is to make ACT accessible and understandable so that it can be used by therapists and others who may benefit from it. We describe relevant concepts, principles, and techniques in an easy-to-understand language so that therapists may make use of this information in their daily practice with clients who present with anxiety disorders.

Part 3 of the book describes the application of ACT principles and techniques to the treatment of the major anxiety disorders. In this section you will find session-by-session guidelines on how to conduct acceptance-based behavior therapy. You will see that we present a unified approach to the treatment of anxiety problems, emphasizing emotional acceptance, experiential mindfulness, and actions that are consistent with what clients value and wish their lives to stand for. Most of the treatment guidelines are applicable to all anxiety disorders. Where appropriate and necessary, we also describe some disorder-specific considerations and procedural variations. We also provide detailed practical guidelines so that you may integrate ACT principles and techniques with the most successful and effective aspects of cognitive behavioral interventions for anxiety disorders (e.g., exposure and behavioral activation). The material is outlined in sufficient detail so that you may put what you read into therapeutic action and readily use it in your clinical work. As already mentioned, however, we do not want you to go immediately to part 3 of the book, read it, and then apply the interventions in a cookbook-type fashion with your clients. The results could be disastrous for them and disappointing for you. Understanding the rationale for the interventions is critical.

Rather than a technology, ACT truly is an approach to understanding and treating anxiety. It is not a set of techniques, metaphors, and exercises, although there are many. You should individualize and tweak techniques based on the specific circumstances and responses of each patient, an understanding of the core processes involved in maintaining your client’s behavior, and what it is you want to change at the process level. We encourage you to use exercises and metaphors in a flexible and creative fashion. You should tailor and match the specific techniques to the unique circumstances of the client and the client’s responses in the therapeutic interaction. So, do not feel compelled to use the exercises in exactly the same way, or in the exact same order, as we suggest. These are simply meant to be starting points. We expect that you will alter and adapt them to your clients’ specific needs. You will probably also create new ones along the way. This is all fine and desirable as long as you target the critical processes that underlie disordered anxiety. It is for this reason that we consider it essential to read and learn about these processes in part 2 first before moving to the treatment guidelines in part 3 and attempting to apply any of the techniques we describe.

You will see that this book focuses on the functional overlap and similarities amongst the major anxiety disorders in terms of both etiology and treatment principles and techniques. This may be welcome news for you. It is a view that is quite different from the typical professional book about anxiety disorders. Such books, as you know, tend to emphasize unique aspects of each particular anxiety disorder. This we believe, does not jibe with clinical reality nor emerging evidence suggesting that we may have been artificially splitting up the anxiety disorders for too long. These and related issues are clearly laid out in part 2 of this book. For instance, chapter 4 describes a major commonality of all anxiety and related disorders: the toxic effect of experiential avoidance and efforts to control unwanted private experiences that most individuals with anxiety disorders engage in regardless of their particular DSM diagnosis. Rigid inflexible patterns of avoidance are common to all anxiety disorders. Such tendencies function to exacerbate and perpetuate client problems, regardless of the specific diagnosis or name we give them. We therefore encourage you to understand anxiety disorders as disorders of experiential avoidance. It is this experiential avoidance that becomes the explicit treatment target within the ACT approach we describe for you in part 3 of this book. Unless you have a good understanding of these processes and principles, including how they may play out in your own life, you will not be able to do ACT.