CognitiveBlackwell Publishing Inc Behavioral Therapy and Acceptance (e.g., Hofmann & Asmundson, 2008). Part of our and Commitment Therapy for the Anxiety pleasure at seeing these articles is that they help us to come to a place of mindful distance, observation, and Disorders: Two Approaches With engagement. As Arch and Craske (2008) point out, Much to Offer attempts to distinguish novel treatment approaches from Richard G. Heimberg and Michael R. Ritter, more traditional ones may serve to amplify differences Temple University rather than similarities, providing us with less than a totally accurate snapshot of the current state of affairs and sometimes interfering with attempts to seek out meaningful Arch and Craske (2008) examine the similarities and differences. In this commentary, we consider what we differences between cognitive behavioral therapy and see as the most important similarities and differences acceptance and commitment therapy for the anxiety between CBT and ACT for the anxiety disorders. disorders and suggest that the two treatment The discussion of the theoretical and pragmatic approaches have as many similarities as differences. We distinctions between cognitive restructuring in CBT and agree and believe that there is merit in this conclusion—it cognitive defusion in ACT is quite interesting. One of brings us together in common purpose and helps move the criticisms leveled at CBT by advocates of ACT is us toward improved approaches to reducing client that cognitive restructuring may be counterproductive. suffering. Our discussion focuses on the similarities that In discussing this criticism, both Arch and Craske (2008) we think about most positively and the differences of and Hofmann and Asmundson (2008) refer to the work which we should be mindful. of Gross (2002) on emotion regulation. Hofmann and Key words: acceptance and commitment therapy, Asmundson draw the useful distinction from Gross’s anxiety disorders, cognitive behavioral therapy, meditation, work that CBT relies more heavily on antecedent- focused strategies for emotion regulation, whereas ACT treatment mechanisms. [Clin Psychol Sci Prac 15: 296– relies more heavily on response-focused strategies for the 298, 2008] same goal. Gross (1998, p. 275) defines emotion regulation as “the processes by which individuals influence which Unlike much of the rhetoric that has attempted to describe emotions they have, when they have them, and how acceptance and commitment therapy (ACT) as the next they experience and express these emotions.” These are wave of behavior therapy, holding the promise to correct the important goals for individuals with anxiety disorders multitudes of inadequacies of cognitive behavioral therapy when applied in adaptive fashion: When maladaptively (CBT), Arch and Craske (2008) give credit to both CBT applied, they become a mechanism for avoidance of and ACT for their substantial contributions and for their emotional experience (Mennin, Heimberg, Turk, & potential importance to the future understanding and Fresco, 2002, 2005). Emotional avoidance is not an treatment of anxiety and its disorders. We believe that the acceptable outcome for either CBT or ACT, although philosophical, and ultimately empirical, approach espoused ACT proponents have made experiential avoidance by Arch and Craske will lead us more efficiently to answer (somewhat broader than emotional avoidance) a key a most important question: How do we best go about target of treatment. the business of assisting clients with anxiety disorders to Hayes, Strosahl, and Wilson (1999) suggest that lead less distressing, happier, and more fulfilling lives? cognitive restructuring (a) focuses too much on cognitive Examinations of the similarities and differences content and (b) communicates to the client that anxious between CBT and ACT have appeared here and elsewhere thinking needs to be suppressed. Of course, the literature on thought suppression (e.g., Wenzlaff & Wegner, 2000) Address correspondence to Richard G. Heimberg, Adult would suggest that this is a bad idea. However, cognitive Anxiety Clinic, Department of Psychology, Temple University, reframing or reappraisal is a key aspect of cognitive 1701 North 13th Street, Philadelphia, PA 19122-6085. E-mail: restructuring work, and it is not dependent on suppres- [email protected]. sion. Arch and Craske note that reframing generally

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decreases the intensity and expression of negative emotion anyone else for that matter) are capable of adopting a without the counterproductive effects of suppression truly mindful distance from their thoughts if those and, in fact, go so far as to describe cognitive restructuring thoughts include irrationally excessive assessment of as an approach-oriented technique for responding to threat. Although this may be an empirically difficult anxiety. We add that (without the ACT framework or question, evolutionary theory would suggest that we the label of cognitive defusion) many clinicians who would be unlikely to do so or be able to do so, because identify themselves with CBT to one degree or another the perception of threat should be tied to survival of the have engaged in cognitive defusion techniques for many species (when that mechanism is functioning correctly). years. In working with panic disorder patients, for We were struck by Arch and Craske’s statement that instance, it is typical to teach clients to identify thoughts both CBT and ACT require thinking to avoid getting as panic thoughts and simply instruct them to observe tied up in thinking. This point has been clearly made these thoughts and let them flow “in one ear and out the about CBT by advocates of ACT, but it is clearly true for other.” We acknowledge that this is not ACT terminology, both approaches. Mindful recognition of one’s thoughts nor do we take credit for any of this. If one looks at and deciding to allow them or to react to them in particularly current work on the treatment of generalized anxiety helpful ways requires a great deal of quite sophisticated self- disorder (e.g., Borkovec & Sharpless, 2004; Craske & instructional thinking. Not a thing wrong with that either. Barlow, 2008; Dugas & Robichaud, 2006; Mennin, Arch and Craske call for empirical research looking 2005), there is an emphasis on the distinction between into components of the therapies that actually make a worries that one can objectively do something about, difference. We add that an examination of how much of typically treated with a problem-solving approach, and each therapy actually exists in the other is quite important worries that represent the creation of a fictional future or to undertake. There is a lot of acceptance-oriented about which the person can actually do nothing, which material in the way many do CBT. are treated with various techniques that are consistent An aside that is relevant to the treatment of anxiety with an acceptance point of view. Similarly, cognitive disorders, the question of whether cognitive restructuring restructuring involves looking at one’s thoughts from a adds to the efficacy of exposure, is a bit of a straw person. different stance than has been most habitual—a method A careful examination of research studies reveals that they of creating distance but staying in the present moment, a are typically underpowered to find differences between variant of cognitive defusion. Cognitive restructuring active treatments. They also tend to use a design where a challenges the frequent belief that thoughts are facts by control group (sometimes) is tested versus exposure alone redefining them as hypotheses to be tested against versus exposure plus cognitive techniques—a design that experiential evidence. It also interrupts the process of compares 0 treatment versus 1 treatment versus 2 treat- one negative thought leading to another by the mindful ments. One can argue that the component added last will substitution of one cognitive activity for another. be least likely to demonstrate an effect. The literature is Arch and Craske aptly note that exposure, which is a almost totally devoid of full factorial designs. Along common intervention in both CBT and ACT for anxiety another line of reasoning, treatments involving exposure disorders (e.g., Eifert & Forsyth, 2005), may involve plus cognitive techniques actually use less exposure to some form of cognitive restructuring as thoughts may be achieve roughly the same outcomes. Given that expo- changed without the use of specific change techniques. sure can be emotionally painful and difficult to arrange, Furthermore, cognitive restructuring may be a form of a tie in terms of outcomes may actually favor the full exposure to one’s own internal events, a process important CBT package. This view is important in interpreting to ACT for the anxiety disorders. Although not often some of Arch and Craske’s points, and it suggests that the mentioned, one must learn to be aware of a thought position attributed to Hayes et al. (i.e., that cognitive before deciding to either distance oneself from it or to techniques are not needed) can be viewed from a change it. Engagement with the content of the thought broader perspective. is essential, and unavoidable, before selecting the appropriate It is important that we do not place mindfulness strategy. One of us (RGH) has asked whether clients (or under the sole purview of ACT. It is a potentially potent

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therapeutic tool and ACT uses it well. However, it has therapy for anxiety disorders: A practitioner’s treatment guide to been used by others for a long time. This includes Kabat- using mindfulness, acceptance, and values-based behavior change Zinn (1990), Borkovec (2002; Borkovec & Sharpless, strategies. New York: Guilford Press. 2004), and Roemer and Orsillo (2002, 2007). Gross, J. J. (1998). Antecedent- and response-focused emotion The debate on the relative emphasis on symptom regulation: Divergent consequences for experience, expression, and physiology. Journal of Personality and Social Psychology, reduction versus valued living is important, and ACT 74, 224–237. advocates have brought this into focus. However, we Gross, J. J. (2002). Emotion regulation: Affective, cognitive, have long wondered about the size of the gulf between and social consequences. Psychophysiology, 39, 281–291. the two therapies. ACT’s position is perhaps more clearly Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance articulated, but there are few CBT therapists who want and commitment therapy: An experiential approach to behavior to help their clients achieve anxiety reduction so that change. New York: Guilford Press. they can sit more comfortably at home doing nothing. Heimberg, R. G., & Becker, R. E. (2002). Cognitive-behavioral Coming from the perspective of either ACT or CBT, we group therapy for social phobia: Basic mechanisms and clinical work with clients to achieve their important (valued) life strategies. New York: Guilford Press. goals (e.g., relationships, independence). CBT endorses Hofmann, S. G., & Asmundson, G. J. (2008). Acceptance and the idea that it is easier to do this in the context of less mindfulness-based therapy: New wave or old hat? Clinical anxiety, but it is also fine with the idea that clients need Psychology Review, 28, 1–16. Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of to take action, even when anxious, if such action moves your body and mind to face stress, pain, and illness. New York: them closer to the goal. In fact, this is often a focus of Delta. cognitive intervention in CBT for social anxiety (Heim- Mennin, D. S. (2005). Emotion and the acceptance-based berg & Becker, 2002). Perhaps the “values” piece of approaches to the anxiety disorders. In S. M. Orsillo & ACT, though with the least empirical support at present, L. Roemer (Eds.), Acceptance and mindfulness-based approaches may emerge as most important. to anxiety: Conceptualization and treatment (pp. 37–58). New York: Springer. REFERENCES Mennin, D. S., Heimberg, R. G., Turk, C. L., & Fresco, D. M. Arch, J. J., & Craske, M. G. (2008). Acceptance and commitment (2002). Applying an emotion regulation framework to therapy and cognitive behavioral therapy for anxiety disorders: integrative approaches to generalized anxiety disorder. Different treatments, similar mechanisms? Clinical Psychology: Clinical Psychology: Science and Practice, 9, 85–90. Science and Practice, 15, 263–279. Mennin, D. S., Heimberg, R. G., Turk, C. L., & Fresco, D. M. Borkovec, T. D. (2002). Life in the future versus life in the (2005). Preliminary evidence for an emotion dysregulation present. Clinical Psychology: Science and Practice, 9, 76–80. model of generalized anxiety disorder. Behaviour Research Borkovec, T. D., & Sharpless, B. (2004). Generalized anxiety and Therapy, 43, 1281–1310. disorder: Bringing cognitive behavioral therapy into the Roemer, L., & Orsillo, S. M. (2002). Expanding our con- valued present. In S. Hayes, V. Follette, & M. Linehan ceptualization of and treatment for generalized anxiety (Eds.), New directions in behavior therapy (pp. 209–242). New disorder: Integrating mindfulness/acceptance-based approaches York: Guilford Press. with existing cognitive-behavioral models. Clinical Psychology: Craske, M. G., & Barlow, D. H. (2008). Panic disorder and Science and Practice, 9, 54–68. agoraphobia. In D. H. Barlow (Ed.), Clinical handbook of Roemer, L., & Orsillo, S. M. (2007). An open trial of an psychological disorders: A step-by-step treatment manual (4th ed., acceptance-based behavior therapy for generalized anxiety pp. 1–64). New York: Guilford Press. disorder. Behavior Therapy, 38, 72–85. Dugas, M. J., & Robichaud, M. (2006). Cognitive-behavioral Wenzlaff, R. M., & Wegner, D. M. (2000). Thought suppression. treatment for generalized anxiety disorder: From science to practice. Annual Review of Psychology, 51, 59–91. New York: Routledge. Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment Received January 14, 2008; accepted January 27, 2008.

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