Michael Anestis - Acceptance and commitment therapy versus traditional cognitive therapy in the treatment of anxiety and depression

Great post from the Psychotherapy Brown Bag blog - an excellent psych blog if you've never seen it. A nice collection of posts.

Acceptance and commitment therapy versus traditional cognitive therapy in the treatment of anxiety and depression

by Michael D. Anestis, M.S.

Recently, I wrote an article describing a study that examined the utility of acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) for weight loss. That particular study, unfortunately, was fairly flawed in a variety of ways detailed in my article; however, as I pointed out then, the flaws of that study do not reflect a lack of empirical support for ACT in general. All that being said, today I would like to call your attention to a more positive outcome for ACT.

In a study published in Behavior Modification, Evan Forman of Drexel University and several colleagues described a randomized controlled effectiveness trial for ACT and traditional cognitive therapy (CT) for individuals presenting with anxiety or depression. The authors had two primary goals. First, they wanted to compare the two different treatment approaches with respect to their impact on client and therapist rated levels of symptoms as well as overall well-being. In other words, they wanted to see if one treatment was better than the other at reducing symptoms of depression and anxiety and improving the lives of individuals struggling with these conditions. Second, they wanted to examine whether each treatment led to changes in symptoms through different mechanisms. In other words, do they lead to improvement for different reasons? Before describing this study in some detail, I would like to provide a basic description of ACT and the manner in which it differs from traditional CT. Bear in mind as you read this description, however, that it is too brief to be considered comprehensive and that further reading is required in order to fully understand the theory and methods of ACT. At the end of this article, I will describe some more comprehensive resources for both ACT and CT.

ACT is a "third generation" behavior therapy. Unlike traditional CT (including cognitive-behavioral therapy, as outlined in several PBB articles), which focuses primarily on identifying distorted thoughts and changing them so as to better reflect reality, ACT aims to change the context within which thoughts are experienced rather than changing the thoughts themselves. Mindfulness, which we describe in detail in earlier articles on mindfulness-based cognitive therapy and dialectical behavior therapy, thus plays a pivotal role, as clients are taught to view their thoughts as simply thoughts, rather than part of their identity and as stimuli to which they must respond accordingly. ACT theorists believe that attempting to control unwanted subjective experiences is often counterproductive, resulting in higher levels of distress. In other words, trying not to feel anxious can lead to more anxiety. As a result, in ACT clients are taught to accept distressing thoughts and emotions without trying to actively change them, but to simultaneously move toward goals consistent with their values. In this sense, clients are taught to step back, observe that they are upset, accept this feeling, and choose a behavior that will help them attain a valued goal. ACT is thought to work by decreasing experiential avoidance - the tendency to disconnect from, avoid, or attempt to alter aversive experiences - thereby helping clients to maintain a focus on their values and goals in the midst of discomfort. A complete summary of the empirical support for ACT would be beyond the scope of this article; however, it is important to note that ACT theorists, like CT theorists, place a heavy emphasis on testing the efficacy and effectiveness of their chosen therapy rather than simply telling us that it works. We recommend that you consult a recent meta-analysis conducted by Hayes, Luoma, Bond, Masuda, and Lillis (2006) for more information (see our references page for a detailed citation or email us for instructions on how to find this article).

Returning to the current study, Forman and colleagues (2007) randomly assigned clients presenting at a counseling center to either ACT or CT. Therapists were trained in both approaches and treated clients in both conditions. Therapists were supervised and therapy sessions were evaluated for fidelity to the therapeutic approach. In total, 101 individuals were enrolled in the study. Of these participants, 57 completed a post-treatment questionnaire and were included in the analyses. Obviously, this represents a substantial amount of attrition (dropping out of treatment); however, this result is not abnormal for treatment trials or everyday practice and should not be seen as a flaw beyond the fact that it reduced the sample size, thus diminishing the power of the analyses to detect differences (e.g., it makes it difficult for the researchers to determine if one condition out-performed the other). On average, participants in the CT condition received 15.27 weekly sessions and participants in the ACT condition received 15.60 weekly sessions.

As the authors expected, both treatment groups demonstrated significant improvements post-treatment. Additionally, the two groups were equivalent, meaning participants in the ACT group improved as much as participants in the CT group. These findings are important for two reasons. First, it indicates that both treatments led to significant improvements. Second, it indicates that neither treatment stood out relative to the other in terms of the degree to which participants improved.

A second set of analyses offered some more interesting information. Forman and colleagues (2007) were interested in mediators of treatment. A mediator, remember, is a variable that explains a relationship. For example, sex mediates the relationship between height and baldness. The taller you are, the more likely you are to be bald; however, this is only because men are more likely to be tall and more likely to be bald. Tall women are no more likely to be bald than are short women. So, when you control for the effects of sex, the relationship between height and baldness disappears. In this study, the authors wanted to do a similar analysis. They knew that both ACT and CT were related to improvement, but they thought each treatment would be related to improvement for a different reason. This, in fact, was shown to be true. The degree to which participants improved their ability to recognize and describe their thoughts and emotions explained the improvement in the CT condition whereas the degree to which participants increased their willingness to accept rather than avoid negative emotional and cognitive experiences explained improvement in the ACT condition.

There are several aspects of this study that I think are extremely important. First, the authors respectfully examined two related but differing perspectives and took care to ensure that both were fairly represented in a trial comparing them to one another. In other words, the priority was on examining the evidence rather than supporting a favored philosophy. This places the emphasis on the client rather than the therapist, which I favor heavily. Secondly, the results offer hope to individuals with depression and anxiety, as they provide preliminary evidence for another empirically supported treatment for these conditions. Currently, APA division 12 lists ACT has having modest empirical support as a treatment for depression. Another strength of this study is that it demonstrates how science can improve upon treatments for mental illness. Two strong treatments based on distinct theories were tested against one another and the researchers were careful to assess why they worked. Doing this allows other researchers to make adjustments to these treatments and then test the newer improved versions against one another. As such, treatment systematically improves as we compare different approaches to one another and learn what works and how it causes changes in clients. As an individual trained in CBT and highly supportive of its theory, I am nonetheless ecstatic to see a strong study that demonstrates equivalent efficacy for a different approach, as this represents progress and an opportunity for treatments to improve.

If you would like to learn more about ACT, CT, or mindfulness, we recommend the following resources, all of which are available through our online store:

Acceptance and Commitment Therapy

Get Out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy

The Mindfulness & Acceptance Workbook for Depression: Using Acceptance & Commitment Therapy to Move Through Depression & Create a Life Worth Living

The Mindfulness and Acceptance Workbook for Anxiety: A Guide to Breaking Free from Anxiety, Phobias, and Worry Using Acceptance and Commitment Therapy

Learning Act: An Acceptance & Commitment Therapy Skills-Training Manual for Therapists

Mindfulness for Two: An Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherap

Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change

Cognitive Therapy

Cognitive Therapy of Depression

Cognitive Therapy and the Emotional Disorders

Cognitive Therapy in Clinical Practice

Mindfulness

Mindfulness-Based Cognitive Therapy for Depression: A New Approach to Preventing Relapse

Mindfulness-Based Treatment Approaches: Clinician's Guide to Evidence Base and Applications

Peace Is Every Step: The Path of Mindfulness in Everyday Life

Mindfulness for Beginners

The Miracle of Mindfulness

~ Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University

Tags: Psychology, therapy, anxiety, depression, Psychotherapy Brown Bag, Michael Anestis, Acceptance and commitment therapy, cognitive therapy, treatment, anxiety and depression