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Arch-And-Craske-Act-V-Cbt-2008.Pdf AcceptanceBlackwellMalden,CPSPClinical0969-5893©XXXOriginalACTCLINICAL 2008 AND AmericanPsychology: USAArticle Publishing CBTPSYCHOLOGY: PsychologicalFOR ScienceInc ANXIETY and Association. SCIENCEPractice DISORDERS PublishedAND PRACTICE •by ARCH Wiley Periodicals,& • V15CRASKE N4, Inc., DECEMBER on behalf of 2008the American Psychological and Association. All rights reserved. For permission,Commitment please email: [email protected] Therapy and Cognitive Behavioral Therapy for Anxiety Disorders: Different Treatments, Similar Mechanisms? Joanna J. Arch and Michelle G. Craske, University of California, Los Angeles Cognitive behavioral therapy (CBT) and acceptance and to broaden, improve upon, and provide alternative behavior- commitment therapy (ACT) researchers and scholars ally based treatments to CBT, researchers and practitioners carry assumptions about the characteristics of these over the past decade have shown increasing interest in therapies, and the extent to which they differ from one mindfulness and acceptance-based treatments for psy- another. This article examines proposed differences chopathology, including anxiety disorders. One creative between CBT and ACT for anxiety disorders, including approach that has gained attention in the research and therapy community and in the treatment of anxiety aspects of treatment components, processes, and out- disorders is acceptance and commitment therapy (ACT; comes. The general conclusion is that the treatments Eifert & Forsyth, 2005; Hayes, Strosahl, & Wilson, 1999; are more similar than distinct. Potential treatment Orsillo, Roemer, Block-Lerner, LeJeune, & Herbert, mediators and issues related to the identification of 2005; Twohig, Hayes, & Masuda, 2006). mediators are considered in depth, and directions for In the excitement and curiosity that comes with new, future research are explored. thoughtful treatment approaches, attempts to distinguish Key words: acceptance and commitment therapy, the novel treatment approach from previous approaches anxiety disorders, cognitive behavioral therapy, mediation, often emerge (e.g., Eifert & Forsyth, 2005). As the social treatment mechanisms. [Clin Psychol Sci Prac 15: 263– cognition literature suggests (e.g., Tajfel, 1982), group 279, 2008] comparisons tend toward amplification and dichotomi- zation of differences between one’s own group and an The development of behavioral and cognitive behavioral outside group. Comparisons of ACT and CBT sometimes therapies for anxiety disorders (Barlow & Cerny, 1988; reflect this tendency. Emphasizing differences may limit Beck, Emery, & Greenberg, 1985; Clark & Beck, 1988) our capacity to investigate the common mechanisms introduced time-limited, relatively effective treatments that underlie effective therapies. To identify the most for these disorders. As a result of clinical efficacy and ease potent elements of behavioral therapies, and move the of implementation, cognitive behavioral therapy (CBT) field forward, it is necessary to look beyond dichotomiza- arguably became the most dominant empirically supported tion. Identifying similarities helps to distinguish where treatment for anxiety disorders. However, in an attempt true differences are likely to be found, facilitating the potential to uncover unique contributions of each therapy. Noting the relative absence of research that directly Address correspondence to Joanna J. Arch, Department of Psy- addresses these issues, we offer reflections on potential chology, University of California, Los Angeles, 405 Hilgard similarities and differences between ACT and CBT for Ave., Los Angeles, CA 90095-1563. E-mail: [email protected]. anxiety disorders. In particular, we consider the ways in © 2008 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association. All rights reserved. For permissions, please email: [email protected] 263 which differences between the two treatments are dichoto- cognitive restructuring, clients learn to challenge the mized, whereas upon close examination the treatments absolute truth of anxious thoughts by noting evidence share significant commonalities. Our goal is to raise for and against the thought, identifying cognitive errors questions for consideration that have been overlooked or the thought reflects, and/or developing alternative thoughts underplayed in the current discussion on ACT and CBT that better reflect the full range of their experience. for anxiety disorders. We also aim to guide future research Behavioral experiments serve to directly challenge by broadening the scope of the questions and methods anxiety-related predictions by helping clients approach used to investigate and compare these therapies. feared stimuli and noting whether the predicted disastrous Our focus on treatment for anxiety disorders is not result(s) occurs. Response prevention exposes clients to accidental. Anxiety disorders have enjoyed relative success feared stimuli and contexts, while preventing anxiety- from CBT approaches to treatment, and have inspired reducing and avoidant behaviors. More streamlined CBT extensive basic and applied research. For example, therapy may include only psychoeducation, cognitive etiological models based on modern learning theory restructuring, and behavioral exposure. (e.g., Bouton, Mineka, & Barlow, 2001) have been applied Acceptance and commitment therapy is a behavioral extensively to anxiety disorders. Furthermore, anxiety therapy that uses mindfulness, acceptance, and cognitive disorders were among the first disorders for which defusion skills to increase psychological flexibility and cognitive behavioral therapies were developed (Barlow, promote behavior change in the direction of chosen 1988; Beck et al., 1985; Chambless, Goldstein, Gallagher, values. Within ACT, psychological flexibility is defined & Bright, 1986; Clark, 1986). Hence, the broad base of as enhancing the capacity of clients to make contact with treatment research and clinical experience with CBT for their experience in the present moment, and based on anxiety disorders makes a relatively informed launching what is possible for them in that moment, choose to act place from which to examine key differences and similari- in ways that are consistent with their chosen values ties with a newer treatment (e.g., ACT). (Hayes et al., 1999). From a broader perspective, ACT is grounded in radical behaviorism, and attempts to integrate ACT AND CBT: BASIC TREATMENT ELEMENTS cognition and language into a behavioral analytic frame- First we describe the elements of the actual therapies work. The components of ACT will be explored in (e.g., what is presented to clients in therapy), very briefly somewhat more detail, because it is a newer therapy that touching on the assumptions and philosophies behind may be less familiar to many readers. them. Additional examination of underlying assumptions Acceptance and commitment therapy describes itself is pursued in subsequent sections. as based on an extensive empirical, theoretical, and Cognitive behavioral therapy for anxiety disorders philosophical research program that demonstrates how aims to help clients reduce their distress by changing language embroils clients in a fight with themselves and their cognitive and behavioral responses to anxiety their experience (Hayes et al., 1999). This research pro- (Craske, 1999; Craske & Barlow, 1993). From the per- gram centers on relational frame theory (RFT; Hayes, spective of learning theory (Foa & Kozak, 1986), CBT Barnes-Holmes, & Roche, 2001; Hayes et al., 1999), enables clients to develop a new associative network of which is a “post-Skinnerian” contextual behavioral theory adaptive thoughts and behaviors that compete with or about how language influences cognition, emotion, and modify maladaptive, fear-based networks and memories. behavior. From the perspective of RFT, “the core of Toward that aim, CBT for anxiety disorders may include human language and cognition is the learned and the following components: (a) psychoeducation on the contextually controlled ability to arbitrarily relate events nature of fear/anxiety; (b) self-monitoring of symptoms; mutually and in combination, and to change the functions (c) relaxation/breathing retraining; (d) cognitive restructuring of specific events based on their relations to others” (logical empiricism and disconfirmation); (e) behavioral (Hayes, Luoma, Bond, Masuda, & Lillis, 2006, p. 5). A experiments; (f) imaginal and in vivo exposure to feared full discussion of the reasoning, evidence, and conclusions images, bodily sensations, and situations; (g) weaning of of RFT is beyond the scope of this article (see Hayes safety signals; and (h) response and relapse prevention. In et al., 2001). However, an important RFT implication is CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V15 N4, DECEMBER 2008 264 that verbally mediated relationships among objects can or ugly” (Kabat-Zinn, 1990). Thus, the goal is not alter behavioral processes: a person shocked in the changing cognitions or symptoms, as in CBT, but mindful presence of B who learns verbally that B is smaller than tolerance and acceptance of cognitions and symptoms. C will show a greater emotional response to C than to Within ACT, behavior alone is targeted for content B, even though only the latter was paired directly with change. shock (Dougher, Hamilton, Fink, & Harrington, as cited Beyond cognitive defusion, additional components of in Hayes et al., 2006).
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