Acceptance & Commitment Therapy for Anxiety Disorders

Chapter 3

Cognitive Behavioral Views and Treatments of Anxiety Disorders

Clinical experience has shown that, ironically, it is often the patient’s very attempt to solve the problem that, in fact, maintains it. The attempted solution becomes the true problem.

–Giorgio Nardone & Paul Watzlawick

Behavioral and cognitive behavioral treatments are the treatments of choice for anxiety disorders. In fact, they represent the best psychosocial interventions that we have to offer persons suffering from anxiety disorders. Yet, cognitive behavioral therapies are still far from being curative. A significant number of anxiety sufferers fail to respond to cognitive behavioral therapies. More people than we’d like to admit never even start treatment when they hear what it involves (Becker & Zayfert, 2001). Many others drop out before completing treatment, and of those who complete treatment, many ultimately relapse and require additional treatment. It is simply not the case that we have reached the efficacy ceiling with regard to cognitive behavioral therapies for anxiety disorders (Barlow et al., 2004; Foa & Emmelkamp, 1983; Foa & Kozak, 1997a). Far from it. We can and should do better. In fact, we must do better. Meeting this challenge will require rethinking some of the basic assumptions guiding our views of anxiety-related problems and their treatment. In particular, we need to reexamine what makes anxiety and fear disordered. The aim of this chapter is to provide some background for this reexamination and a new perspective.

Cognitive Behavioral Views

Early behavior therapy owes much of its success to its account of the etiology and maintenance of anxiety disorders. This account was based on the simple notion that anxiety disorders are learned or acquired via a process of conditioning and are maintained via escape and avoidance behavior (Mower, 1960). The logical consequence of this account was that successful treatment needs to involve helping clients to confront feared stimuli and situations in a safe therapeutic environment so as to allow for new corrective emotional learning and extinction of excessive fear and anxiety (Wolpe, 1958). This view survived more or less intact until the 1970s, when criticisms mounted suggesting that anxiety disorders are not solely about conditioning. There is more to the human experience than conditioning because of the human capacity for language and our propensity to engage in complex and infinite verbal-symbolic cognitive processes. A more cognitive view of disorders and their treatment ensued that focused on the role of memory, attention, catastrophic thinking patterns, irrational beliefs, unrealistic self-statements and appraisals, and the like. These notions were quickly integrated within behavior therapy and became known as cognitive behavioral therapy (Beck & Emery, 1985). Below we briefly trace some of these developments, and highlight where both the original conditioning and the cognitive behavioral accounts fall short.

Limitations of the Behavioral Account

Early behavior therapists tended to conceptualize the etiology of anxiety disorders in terms of straightforward Pavlovian or classical conditioning principles. Thus, when an otherwise benign stimulus occurs in close contingency with an anxiety-inducing event, it becomes highly likely that the stimulus will later elicit anxiety and fear without further trauma. In fact, a relation between otherwise neutral stimuli and a false alarm (i.e., a panic attack) may be enough to set this learning in motion (Barlow, 1988; Bouton, Mineka, & Barlow, 2001; Forsyth & Eifert, 1996; Wolpe & Rowan, 1988). For instance, several studies out of our lab group have shown that panic attacks can function as conditioning events in the etiology of anxiety disorders (Forsyth, Eifert, & Thompson, 1996; Forsyth, Daleiden, & Chorpita, 2000; Forsyth & Eifert, 1996, 1998a, 1998b). Importantly, this work suggests that conditioning involves, at least from an individual’s perspective, relations between bodily and environmental cues and a highly unpleasant false alarm response (i.e., a panic attack; Barlow, 2002; Forsyth & Eifert, 1996; Wolpe & Rowan, 1988). It is the false alarm response, not necessarily the aversive stimulus capable of evoking it, that humans experience as traumatic. This view is at the core of contemporary thinking about the critical processes involved in fear learning, wherein panic attacks or paniclike responses function as critical conditioning events in the genesis of anxiety disorders (Bouton et al., 2001).

Nonetheless, numerous criticisms have been raised about the clinical relevance of a conditioning account of anxiety disorders. Our intent here is not to redress all of these criticisms (e.g., Marks, 1979; Menzies & Clarke, 1995; Rachman, 1977, 1991), as only one of them holds up in light of contemporary learning theory. The conditioning model of anxiety disorders has not fully explained how adaptive learning processes (i.e., conditioning) coupled with adaptive emotional responses (i.e., fear and anxiety) would send some individuals down the path to an anxiety disorder and not others. Indeed, critics and proponents of the conditioning model of anxiety disorders have largely ignored this critical issue. Yet, coming to terms with it has profound implications for understanding anxiety-related suffering (see Forsyth, Eifert, & Barrios, in press, for a detailed account). Here, we will briefly summarize a few key points.

First, consider classical fear conditioning. There is nothing disordered about this form of learning. In fact, it is ubiquitous and highly adaptive. Classical conditioning occurs in forms ranging from subtle to obvious across all mammalian species, and even has been found to occur in single-cell organisms (e.g., paramecia; see Hennessey, Rucker, & McDiarmid, 1979). The main function of this form of learning is to tinge stimuli with emotional significance or meaning, and thus direct behavior as a consequence (Staats & Eifert, 1990). At times fear learning can be quite dramatic, as with the trauma of 9/11, natural disasters, accidents, assault, or war. Yet, even in these and other more extreme examples, the learning is perfectly adaptive. It makes sense to learn to fear stimuli that have been associated with aversive consequences. As indicated in chapter 2, it also makes sense to avoid people and situations that have been associated with aversive and harmful consequences. In fact, the consequences of not doing so could be quite disastrous.

Second, the alarm response, whether conditioned or unconditioned, is no less adaptive. When fear is evoked in nonhuman animals, they engage in a number of behaviors that we describe as behaving fearfully. They freeze, shake, struggle to escape, cry out, and even urinate and defecate. Numerous neurobiological responses underlie such actions, involving in particular the amygdala and hippocampus and the sympathetic branch of the autonomic nervous system (LeDoux, 1996, 2000; Selden, Everitt, Jarrard, & Robbins, 1991). When such responses are evoked, the typical acute consequence is disruption and narrowing of ongoing behavior. Such disruptions make organisms ready to take immediate action to prepare for, and subsequently to escape from or avoid, potential sources of threat. Following such experiences, most mammals, including humans, will actively avoid exposing themselves to stimuli that predict such responses, in part because it makes adaptive sense to do so.

Classical fear conditioning has survived as a model of anxiety disorders largely because of Watson and Rayner’s (1920) dramatic demonstration of phobic fear acquisition in Little Albert. The correspondence between the behavior of Albert and the phobias and other anxiety problems was so dramatic that behavior therapists never stopped to ask whether it would have made sense for Little Albert to have responded any differently than he did under the circumstances. We are suggesting that the emotion of fear and the classical conditioning of fear are not disordered processes, but rather normal and mostly adaptive dimensions of everyday human experience. The real challenge is to explain why classical fear learning would result in an anxiety disorder.

This issue, as we will suggest, requires consideration of what humans do to manage the experience and expression of emotions. This is a key point of difference between nonhuman animals and humans. There is no indication that nonverbal mammals suffer about their own suffering. Nonhuman primates will also learn to avoid the source and context of aversive stimulation, but as best we can tell, they do not act deliberately and purposefully to regulate their emotional experience. Humans, by contrast, can and do suffer about their own emotional pain and histories by responding to conditioned responses with evaluative verbal behavior and thinking, and by engaging in efforts to suppress, avoid, or escape from their emotional pain and related thoughts. Thus, humans can become fearful or fear, depressed about anxiety, worried about the future, tormented about the past, and struggle to avoid and escape from unpleasant thoughts, images, sensations, feelings, behavioral tendencies, and the circumstances that have evoked them or those that may evoke them in the future. The capacity of language, coupled with powerful social contingencies regarding the experience and expression of emotion, make all this possible.

Emotional Regulation Can Transform Normal Fear Into a Clinical Problem

When a fear learning process is juxtaposed with emotional regulation processes, something new may emerge that is far from functional. Emotion regulation simply refers to actions that are designed to influence “which emotions we have, when we have them, and how we experience and express them” (Gross, 2002, p. 282). Putting on a smile at a social gathering, despite feeling and thinking negatively about the situation, is one example of emotion regulation in action. Though emotion regulation is itself not a dysfunctional process, it can become dysfunctional when the emotions one is attempting to regulate cannot and need not be regulated, and when the very act of emotion regulation gets in the way of meaningful life activities.

model of emotion regulation

Figure 1 illustrates the typical points where emotional experience tends to be regulated. In a somewhat simplified fashion, this model suggests that humans may regulate the antecedents and consequences of emotions. Antecedents, in the case of anxiety disorders, may include situations where anxiety and fear are likely to occur, bodily and environmental cues that tend to evoke such reactions, whether emotionally relevant information is attended to, and how such information is appraised (e.g., “This is bad,” or “I can’t get through this”). Strategies used to regulate emotions on the front end are important precisely because how one responds to emotional inputs, and particularly the verbal evaluation of those inputs (i.e., “This is dangerous [awful, harmful, etc.]”), affects the emotional consequences that may follow. Thus, escalation of the emotional sequence can be attenuated or avoided altogether depending on how one manages the antecedents of emotional experience. Once the emotion occurs, regulation efforts tend to focus on the intensity, duration, and general quality of the emotional experience and its consequences. Such response-focused regulation strategies may involve taking a break, relaxation, deep breathing, or doing something pleasant. There is nothing particularly disordered or problematic about such strategies, particularly when applied in a context-sensitive and flexible manner.

EMOTIONAL DYSREGULATION IN ANXIETY DISORDERS

The problems come about when persons make rigid and inflexible efforts to down-regulate the cognitive, physiological, or behavioral components of negative emotions such as anxiety and fear. Such strategies are often subtle and idiosyncratic in persons suffering from anxiety disorders, and usually take the form of suppression, control, avoidance, or escape (Barlow, 2002; Barlow et al., 2004). People suffering from anxiety disorders do not experience fear and anxiety as adaptive, normal emotional events. Rather, they are bad emotional events that need to be managed and controlled at all costs.

These emotion down-regulation efforts provide the context in which persons suffering from anxiety disorders experience anxiety, fear, and the circumstances that give rise to them. That is, down-regulation efforts function as important predispositions that make the otherwise adaptive emotions of anxiety and fear disordered. As we describe in chapter 4, emerging data on several fronts suggest that emotion regulation efforts only work to a point, and these efforts are particularly unworkable when the emotions are highly aversive. In fact, attempts to escape from and/or avoid unpleasant emotions typically backfire, resulting in an increase of the very emotion that is undesired, as demonstrated by the effects of attempts to control emotions after initial panic attacks (Craske, Miller, Rotunda, & Barlow, 1990).

THE ROLE OF AVOIDANCE AND ESCAPE BEHAVIOR

Within the traditional behavioral account, avoidance and escape behavior are thought to represent the two main antecedent and response-focused emotion regulation strategies that emerge as a natural consequence of fear learning. Yet, this account begs the question as to why the powerful action tendency to avoid and/or escape fear-evoking stimuli would yield an anxiety disorder in some individuals and not others. When persons encounter a stimulus that was previously associated with danger, harm, or pain, they will indeed experience a powerful behavioral urge to escape and will often act to stay away from that situation as much as they can. In chapter 2 we used the example of a woman who was sexually assaulted and subsequently experiences a strong fear response when thinking of her assailant or the previous assault. If she were to encounter the man again, such fear would lead to an immediate escape or other defensive responses to protect herself. As we indicated, there is nothing disordered about such learned alarm responses and related avoidance and escape behaviors. They are normal and adaptive.

In our view, the main reason why fear learning becomes disordered is related to individual differences in the application of emotion regulation strategies when such strategies are unworkable and/or uncalled for by the situation. Going back to the sexual assault example, if this woman were to apply escape and avoidance behavior in a rigid and inflexible way, to avoid not only her assailant but all men (including those who have never harmed her, such as her husband), then she might well be on her way to developing an anxiety disorder. It is unworkable for this woman to avoid feelings of apprehension the first time she is about to have sex in a safe environment (e.g., with her husband) after she was sexually assaulted. It is unworkable because feeling anxious and apprehensive in this sexually charged situation is a natural consequence of the previous highly aversive experience with her assailant—even though the contexts could not be more different. It is simply impossible for her to shut down or avoid apprehension, anxiety, and perhaps even some aversion. Avoiding those feelings (and her husband) is also uncalled for in the sense that the situation does not require her to escape in order to be safe because her husband poses no danger to her safety. Nonetheless, the urge to escape is there and quite real. The woman must choose whether to give in to that urge or to stay and be anxious and be sexually intimate with her husband because that is more important to her than not being fearful. The choice she makes will be closely related to her values as well as to her history of handling aversive experiences. Thought and emotional regulation can get in the way of such choices.

A less complex example might help clarify the important distinction between flexible (healthy) and inflexible, rigid (possibly disordered) responses. When a child falls off her horse and hurts herself while learning to ride, she will be apprehensive about getting back into the saddle. After all, horse riding has just been associated with pain. So experiencing some fear at the sight of the horse is quite natural. Yet we all know that this child needs to get back into the saddle pretty soon, or else she will never learn to ride the horse. She will also miss the chance to experience that horse riding, for the most part and when done with caution, is not harmful and can be quite useful and enjoyable. Now consider the child who falls off the horse and does not get back onto the horse. In fact, she starts to avoid all horses as well as anything that is horse related (e.g., barns, the countryside, movies featuring horses). She may even come to avoid situations unrelated to riding where taking a fall is a possibility. This child will neither learn to ride a horse safely nor lose her apprehension about horses, and she may also very well be on her way to developing a horse phobia and broader problems related to a fear of falling.

Although we know woefully little about this process, it is likely that people learn such rigid avoidance strategies early on in life, with observational learning probably playing a major role (Hayes et al., 1996). People also learn not only to avoid the fear-related objects and events, but to avoid feeling fear and other aversive emotions themselves. In any case, persons who have learned to avoid unpleasant thoughts and feelings, and who do so rigidly and inflexibly, are likely to respond to fear learning experiences quite differently than persons who are not so predisposed. In this context, fear and anxiety, and the cues and contexts associated with them, must be managed even at significant personal cost. This quite literally traps people—it keeps them stuck—and creates the context that may help explain the shift from normal fear and anxiety to disordered fear and anxiety, and why fear learning may contribute to the development of full-fledged anxiety disorders.

Cognitive Behavioral Therapies and the Mastery and Control Agenda

Mainstream cognitive behavioral therapies for anxiety disorders tend to conceptualize anxious thoughts and feelings as problems that warrant clinical attention (e.g., Barlow, 2002; Beck & Emery, 1985). Accordingly, the therapeutic solution is to help clients to alleviate their symptoms as a means to attain psychological health (e.g., Barlow, 2002). Often this is achieved, or at least initiated, by getting clients to confront feared objects or aversive bodily events in a safe therapeutic context, which is believed to facilitate corrective emotional learning and fear reduction.

A variety of techniques can facilitate this process, including direct exteroceptive or interoceptive in vivo exposure, imaginal exposure, response prevention, flooding, systematic desensitization, worry exposure, decatastrophizing, cognitive restructuring, guided imagery, breathing retraining, and progressive muscle relaxation. Such techniques, in turn, have a more general objective; namely, to get clients to experience unpleasant thoughts and feelings that they have otherwise avoided and to learn how to reduce or control them in the future. Many of these and other related techniques have been shown to be quite efficacious, at least in the short term, in producing symptom reduction and relief for most clients most of the time. Many empirically-derived treatments for anxiety disorders include such techniques as components of comprehensive treatment manuals developed for many of the DSM-IV-TR anxiety disorders: panic disorder (e.g., Mastery of Your Anxiety and Panic, Craske & Barlow, 2000), specific phobias (e.g., Mastery of Your Specific Phobia, Craske, Antony, & Barlow, 1997), obsessive-compulsive disorder (Mastery of Obsessive-Compulsive Disorder, Foa & Kozak, 1997b), and generalized anxiety disorder (Mastery of Your Anxiety and Worry, Zinbarg, Craske, & Barlow, 1993), to name a few.

The word “mastery” as contained in the titles of such manuals is not accidental and reflects the underlying philosophy and approach of such treatments. For in most cases, the aim of the techniques outlined in manualized treatments is to assist clients in becoming better at controlling (i.e., mastering) their thoughts and emotional experiences (i.e., the symptoms) by giving clients more and “better” thought and emotion regulation strategies, and by replacing “dysfunctional” thoughts with more “functional” ones. Mastery and control-based techniques are simply another way of saying “you must regulate your anxiety, because such regulation is important for psychological health.” This more general approach is what many anxious clients have come to expect from psychotherapy. That is, they want to learn better and more effective ways of regulating unwanted anxious thoughts and feelings. Virtually all cognitive behavioral therapies play into this system and teach clients that (a) their thoughts and feelings are the cause of their suffering and life problems; (b) in order to live a happy and successful life they need to become better at mastering (i.e., controlling or reducing) unwanted thoughts and feelings; (c) therapy is going to give them new techniques to accomplish better control of their private experiences; and (d) if and when they become better at controlling their anxious thoughts and feelings, they will then become better at living a happy and productive life.

As we describe throughout this book, we suggest a different strategy, which is to directly address the struggle to control and avoid unwanted thoughts and feelings. This means addressing the agenda of emotion regulation itself. Thus far, people have desperately tried to relax away fear and anxiety by pushing their unwanted thoughts and feelings away. Instead, we want to help people relax with their anxiety by being and moving with it.

Suppose instead that it is what clients do to regulate anxiety and fear, not anxiety and fear per se, that is the problem. Suppose also that anxious thoughts and feelings are not “symptomatic” of anything, but rather normal facets of human experience. Attempts, therefore, to teach clients to become better suppressors or avoiders of their unwanted thoughts and fearful or anxious feelings is unlikely to work as a lasting solution, for this is what many persons with anxiety-related problems are already doing by the time they enter therapy. We must ask ourselves in all honesty, if that was a workable and functional solution, then why have they come into therapy?

Targeting unwanted thoughts or feelings in therapy can, at best, result in only short-term gains. The reason is that this approach implies that such private events are the problem and need to be dealt with. Such strategies also imply that psychological health occurs only at one end of the emotional spectrum (i.e., positive thoughts and feelings), and that negative emotional experiences are problematic and the cause of life problems. Thus, when anxious thoughts and feelings occur again (and they will occur again), they should be controlled or else more problems will result. Yet, we do not live in a world where people only experience good thoughts and feelings (Hayes, 1994). Indeed, what makes us human is our capacity to experience a wide range of emotional experience, willingly and without defense, and to adapt and behave effectively despite what we may think or feel. Those who do so willingly and without defense, and adapt and behave effectively despite what they may think or feel, are very healthy indeed.

In fact, at a very basic level, what differentiates psychological health from disordered suffering is not the absence of trauma, pain, and negative private events. The difference is whether people are willing to experience the totality of their psychological and emotional world and still do what matters most to them. Willing here is not about brute force of will. It means being open and experiencing and accepting what is for what it is. It is about finding a way to live a meaningful and productive life. It means being willing to live such a life and taking the totality of personal pains and joys along for the ride. This perspective is quite different from unwillingness, where lives can quite literally be about living to avoid or manage psychological and emotional pain. This is not a way most persons would want to live. Yet, this is what the lives of many anxious clients have become and why we now think that anxiety itself is not disordered. It is what people do to regulate anxiety that makes it disordered. This view, by the way, is now making its way into mainstream cognitive behavioral interventions, resulting in a rethinking of the mastery and control symptom-focused change agenda (Barlow et al., 2004).

New-Wave Behavior Therapies for Anxiety

Most behavioral and cognitive behavioral therapies for anxiety are predicated on the notion that changing anxious thoughts and feelings would naturally foster a more vital life. Newer-generation behavior therapies, by contrast, tend to focus on domains of human experience that go well beyond symptom alleviation and control as therapeutic goals. Instead, they emphasize topics traditionally reserved for less empirical wings of psychology, such as acceptance, mindfulness, values, spirituality, meaning and purpose, relationships, and quality of life, to name a few (Hayes, Follette, et al., 2004). Examples of approaches that are part of this movement include Dialetical Behavior Therapy (Linehan, 1993), Functional Analytic Psychotherapy (Kohlenberg & Tsai, 1991), Integrative Behavioral Couples Therapy (Jacobson, Christensen, Prince, Cordova, & Eldridge, 2000), Mindfulness-Based Cognitive Therapy (Segal, Williams, & Teasdale, 2002), and of course Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999). At the core, these approaches challenge the symptom- and syndrome-focused change agenda that has come to characterize much of mainstream cognitive behavioral therapy. In so doing, they offer a unique and expanded view of human suffering and what it means to foster psychological health and wellness. We will have much more to say about this throughout this book. How an ACT approach differs from, and at times complements, mainstream cognitive behavioral approaches for anxiety problems is described below.

Emotion Regulation Gets People into Trouble

Emotion theorists generally regard emotion regulation as an adaptive process that can go awry under some conditions (Gross, 2002). For instance, one could argue that persons suffering from anxiety disorders lack the appropriate emotion regulation skills, or tend to apply emotion regulation techniques (e.g., avoidance, escape, suppression, inhibition) that are counterproductive. From this perspective, it would make sense to teach clients more effective anxiety regulation strategies, or to correct instances where counterproductive strategies are being applied (e.g., distraction, avoidance, escape). In some sense most cognitive behavioral interventions are designed to correct for deficient and inappropriate anxiety regulation strategies. Most often, the correction simply involves substituting one emotion regulation strategy for another (e.g., tension with relaxation, catastrophic thinking with more realistic thoughts). This, as will be seen, is not what an ACT approach is about.

From an ACT perspective, the very act of emotion regulation can get people into trouble. Emotion regulation becomes troubling (psychologically and experientially) when it is unworkable or when there is no need for it (i.e., when the situational context does not require it). Such strategies, in turn, are often driven by the view that “I ought to be thinking and feeling something differently than I am.” This tends to get people into trouble because it makes successful emotion regulation a prerequisite for effective action. For instance, anxious clients are quite often guided by the view that “To do X will require that I think or feel something differently than I am thinking or feeling right now.” With anxiety disorders, this form of regulation usually centers on anxious thoughts and feelings that are unwanted or undesired, including the situations that might occasion them. In the process, many anxious clients spend their whole lives focused on the regulation of anxiety and fear, instead of doing what is most important to them. It is for this very reason that persons suffering from anxiety disorders have been described as suffering from an experience phobia. This is an important predisposition that anxiety sufferers apply to anxiety and fear, and quite often other unpleasant psychological and emotional content as well.

ACT tries to undermine the need for excessive and rigidly inflexible emotion regulation. It does so by fostering psychological and experiential flexibility, willingness, and openness to all human experience as it is, rather than how clients evaluate their experience (both the pleasant and unpleasant). When the full range of emotional experience is allowed in for what it is, the very notion that emotions need to be regulated becomes nonsensical under most circumstances. This acceptance posture, somewhat paradoxically, frees up clients to act and use their hands and feet to regulate how they live their lives—what they do—consistent with their values and goals. This is the kind of life regulation that ACT is after, even if living that way means bringing along anxious thoughts and feelings and other facets of clients’ private world (e.g., their memories, behavioral histories, physical sensations) into situations where they make no sense and where it might be easier to act effectively if they weren’t there.

Narrowband Versus Broadband Outcomes

Cognitive behavioral interventions typically focus on narrowband clinical outcomes, most often in the form of symptom reduction and alleviation. Clients typically want this too, guided by the view that “In order to live better, I must first think and feel better.” Yet, to get there, clients typically must go through quite a bit of pain by confronting anxiety and fear-evoking cues and situations during in vivo or imaginal exposure exercises. Interestingly, this is the point at which some anxious clients drop out of therapy. In fact, two recent studies completed in our labs showed the positive effects of an acceptance context for preventing dropouts. The first study (Karekla, 2004; Karekla & Forsyth, 2004) showed significant differences in the pattern of attrition rates between CBT and ACT-enhanced CBT for persons suffering from panic disorder. Prior to the introduction of the rationales for interoceptive and exteroceptive exposure, none of the CBT clients and only three ACT clients dropped out of therapy prematurely. However, following the introduction of the exposure rationales, five persons discontinued therapy in the CBT group whereas only one person discontinued treatment in the ACT group.

The main difference between the exposure rationales was in how they were framed (i.e., mastery and control of panic versus mastery of experiencing panic) and for what purpose (i.e., controlling panic symptoms versus living more fully and consistently with what one values). The results of this study suggest that exposure conducted in the service of feeling better is somewhat limiting and not very inspiring. Clients appear to recognize this too. All the pain of therapy and for what? The hope of feeling less anxious? At some level, anxious persons also recognize that feeling less anxious does not mean that they will be anxiety free, or that somehow their lives will be better, richer, or more meaningful. In the second, related study with highly anxious females (Eifert & Heffner, 2003) who experienced paniclike responses in an acceptance or a control context, we found that 20 percent of control participants dropped out of the study, whereas none of the acceptance participants did. Here, too, by giving up their efforts to gain control, people felt they had actually gained control and strength.

While ACT allows room for symptom alleviation, it is not a main target or the therapeutic goal. Rather, the real focus is on what we call broadband outcomes. Such outcomes are about helping the client move in life directions that they truly care about. For instance, a client may value having deep and meaningful relationships with her children, but is letting her anxiety regulation efforts get in the way of that. Within ACT, the focus would be about removing barriers to having that kind of relationship with her children (e.g., unnecessary emotion regulation strategies). Anxiety reduction may occur as a consequence, but it is not an explicit target. As you will see, ACT is very much about fostering the development of fully functioning human beings who are able to live in a manner consistent with meaningful values and goals. Making and keeping value-guided commitments are very important parts of an ACT approach to anxiety disorders. Valued living dignifies the treatment and makes the hard work of therapy worthwhile.

Use of CBT Interventions in an ACT Context

There are several other ways in which CBT and ACT differ in their philosophy and approach to the alleviation of human suffering. Many of these differences will become apparent as you go through this book. In the process, you will see that we have not thrown the baby out with the bathwater. There are several useful CBT interventions for anxiety sufferers. It would be misguided to dismiss them given the strong evidence for their efficacy. This applies in particular to all CBT techniques (e.g., exposure, response prevention) that aim to help clients do the opposite of what clients think ought to be done about their anxiety. The reason is that these techniques let clients experience that escape and avoidance are uncalled for and do not serve any functional adaptive purpose. One could speculate that this process may underlie the extinction of fear over time, as approach behaviors begin to predominate over escape and avoidance behaviors. This is why exposure-like techniques are also part of an ACT approach.

Yet, you will see that the traditional CBT exposure interventions for anxiety have a different feel as used throughout this book. Virtually all of them are recast within an acceptance and mastery of experiencing framework. We talk very little about symptoms, because anxious thoughts and feelings are not symptoms of anything. They are what they are, namely facets of human experience that anxious clients happen to respond to much as they would when placing their hands on a hot stove. The approach we describe in detail is very much about altering how clients with anxiety respond to their emotional and psychological experiences, not the structure or content of those experiences. In so doing, we are trying to make room for those experiences, while freeing up psychological and behavioral space for clients to use to get on with the task of living their lives consistently in the direction of their chosen values.

Summary of Key Concepts

In this chapter, we began with an overview of first- and second-generation behavior therapies, represented early on with classical conditioning as a model of anxiety disorders, and later with the notion that anxiety-related suffering has to do with problematic cognitive and psychological content. Within a coherent theoretical and philosophical framework, ACT illuminates the ways that language entangles clients into futile attempts to wage war against their own inner lives. This war, as we have described, is fundamentally about the application of unworkable emotion regulation efforts in contexts where such regulation efforts are unnecessary. It is such emotion regulation efforts (i.e., control, suppression, avoidance, and escape) that make fear learning, anxiety, and related thoughts and physical sensations problematic or disordered. ACT, in turn, is very much about loosening the hold that emotion regulation has on the lives of anxiety sufferers. It shows how interventions based on metaphor, paradox, and experiential exercises can help clients make contact with thoughts, feelings, memories, and physical sensations that have been feared and avoided. As a consequence, clients learn to recontextualize and accept these private events, develop greater clarity about personal values, commit to needed behavior change, and embark on the journey to put those commitments into action.