Acceptance & Commitment Therapy for Anxiety Disorders

Chapter 12

Practical Challenges and Future Directions

Carefully watch your thoughts, for they become your words. Manage and watch your words, for they will become your actions. Consider and judge your actions, for they have become your habits. Acknowledge and watch your habits, for they shall become your values. Understand and embrace your values, for they become your destiny.

—Mahatma Gandhi

The Road Ahead

The psychotherapy scene is flooded with books promising new and “better” approaches to alleviate human suffering. We simply cannot promise you that an ACT approach applied to persons suffering from anxiety disorders will turn out to be better or more useful than other well-established approaches. It may. It may not. Only time will tell. What we can be relatively sure of is that ACT will change over time because of its coherent philosophical foundation, intriguing treatment technology, and rapidly evolving empirical base. Such changes, we hope, will move us closer to alleviating a wider range of human suffering.

This somewhat humble way to open the closing chapter of this book is meant to serve a function. Most of us genuinely wish to leave the world a better place than we found it. In a therapy context, this value usually translates into therapeutic actions that are designed to help our clients live better long after therapy has ended. This is the real legacy of our actions as therapists and what we usually mean when we talk about “good therapeutic outcomes.” When a new treatment technology is disseminated in a practical form, as we have tried to do here, there is a risk that the approach and related technology may be held too tightly. This, we believe, would be a mistake. Throughout the book we have laid out the conceptual and practical foundation for using ACT with anxious clients. This book is not meant to be the way to do ACT with anxious persons. Rather, we hope you will use the material in a spirit of openness, creativity, flexibility, genuineness, curiosity, humility, sharing, respect, and investigative play. This is the spirit that guided us in writing this book and a posture that we believe is necessary when using ACT—or any psychotherapy approach—with other suffering human beings. We also recognize that there is more work to be done and that we still have a long way to go. There are no psychotherapies that are wholly curative. The same is true of ACT. Thus, it seems fitting and appropriate to explore some practical challenges that you may encounter when using ACT with your anxious clients, and where we see the third-generation behavior therapies headed in the years to come.

Practical Challenges in Conducting ACT

We have said that ACT is a treatment approach, not merely a treatment technology. It flows naturally from a conceptualization of human suffering that underscores language traps and blind alleys, and unworkable self-regulation processes, and how these get in the way of living fully and meaningfully. It entails a therapeutic stance and a range of concepts that have been acknowledged and embraced by less behavioral schools of psychotherapy for some time. Some of you will find comfort in the ACT approach and technology because it fits your own training and experience. Others of you may find ACT hard to swallow. This is understandable given that many of us were trained in the tradition of “eliminating symptoms of disorders.” Yet, we do not wish the ACT model to be a barrier for you or your clients.

The Approach Is Counterintuitive

The ACT approach is counterintuitive and goes against the grain of what most of us have learned needs to be done and ought to be done to alleviate human suffering, particularly in the West. Many (not all) of your anxious clients will also find the approach at odds with what they have come to expect from psychotherapy. That is, therapy is about alleviating suffering by focusing on the unwanted experiences. For anxious persons, suffering occurs because they typically focus on content (i.e., thoughts, feelings, physical sensations, and behavioral tendencies) that is undesired and the situations that may occasion such experiences. ACT, as we have seen, turns this view on its head by focusing on what people do about their pain, and how that doing creates suffering by getting in the way of living. Hence, the aim of ACT is not to fix people, because they are not broken, but to break them loose.

The counterintuitive nature of the treatment is, in part, what makes it effective. Yet, this feature can also be a real obstacle as you work to use ACT effectively with your clients. Remember that you are in the same soup as your clients. You have played the language game yourself when it comes to your own suffering. You have likely sought out solutions that resemble those tried by your anxious clients. Some of these probably include strategies to manage and control your own suffering. You also have likely received professional training and experiences that may have played into this very system. As a consequence, you may find yourself modeling nonacceptance by slipping back into control and symptom-focused kinds of talk, or by selectively suggesting that negatively evaluated experiences be reduced in the service of promoting more socially desirable experiences. You may even delve into the past history of your clients in an effort to achieve insight into the reasons for their problems, or find yourself wanting to offer solutions, explanations, and the like that would remove the discomfort your clients may be experiencing—and some of your own discomfort by extension. These and other actions are precisely what most anxious clients have been doing before coming into therapy. ACT is not about doing more of the same.

This is why it is so important to get your head and heart around the ACT model in your own life and in your professional role as a therapist. Acceptance is not something that can be instructed or faked. Nonacceptance may emerge in you and your clients in subtle forms during the course of therapy. When left unchecked, a lack of acceptance on your part can set up expectations about therapy that can be difficult to undo. As we have said, nonacceptance tends to play into the social-verbal system (i.e., rules, reasons, justifications, evaluations, avoidance, control) that an ACT approach is trying to help clients break loose from. This is why the counterintuitive nature of the treatment is so compelling. It functions to weaken verbal-cognitive forms of control, so as to make room for actions that are more flexible, less evaluative, and more experientially based. There is no magic to this. No smoke. No mirrors. It is what it is. As you struggle with the background material and its application in therapy, play with it and use it in your own life and in your clinical work. We think that you find ACT more experientially intuitive when you do so.

Handling Client Resistance

Resistance is ubiquitous in psychotherapy and everyday life. Virtually all psychotherapists have experienced client resistance in one form or another. All human beings have resisted some aspect of their experience. Though resistance can take several forms, it usually involves a fundamental dialectic between knowing what we should or should not do while at the same time not being able to do or not do it for reasons we often do not understand. Sometimes we cannot even see those reasons clearly. In ACT terms, resistance is fundamentally about verbal behavior getting in the way of effective action. It is a natural process of change and growth and a process that can keep people stuck. At the core, it is about taking charge of one’s own life and living it!

RESISTANCE TO ACTION AND RESPONSE-ABILITY

Anxious persons tend to show up in therapy with quite a bit of resistance under their belts. At some level, they know what they should be doing with their lives, but cannot seem to get going and doing. They are on autopilot, listening and responding to what the mind says “is” or “ought” to be. The anxiety monster rules the roost. Anxiety News Radio is broadcasting 24/7, repeating again and again old habitual patterns of relating with oneself and the world. The old programming is in place, and behavioral tendencies follow automatically. There is little room for response-ability in this system, because the system runs the show. It is never challenged directly for what it is. Actions that run counter to this system, in turn, do not fit the programming. They are met with resistance. There is no room on Anxiety News Radio for doing something new. Nothing changes. Nothing needs to change.

The very act of coming into therapy challenges this system by providing an alternative to it. Yet, so long as the system remains in place, therapeutic efforts that challenge the system directly are met with more resistance, not less. This is why ACT goes after the system first, and hence the problem of resistance to change. All of the procedures contained in this book are about undermining subtle and at times obvious forms of client resistance (e.g., unwillingness, experiential avoidance, cognitive fusion) by fostering psychological flexibility, experiential openness, responsibility, and value-guided actions. Metaphors and experiential exercises weaken forms of resistance, in part, because they challenge the programming. We encourage clients to turn off Anxiety News Radio and tune in to Just So Radio instead. The anxiety monster need not be fed. Clients can be response-able and do what matters most to them. The bus can head north even while the mind is broadcasting, “Go south or else!” To get there, however, clients need to open up to the possibility that the programming is simply the programming. It will always be there. Clients can feed into the programming with more of the same, or choose not to buy into it by doing something different with their hands and feet. This is a moment of choice, personal response-ability, and courage, and quite often a turning point in therapy. It emerges once clients make contact with how they have lived up to this point and how they wish to live now and into the future.

BEING WITH NONCOMPLIANCE

One of the most common forms of resistance occurs when clients fail to complete a task they committed to doing. When that happens, therapists need to examine what got in the way of task completion and move through barriers to valued action using some of the strategies described in the previous chapter. In the process, therapists should attend to the possibility that the task was not clearly linked to client values or that the client fails to see the connection. It is important to note that noncompliance is not failure. Therapists should refrain from pressuring or threatening clients with statements such as, “If you don’t keep your commitments, then things are not going to change much.” Such statements are coercive and do not work. They model self-denigration. Instead of resorting to social pressure, confrontation, or interpretations of “resistance,” this is a time for therapists to model acceptance and compassion:

No matter how carefully the stage is set for the client to choose valued actions, it is a choice only the client can make. Choosing not to go forward with a plan is a legitimate choice, as long as it is actually a choice. The gentlest [and most compassionate] way to work with a client in such circumstances is to completely validate the client and the dilemma he or she is facing. The therapist might say, “If this were my life and I were seeing the consequences you are seeing, I could well imagine myself choosing not to go forward.” (Hayes, Strosahl, & Wilson, 1999, p. 260)

As indicated earlier, the commitment is to do it and mean it 100 percent. The commitment is not that the client will never break it. What is important is that when clients do break a commitment, they recommit, mean it, and get back on their chosen path.

RESISTANCE IS ABOUT CHOICE, GROWTH, AND CHANGE

Forms of resistance, including noncompliance, are neither good nor bad. They are what they are, and they reflect where the client may be with you as a person and with aspects of themselves. Resistance can be defused from, embraced, and experienced for its workability in the context of client goals and values. This is a critical point. When resistance emerges, evaluate whether you are operating from an equal stance with the client. Ask, who is setting the agenda here? Are you, as a therapist and another human being, operating in the role of bus driver? Are you setting the agenda for your client, or are they setting the agenda? Resistance cannot be overcome by therapeutic efforts to push the client harder, to set their goals, to make their choices. Pushing in this way typically will guarantee more resistance, not less. You can let them experience what hasn’t worked and that there is a different radio station out there they can choose to tune into. Change is a choice only clients can make.

The same is true of resistance. For instance, most anxious clients are showing up for therapy in an effort to get help. The therapist, in turn, is there to help, and yet the client is resisting those helping efforts. In this sense, resistance seems to run counter to what therapists and clients are there for: to provide help and to receive help. Yet, this state of affairs is also a potential trap, for it places the therapist in the role of giver and the client in the role of receiver. Resistance emerges naturally from this relationship, particularly if one does not wish to take what is being offered.

Instead we suggest to keep the focus on how resistance is working for the client in the therapeutic moment. Is resistance just another barrier to valued living in disguise? Is resistance moving the client north or south? Be mindful that resistance is a process of change and growth, not an outcome. It is not about comfort or being comfortable. It is about confronting the familiar—the programming—and doing something different, perhaps even radically different. This view is nicely illustrated in the following Zen poem.

“Go to the edge,” the voice said. “No!” they said. “We will fall.” “Go to the edge,” the voice said. “No!” they said. “We will be pushed over.” “Go to the edge,” the voice said. So they went and they were pushed and they flew.

—Anonymous

Jan Luckingham Fable (1998) described progress through resistance as an “Oops! I did it again,” “Oops! I did it again,” “Oops! I almost did it again” stage in a person’s movement toward awareness and acceptance. The “Oops! I almost did it again” stage is the beginning of action and change, where resistance is transformed into willingness and movement north. This is the difficult part and why, even after we know and accept, we sometimes slip up and slip back. That is, acceptance and change may not occur in lockstep. Even with acceptance on board, there are times when we slip, fall, fail to keep commitments, and get caught up in self-doubt and don’t do what we intend to do.

Dealing with Medication Management and Discontinuation

You will likely find that many anxious clients have used, or are currently taking, some form of anxiolytic or antidepressant medication. Indeed, clients often turn to medications as a first-line treatment for anxiety, guided by the view that reduction in symptoms will restore health and life functioning much like aspirin may alleviate a headache. Numerous medications (e.g., benzodiazapines, tricyclic antidepressants, SSRIs), in turn, are effective in reducing symptoms associated with anxiety disorders (Van Ameringen, Mancini, Oakman, & Farvolden, 2000). Yet, most clients do not wish to be on medications, largely because of their unpleasant side effects. Others, however, eventually make contact with the simple truth that life restoration does not necessarily follow from symptom reduction. They are right. There is no “life” pill that we know of. Your clients probably sense this too. Otherwise, they would not be in the room with you.

MEDICATIONS ONLY GO SO FAR

We are learning from large-scale clinical trials that medications for anxiety typically result in faster symptom relief relative to psychotherapy. Yet, medications are not curative in the long term and are quite often associated with higher rates of relapse relative to psychotherapy. For instance, CBT for panic disorder by itself generally outperforms medications (i.e., imipramine) in the long term, but not in the short term (Barlow, Gorman, Shear, & Woods, 2000; see also Boyer, 1995; Clum, Clum, & Surls, 1993; Cox, Endler, Lee, & Swinson, 1992). Similar patterns have been observed with social phobia (Heimberg et al., 1994; Turner, Beidel, & Jacob, 1994); though with obsessive-compulsive disorder and generalized anxiety disorder, the tendency is for combined treatments to result in better long-term treatment gains relative to CBT or SSRIs alone (Cottraux et al., 1995; Kasvikis & Marks, 1988; Power, Simpson, Swanson, & Wallace, 1990). Data regarding the efficacy of combined treatments for PTSD are still too limited to draw any meaningful conclusions. Nonetheless, findings from such studies are converging on one simple conclusion, namely, that psychotherapy and life change alone result in the best long-term outcome for most anxiety disorders compared to medications alone or medications combined with psychotherapy.

MEDICATIONS IN THE CONTEXT OF ACT

There is nothing particularly problematic about medication use in the context of ACT for anxiety disorders. Past and present medication use would normally be addressed early on in the therapy process. For instance, in the context of fostering creative hopelessness, you will want to carefully evaluate why your client is taking anxiolytic medications. Is the client relying on medications so as to not experience anxiety? If so, this ought to be addressed experientially in the context of acceptance and mindfulness activities. One might anticipate, for example, that a client who routinely relies on benzodiazapines for anxiety or panic might be less inclined to do so as they become more willing to experience anxiety for what it is, not for what they say it is.

On the other hand, medication use may actually interfere with ACT-relevant treatment processes. Think about it this way: Most antianxiety medications diminish the frequency, intensity, and duration of problematic content associated with anxiety disorders. This is precisely the outcome that clients want (“My control efforts are finally working!”). This is problematic from an ACT perspective because it creates the illusion that we can successfully control our internal world if we only try hard enough. Most research studies, as we described in chapter 4, suggest the exact opposite to be the case. Remember that ACT is about making contact with problematic content, fully and without defense. As anxiolytic medications function to diminish full contact with problematic content, there is the real risk that clients may not derive maximum benefit from the treatment. They cannot fully make contact with the problematic content so long as medications change the properties of that content! FEEL exposure exercises that would normally evoke difficult content cannot possibly do so under such circumstances. This may, in turn, contribute to therapeutic setbacks or relapse following medication discontinuation. At present, we simply do not have any firm evidence to guide us here in recommending how best to address medication use in the context of ACT for anxiety disorders. Again, judging by the emerging data on the efficacy of combined treatments for anxiety disorders, our suggestion would be to help move clients in the direction of change that relies on their efforts in therapy, not temporary symptom relief that may be found by taking a pill.

Maintenance of Treatment Gains in a Nonaccepting World

This is perhaps the most important practical challenge you will face in using an ACT approach with your clients. They must live in a world where managing difficult psychological and experiential content is front and center stage. They must live in a world that largely devalues acceptance, mindfulness, openness, genuineness, experiential forms of knowing, and value-guided action. This context, in turn, runs counter to what you and your client have been trying to accomplish in therapy. The risk, therefore, for relapse or setbacks is quite real. Yet, that risk can be handled and addressed in a straightforward fashion prior to therapy termination.

RELAPSE AND VALUE-GUIDED ACTION

Treatment gains are more likely to be maintained when clients set their eyes squarely on valued living and commit daily to living consistently with those chosen values. Obviously, this is easier said than done. Clients ought to expect a full range of psychological content to show up in their daily lives. The critical issue for clients is not to get caught up in the trap of letting that content get in the way of movements, however small, in the direction of their values. Relapse is not about a return of symptoms or difficult content. Rather it is about a return to old ways of responding to problematic content so as to not have it. In other words, relapse is about getting caught up in the experiential avoidance loop we discussed in chapter 4. The natural tendency, once in such a loop, is to fall into old habits and get stuck going round and round. Yet, this need not be the outcome.

VALUED LIVING IS NOT AN ALL-OR-NONE AFFAIR

Valued living is not an all-or-none affair; it’s not something that you either do or don’t do (Hayes, Strosahl, & Wilson, 1999). It is not something that you gain or lose. Values may be hidden from view, but they are always there. Values also may change, but they do not go away simply because one fails to live consistently by them. North is north regardless of where you are. Values will be there long after therapy has ended.

Even the best parents in the world occasionally get tripped up and behave in ways that do not reflect the value of good parenting. In such cases, persons who value parenting do what is necessary to get back on track because being a good parent matters. Remember, values are directions with no clear end point. They may change over time. This is fine. What is not okay is when relapse gives the appearance that values have changed when they have not. Typically, what has changed is confidence in one’s ability to live out those values, not the actual values. In such cases, therapists can simply return to the Life Compass described in chapter 9. By recalling the Life Compass and bus driver exercise, ask clients to consider the following:

Imagine driving your life bus headed north toward your Value Mountain [pick a client value here]. Along the way, you realize that you must have taken a wrong turn and now find yourself about one hour out of your way, headed south. What do you do? What does your mind tell you that you should do? You are, in a sense, lost, but not directionless. Is there anything that would prevent you from turning the bus around and heading north toward the mountain? If getting to the mountain is important to you, then what you need to do is stay in the driver’s seat of the bus and keep on driving north toward the mountain. Now, let’s suppose that I throw in some of those anxious thoughts and feelings that your mind and body will kindly dish out once in a while. Remember, they are the passengers that are in the bus with you. As you get on the road to Value Mountain, they creep in and scream, “Pay attention to us, turn around, go back, you can’t drive to Value Mountain with us … We are more important … Spend time with us … Don’t go there! … Take that detour … It is safer, easier … It will make you feel better.” What will you do? Stopping won’t get you to the mountain, and neither will the detour. Only you and you alone can take yourself there—and you have no choice but to take all of you with you.

The point of going back to the bus driver metaphor is to illustrate that relapse is fundamentally about choice and action. It represents the reality that, every once in a while, each of us fails to live consistently with our values. Yet, every day requires a renewed commitment to take actions that move us in life directions that we care about. Relapse is not about a return of anxiety, fear, or any of a number of possible human sensations that are part of living. Relapse is about not committing to small actions that make life worthwhile and meaningful. It is about not living! This is why we have emphasized values repeatedly throughout this book.

USE BOOSTER SESSIONS TO FOSTER CLIENT AUTONOMY AND GROWTH

A sensible way to evaluate therapeutic progress is to gradually taper the number of client visits over time. Hayes, Strosahl, and Wilson (1999) refer to these as “field experiments” in that they allow you to evaluate how well your client is doing without regular therapy as a support. They are also helpful in determining whether the termination point in therapy was adequate. A good rule of thumb here is to move from weekly to monthly to quarterly booster visits. Although we have written this book as a twelve-session weekly program, the total number of sessions and how you space the final sessions should be kept flexible. The content of the booster sessions will vary depending on the unique circumstances of your client. Normally, you will want to review the client’s efforts in moving in the direction of chosen values and address weak points where experiential avoidance tends to show up and how it may continue to get your client off track. More generally, you should reinforce some of the concepts discussed over the course of therapy. Remember that we are looking to foster the growth and development of fully functioning human beings. This is a process that will take a lifetime, considerable effort, and commitment. It does not end when therapy ends. Therapy can only help clients take the first steps in this process that must continue after therapy has ended.

What About Anxiety Reduction?

As indicated throughout the book, anxiety is likely to go down as clients start engaging in FEEL exercises and goal-related activities. For mere anxiety-reduction purposes, it does not matter whether a man with agoraphobic avoidance drives in his car for one hour in the context of a naturalistic exposure exercise to extinguish fear and to correct catastrophic thoughts about driving, or whether he drives one hour to a job center to get information on a training program in the context of pursuing a chosen value-guided goal. The principle of extinction will work regardless of the reasons why clients engage in previously avoided activities. Interestingly, in the context of valued activities, extinction may work on more than just the conditioned fear response. Previous avoidance behavior may have been set off by a rule (“To get a job, I must first get my anxiety under control”) or evaluation (“I can’t drive because I have too much anxiety”). If the client’s current behavior proves that rule and evaluation to be ineffective with respect to a chosen value, the relation between the ineffective rule or evaluation and the avoidance behavior that used to follow it is weakened. Moreover, an interesting study by Bach and Hayes (2002) with psychotic individuals has shown that the believability of unwanted cognitions (hallucinations and delusions) went down drastically with ACT compared to treatment as usual (TAU). Interestingly, the frequency of unwanted cognitions also went down with ACT but less than in the TAU group. However, ACT patients were 50 percent less likely to be rehospitalized compared to TAU patients.

We have deemphasized anxiety reduction as a treatment goal because it puts the old control agenda right back on the table. When therapists hold out anxiety reduction as a promise in even subtle ways, they may reinforce old experiential avoidance tendencies and undermine the ACT process. Nonetheless, therapists need to be sensitive to the goals of clients, which may still include anxiety relief (see also our discussion in chapter 6, Session 1). It may no longer be the only goal for clients, and perhaps no longer the most important one, but some clients will hold on to it at least to some degree. As therapists, we need to respect and accept that. There are no dogmas in ACT. It is not necessary for clients to buy into ACT 100 percent. If clients give up the old avoidance agenda and embark and stay on their path to valued goals, they are on the right track, regardless of whether they occasionally still dream of and wish for an anxiety-free life. So instead of categorically declaring that anxiety control and reduction is not a treatment goal, we recommend that therapists consistently frame therapy as an opportunity for clients to learn new ways of moving with anxiety on their way to doing what matters to them rather than allowing anxiety or the goal of anxiety reduction to be an obstacle. FEEL exercises and other goal-related activities are opportunities for clients to learn and practice new and more flexible ways of responding when they experience anxiety. We prefer simply to leave the question of anxiety reduction open; the client’s experience will eventually provide the answer.

Practical Integration of ACT Within Traditional Forms of CBT

ACT is very much part of the behavior therapy tradition. It is not a movement to undermine that tradition. ACT brings into the behavior therapy movement a radically different model of psychological health and human suffering. In so doing, it places the therapeutic prize clearly in focus: namely, promotion of human value, growth, and dignity. It normalizes human suffering and redirects clinical attention on feeling well because of living well, not feeling well so as to live well.

How Far Are We Going to Go?

The treatment agenda we have outlined is radically different from the typical mainstream cognitive behavioral therapies for anxiety disorders. We have tried to make it ACT consistent as much as possible. Yet, we also recognize that we are treading on new territory and that ACT is still very much under development. Still, we do think that we are on to something that is worthwhile and important. A rapidly growing group of behavior therapists seems to think so too (Hayes, Follette, et al., 2004).

ACT and other third-wave behavior therapies are challenging the symptom- and syndrome-focused change agenda that has come to characterize behavior therapy as much as it has psychiatry. This shift in focus emphasizes broadband functional outcomes and process-oriented changes that are clinically meaningful and life altering. Acceptance is one such process. Contextualizing therapy in the service of value-guided actions is another development that is quite different from the tendency to focus on altering thoughts and feelings as a means to a life and at times as an end unto itself. Though this movement is making its way into several domains of empirical practice, it still remains unclear just how far researchers and clinicians are willing to go with it. Some researchers and clinicians will no doubt see the revival of interest in nontraditional concepts like acceptance, mindfulness, values, choice, spirituality, commitment, meaning, and purpose as passing fads. This is a real possibility. Yet, we believe it is unlikely for several reasons.

ACT Is Moving Forward on Several Fronts

First, ACT has a solid empirical base focused on the very nature of human language and cognition. It is built upon solid behavioral principles that flow from, and are in some sense guided by, a coherent philosophical and theoretical foundation (i.e., functional contextualism and relational frame theory; Hayes et al., 2001, 1994). This bottom-up approach was precisely the recipe that paved the way for many of the early and continuing successes of first-wave behavior therapy. In fact, treatments that followed this formula, such as exposure therapies for anxiety problems, have been enormously successful and have showed staying power (Barlow, 2002).

Second, the philosophical, theoretical, and empirical strands of ACT are highly integrated, and have yielded an applied technology that flows naturally from them. Applied process and outcome research on ACT is moving forward at a rapid clip, and therapeutic developments are closely tied with advances in the basic and conceptual branch of acceptance research (Hayes, 2004a). This again is highly unusual, but advantageous for the empirical base of ACT. It protects from the kind of faddish trends in psychotherapy that often attract many followers, but yield few lasting good outcomes.

Third, it is becoming increasingly clear that the worldwide ACT research and applied community are a generally kind and sharing bunch. There is a high level of communication among its growing members, and a real sense of common vision and purpose. All share a commitment to advancing an understanding of why humans suffer and the promotion of psychological health. This model of health, as should now be clear, stands in stark contrast to most Western views of health, happiness, and syndrome-based criteria used to judge psychological suffering and therapeutic success. The group as a whole is vital, energetic, and eschews dogma. There are many researchers and clinicians who are working to push ACT to its limits. They are willing to be wrong, just as we are, and do not hold to any particular hidden agenda. This level of communication truly stands to help advance the integration of science and practice in a manner that is relatively uncommon and much needed.

Finally, ACT is behavior therapy. Although ACT has borrowed and integrates techniques from a variety of Western and Eastern schools of psychotherapy, ACT is firmly rooted in psychological science at both the conceptual and practical levels. At a conceptual level, ACT heavily draws on and is derived from new developments in the behavior analysis of verbal and other behavior (for a detailed account, see Hayes et al., 2001). At a practical level, ACT focuses on experiential learning and value-related behavioral change and activation—the hallmarks of good behavior therapy practice. ACT has been developed with the same dedication to rigor and empirical evaluation that has been characteristic of behavior therapy at large and continues to be one of the main reasons for behavior therapy’s remarkable success, growth, and impact. We are optimistic that these roots and strengths, along with a growing empirical support base, provide a unique and solid foundation for the advancement and further growth of ACT at a rapid pace.

The Future

The future of third-generation behavior therapies, such as ACT, will depend on their practical utility. ACT is not an easy treatment to learn, let alone apply. The evidentiary base of ACT is growing, but still sparse compared with well-established CBT for anxiety disorders. We recognize that this presents a challenge and an opportunity.

The Empirical Base Is Growing

The staying power of ACT will depend on whether it yields outcomes that therapists and clients consider worthwhile. A comprehensive review of clinical outcome studies (Hayes, Masuda, et al., 2004) and a number of studies published in a special issue of the journal Behavior Therapy (2004, Vol. 35, Issue 4) show that ACT is an effective intervention for an unusually broad range of clinical problems ranging from depression, substance abuse, chronic pain, and eating disorders, to work-related stress and other problems, some of which are quite severe (e.g., schizophrenia; see Bach & Hayes, 2002). ACT has also proven effective for anxiety-related problems such as OCD (Twohig et al., in press) and trichotillomania (Twohig & Woods, 2004). One of the core findings of most outcome studies to date is that ACT produces rapid and significant decreases in the believability of negative or unwanted thoughts. Interestingly, in many cases, the frequency of such thoughts and other unwanted “symptoms” goes down as well, although such reductions were not targeted outcomes.

Several of the studies examining core processes of ACT, such as acceptance, defusion, and willingness (e.g., Eifert & Heffner, 2003; Karekla et al., 2004; Levitt et al., 2004; Twohig et al., in press), have been done in the anxiety area. So far, all of the published tests of ACT components have been positive. All of this work is consistent with the view that ACT is not merely another narrowband, disorder-specific treatment package. It is much bigger than that. As Hayes pointed out in his foreword to this book, it is a model, an approach, and a set of associated technologies, with data spanning the range from basic process, to experimental psychopathology, to inductive studies of treatment components, to studies of processes of change, to outcome research. It is designed to get at the heart of human suffering by addressing processes that rest at the core of suffering. This is why ACT works well across a broad spectrum of psychological problems.

Though the treatment program we have outlined has not been tested empirically as a whole package, almost every element of this protocol has empirical support. In some cases this support comes from experimental psychopathology studies or clinical outcome research—in other cases it comes from both sources. So there is a growing base of support for this technology and the treatment approach we describe in this book. Researchers in several places around the world are busy testing ACT in experimental settings and randomized clinical trials doing component analyses and testing processes of change. Much of the data are preliminary but strongly supportive. It is time to put this approach before the psychological community.

The fact that not all of these data come from anxiety-related studies is not particularly relevant because the processes accounting for pathology (e.g., experiential avoidance and control) as well as the processes of change (greater acceptance, willingness, cognitive defusion, and valued living) apply to anxiety as much as they do to substance abuse, depression, or chronic pain. Though forms of human suffering may differ from one person to the next, the underlying issues tend to revolve around these basic processes. To further advance this work in the area of anxiety disorders requires bundling the approach into a technology that is suitable for use by clinicians and researchers alike. The next step calls for systematic empirical evaluation. For instance, we are currently conducting a randomized clinical trial comparing our program with traditional CBT at UCLA, and a related trial will soon start in Albany, New York. We sincerely hope that some of you will also contribute to this empirical effort by reporting on your work with this treatment via single case reports or other studies. To enable you to do so is one of the main purposes of this book.

Challenges

There are other challenges that the ACT community faces that may work against its staying power. For instance, we are still far from having psychometrically sound assessment devices to evaluate core processes that are believed to underlie this treatment and related interventions. For instance, assessment of experiential avoidance and acceptance is limited to a self-report device (i.e., the AAQ; Hayes, Strosahl et al., 2004), and several researchers (e.g., Frank Bond) are working to evaluate a revised and expanded version of the AAQ. Yet, it is unclear whether acceptance is a construct that is best assessed via self-report devices. In our view, acceptance and nonacceptance denote actions—what people do, not what they say or think about what they do. We therefore need behavioral methods of assessing acceptance. Similar problems exist in the assessment of mindfulness and values, and, less so, with defusion. Efforts to develop more adequate and versatile measures to assess these key constructs and processes are underway. We are not there yet though.

There is also some concern about whether ACT can or ought to be manualized. Those who see ACT as an approach would say no. Those who see it as a technology guided by the approach, including us, would say “why not?” We have obviously gone to great lengths to manualize the present treatment. We struggled intensely with this activity. We tried to get it right. We hope we have provided a useful tool, because there is a need to make ACT and other related technologies accessible to therapists who wish to use them. It is simply not workable to rely on seminars and workshops to accomplish such goals. Though we encourage you to catch an ACT workshop or two to reinforce points and stay abreast of the latest developments in this area, we ultimately believe that workshops alone are neither the most cost-effective nor most efficient way to disseminate ACT. Therapists should not have to rely on such venues in order to learn how to apply new psychotherapies.

Treatment manuals are necessary now more than ever. As Barlow et al. (2004) suggested, manuals need to be more simple and user-friendly by focusing on a single set of therapeutic principles for all anxiety disorders rather than creating diverse protocols for each anxiety disorder. This is precisely the unified approach we have taken with our protocol. Manuals are also required as part of federally funded clinical trials testing new psychotherapies. They are required for treatments to be considered as empirically supported. And, they help with dissemination efforts and are useful for training purposes. When used in a flexible fashion and when guided by a clear rationale and conceptualization, as we have stressed in this book, manuals can be quite useful to you and your clients and tend to improve therapy outcome (Schulte & Eifert, 2002). At the same time, do not feel compelled to follow the outline we have provided “exactly by the book.” Instead, spend time with the material and then use it as a guide or framework in your work with clients. Stay clinically present and let the approach and technology we have outlined flow from that, not the other way around. This book is not about setting a treatment agenda for your clients. This would be ACT inconsistent and not good clinical practice anyway.

Outlook

Making a difference is what psychotherapy is all about. This book was conceived in the spirit of making ACT accessible to therapists who face human suffering—their own and that of their clients. It was created in the spirit of helping you make a difference in the lives of clients who suffer about anxiety and fear. The differences we hope that you and your clients will achieve are quite broad and sweeping. Imagine, if you will, changes that have a broad impact on the lives of your clients. This may be in their families, their work, their ability to derive joy and pleasure from the world in which they live, freedom of movement, expanded choices and opportunities, new friendships, and deeper interpersonal relationships. It is in these and other areas where our clients’ lives are lived, where joys can be found, and where suffering has its greatest impact. How our clients function in such domains is what matters most. Lives continue long after therapy has ended. Actions do not occur in a vacuum. How we live affects others. The consequences of dropping a small pebble into a still pond is a ring of widening ripples that remain present, ever expanding, long after the pebble has disappeared below the surface. Therapy is like the pebble in this respect. We expect that changes in psychotherapy will have a broad impact on the lives of our clients long after therapy has ended. This is our legacy as therapists and the kind of legacy we hope to achieve with the treatment program outlined in this book. The ACT approach we outline for anxious clients is a pebble. Our hope is that clients will drop the rope so that they can take the pebble.