Acceptance and commitment therapy for anxiety disorders: Three case studies exemplifying a unified treatment protocol - Eifert, Forsyth, et. al. (2009) - Article

Over the past decade research has start to focus more on mindfulness and acceptance-based interventions. Among others, Acceptance and Commitment Therapy is one of these. In this article an application of ACT in treating anxiety disorders is described. The primary goals of ACT are (1) acceptance of problematic unhelpful thoughts and feelings cannot and maybe do not need to be controlled. (2) commitment and action toward living a life according to one’s chosen values. Therefore, ACT is both about change and acceptance. In ACT applied to anxiety disorders, the client is taught to stop being busy with discomfort but to engage in actions that bring him/her to chosen life goals/values. In ACT the clients are taught to observe distressing thoughts and feelings as they occur. According to ACT, anxiety disorders are characterized by experiential and emotional avoidance. The function of experiential avoidance is to control or reduce the influences of aversive internal experiences. Engaging in experiential avoidance can lead to relief for a short period of time. By doing so, the behaviour is also reinforced and it can become problematic when it impairs daily life. Experiential avoidance and rigid down-regulation of emotions might be core psychological diathesis that causes psychopathology to develop and maintain.

Acceptance in contrast to experiential avoidance, exists of an openness to both aversive and pleasant experiences. When individuals try to suppress and control certain events, this can lead to more involuntary thoughts and emotions. One of the main skills that are taught is how to disentangle from self-perpetuating emotional and cognitive behavioural avoidance routines. Clients do not learn how to manage or control anxiety but how to let go this attempts to control their anxiety.

Treatment Overview

The primary goal of phase 1 (session 1-3) is to create an acceptance context for anxiety-related discomfort. The goal of phase 2 (session 4-7) is to focus more on life goals of the client and to learn flexible patterns of behaviour in case of anxiety or fear. Mindfulness is taught since it can be used to treat the experiential avoidance strategies. In phase 3 (session 8-12) the focus is on engaging in value-guided actions despite anxiety-related barriers. From the values written down in the last session concrete goals are specified. There is an important focus on commitment even if anxiety shows up.

Session-by-session Treatment program and core process targets

ACT is a functional approach in which the therapist uses metaphors, concepts and exercises. The focus is to change the function instead of the content of the unwanted thoughts. In treatment the amount of the client’s actions in everyday life are enlarged. In the first session anxiety is described as adaptive emotion to the client. The therapist will indicate that trying to control the fear will probably make it worse. There is also a focus on the active, experiential and participatory nature of ACT and on misconceptions about fear and anxiety. The first step is to identify and abandon strategies that did not provide relief and also did not improve life goals of the client. This is done by the costs and effects of the coping strategies of the client. The client has to perform metaphor based experiential exercises accompanied by a therapist to experience that these strategies are not effective and may even cause more problems. An example could be the Chinese finger trap exercise, a tube of woven straw about five inches long and half an inch wide. The client and therapist have to put in their finger in before they can take them out, otherwise it will feel uncomfortable. Pushing your fingers further into the trap feels counterintuitive, so is approaching what you are feared of.

However, you have to approach it first if you want to get out of it. Tug of war with the anxiety monster is another exercise in which the client together with the therapist pull a rope, the harder the client pulls, the harder the therapists pulls back. Clients will see that they have a choice to keep fighting or to drop the rope. When the client drops the rope he/she will notice what the gains are, less strain and more room to move. Other metaphors are used to induce creative hopelessness by letting clients experience that their old strategies are ineffective. The therapist will offer a alternative strategy in which they have to accept instead of to fight with the anxiety. In a 12 minutes mindfulness exercise that has to be practiced daily, clients learn to direct their attention to a single focus, their breathing and to watch and allow other internal events to come and go. Clients also have to determine their life goals, they will probably notice that the anxiety has taken the place of the life goals. In session 4 and 5 acceptance is also taught and mindfulness skills are used to observe involuntary anxiety-related responses as they occurred.

Acceptance: developing willingness to stay with discomfort

Acceptation is taught as alternative for experiential avoidance this is an aware and active approach of the events without trying to change them, especially not when that would lead to psychological suffering. Clients learn to use mindfulness techniques through observing thoughts as thoughts and emotions as emotions. In session 4 and 5 the clients are convinced of the usefulness of mindfulness techniques. The client learns to perceive feelings and thoughts without suppressing or judging. Acceptance of anxiety is another exercise to teach the clients to take the perspective of someone else and to observe their feelings and thoughts from this perspective. The aim of this exercise is to accept the discomfort without changing this experience. It also emphasizes the choice that the client has in responding to anxiety. There are several other exercises all aimed to observe thoughts and feelings instead of changing them. Acceptation can be viewed as the ability to accept distress and to work towards one’s life goals. This skill can be learned and clients will recognize that anxiety is only a collection of sensations, feelings, thoughts and imaginations, which is the opposite of avoidance and control.

Cognitive defusion

This concept explains why people listen to thoughts although it is known that this is ineffective on the long-term. Cognitive fusion means that people tend to listen to the content of their thoughts literally. These literal evaluative thoughts dominate behavioural regulation whereas less judgemental strategies would have been more effective. Cognitive fusion involves the process in which the individual fuses and merges with the literal content of the own experiences. People do not respond to the thought as if it was just a thought but they respond to the content as if it was an own experience. In ACT clients learn to observe these thoughts instead of to listen to them.

Applying acceptance, willingness , and defusion to stay with anxiety (exposure)

The main purpose of session 6 and 7 is learn to live with the anxiety but in a way that anxiety is not a limiting factor anymore. With the help of FEEL exercises (Feeling Experiences Enriches Living) the clients learn to come to an aware observation and to let go of the avoidance or control of the anxiety related thoughts, worries of bodily symptoms. They even have to acknowledge them and to embrace them. The exercises used are similar to those used in CBT such as hyperventilation, spinning, worst-case imagery etc. the aim is to prepare the clients for the moments that they will be confronted with anxiety, when they are working towards their life goals. The exposure exercises are based on mindfulness exercises and stimulate the willingness of the clients to experience the anxiety and the acknowledgement that giving into it is a choice. However, nobody really decides for anxiety, the question is therefore, is the client willing to give up life goals because of anxiety or is he/she able to manage the anxiety and take it with him/her. Although not the main goal of exposure, reduction of the anxiety can be a positive bonus-effect.

Value-guided action (naturalistic exposure) – Moving with Barriers

In session 7 to 12 the clients learn to engage in meaningful activities that would help them to achieve their life goals. For each week a plan of action is created together with the therapist. The therapist helps with creating realistic goals, giving feedback and monitoring progress. Engaging in these activities look like exposure exercises but the goals is not to reduce anxiety but to reach life goals. Also in these sessions commitment is emphasized by the therapist. Clients learn and are encouraged to move with potential barriers rather than attempt to overcome them. The main point to learn is that it is not necessary that the anxiety has been reduced first before the client can start doing things he/she really wants to do.

Method

In order to show the flexibility of the ACT program, three clients who had very different characteristics were selected to participate. All the clients completed the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) to assess anxiety, mood and other psychiatric disorders. Also a clinical severity rating was made by the interviewer. Clients were called by their therapists for a 6-month follow up. The therapists were three advanced graduate students enrolled in the doctoral program in clinical psychology. The therapists were trained in using ACT. The treatment consisted of 12 weekly sessions lasting 1 hour. The Anxiety Sensitivity Index (ASI) assesses level of fear of anxiety related symptoms such as rapid heart. This is based on the ideas that individuals have about certain sensations. Also the PSWQ was completed to assess generality, intensity/excessiveness and uncontrollability of clinical relevant worry. It also distinguishes GAD from other anxiety disorders. The Mood and Anxiety Symptom Questionnaire, the Anxiety Control Questionnaire, the Fear Questionnaire, and the Padua Inventory-Washing State University Revision (to measure OCD) are all used in the study.

ACT Process Measures

The Acceptance and Action Questionnaire assess psychological flexibility. Other scales that are used to measure mindfulness, suppression, anxious feelings and satisfaction in different areas of life are respectively: the Mindfulness Attention Awareness Scale, the White Bear Suppression Inventory, the Believability of Anxious Feelings and Thoughts and The Quality of Life Inventory.

Case descriptions and Results

James (31-year-old, panic disorder)

James has a panic disorder and despite having experienced only few panic attacks, his life changed significantly after the first time he had such an attack. He does not drink alcohol or coffee anymore and he is having sleeping problems. He was absolutely not content with his life and felt like he failed everything. By performing the Chinese Finger Trap, James realized that his attempts to control his internal experiences was contributing to further distress. After several exercises, such as repeating the word failure over and over again, James became able to listen to this word without feeling distress. He learned that he does not have to take thoughts about failure so seriously. He also learned defusion skills to help him persist maintain value-consistent behaviour although distressing thoughts were present. His worries about panic attacks and not being able to fall asleep slowly disappeared and in the follow-up he hardly reported any panic or OCD related symptoms or distress.

Daniel (51-year-old, social phobia)

Daniel has a social phobia and is also diagnosed with dysthymia. He was afraid of speaking in public, showing assertive behaviour, talking with strangers and attending meetings. He had sleeping problems and was dissatisfied with his quality of life. Metaphors with regard to hopelessness showed Daniel that his way of managing distressing emotions made him even more hopeless. Due to mindfulness exercises he realized that emotions and bodily sensations are changing all the time. He practiced regularly, also exercise focused on acceptation or thoughts and anxiety and this helped a lot. He also reported to find the mindfulness exercises relaxing. When a client reports a relaxing effect the therapist should immediately respond because mindfulness is not aimed to relax or to relief anxiety. Mindfulness is aimed to become aware of thoughts, feelings and bodily sensations and to accept them and to act towards goals that are important for the client. Removing the anxiety completely is not the goal but a side-effect.

Janet (52-year-old, OCD and panic disorder)

Janet has always had OCD related problems. Her primary fears are contamination fear and the fear to urinate. Hence, she washes her hands excessively and avoid places from where she cannot easily escape. She is avoidant in her interaction with other people and she quit school although she was promising. Once Janet became more willing to experience, her anxiety, depressive mood and anger increased and for the first time she really experienced what was going on in her mind. Through acceptation exercises Janet learned to experience intrusive thoughts and feelings of distress but without giving in to it. Her self-acceptation and goal directed behaviour increased. She embraced her OCD-related thoughts as friends and decided to live with them. She engaged in activities that helped her moving toward her personal value of self-respect by finding a new job.

General discussion

This study shows that ACT can be adjusted to different forms of anxiety. Clients notice the change in processes they want to change, such as reduction of experiential avoidance and defusion of anxiety related thoughts and beliefs. However it is not the main purpose of ACT, many clients experience a reduction in distress after the treatment (shown by ratings of anxiety and distress scales). ACT also helps to live a more life-goal-directed life by addressing the anxiety that limits the possibility to live such a life. There continues to be a debate whether cognitions are causal factors for behaviours and feelings. Also when therapists are not sure about their own opinion they can still use ACT to change the function of thoughts. They can teach the client that cognitions do not tell them how to react, even when they are intense it is still possible to engage in life goal-directed behaviour. ACT contains different behaviour therapy interventions such as behavioural activation and exposure exercises, however, they are presented from another perspective. The emphasize does not lie on changing thoughts, feelings and sensations but on the awareness and the relation to it. ACT encourages emotional focused problem solving strategies through accept emotions rather than changing them. Acceptation is appropriate when anxious feelings and thoughts are standing in the way of achieving one’s life goals.