The Behavior Analyst 2006, 29, 161-185 No. 2 (Fall) Acceptance and Commitment Therapy and

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The Behavior Analyst 2006, 29, 161-185 No.2 (Fall)

Acceptance and Commitment Therapy and

Behavioral Activation for the Treatment of Depression:

Description and Comparison

Jonathan W. Kanter and David E. Baruch

University of Wisconsin-Milwaukee

Scott T. Gaynor

Western Michigan University

The field of clinical behavior analysis is growing rapidly and has the potential to affect and

transform mainstream cognitive behavior therapy. To have such an impact. the field must

provide a formulation of and intervention strategies for clinical depression. the "common cold"

of outpatient populations. Two treatments for depression have emerged: acceptance and

commitment therapy (ACT) and behavioral activation (BA). At times ACT and BA may suggest

largely redundant intervention strategies. However. at other times the two treatments differ

dramatically and may present opposing conceptualizations. This paper will compare and

contrast these two important treatment approaches. Then. the relevant data will be presented

and discussed. We will end with some thoughts on how and when ACT or BA should be

employed clinically in the treatment of depression.

Key words: clinical behavior analysis. depression. psychotherapy. acceptance and commitment

therapy, behavioral activation




The field of clinical behavior analysis

is growing rapidly. After beginnings

documented in this journal

(Dougher, 1993; Dougher & Hackbert,

1994) and elsewhere (Dougher,

2000), it has become an integral part

of a "third wave" of behavior therapy

(Hayes, 2004; O'Donohue, 1998)

that has the potential not only to

influence but also to transform mainstream

cognitive behavior therapy in

meaningful and permanent ways.

To have such an impact, the field

must provide a formulation of and

intervention strategies for clinical depression,

the "common cold" of outpatient

populations. The phenomenon

of depression currently is parsed

into several diagnostic categories by

the Diagnostic and Statistical Manual



of Mental Disorders (DSM-IV-TR;

American Psychiatric Association,

We thank Douglas Woods and Gregory

Schramka for helpful reviews of this manuscript.

Address correspondence to Jonathan W.

Kanter, Assistant Professor and Psychology

Clinic Coordinator, P.O. Box 413, Milwaukee,

Wisconsin 53201 (e-mail: jkanter@uwm.cdu).

2000). The most common diagnosis,

major depressive disorder, is applied

when an individual reports a combination

of feelings of sadness, loss of

interest in activities, sleep and appetite

changes, guilt and hopelessness,

fatigue or restlessness, concentration

problems, and suicidal ideation that

persist for most of the day, nearly

every day, for at least 2 weeks.

Epidemiological data from a large

representative U.S. sample indicate

a lifetime prevalence rate for major

depressive disorder of 16% (and an

annual prevalence rate of 7%), which

suggests that over 30 million Americans

will struggle with diagnosable

depression during their lifetimes

(Kessler, McGonagle, Swartz, Blazer,

& Nelson, 1993). The costs of depression

are significant, not only for

those who are suffering but also

because of the high economic burden

of depression, much of which is

attributed 10 work-related absenteeism

and lost productivity (Greenberg

et al., 2003).

Clinical behavior analysts, historically

skeptical of using the DSM as

162 JONATHAN W. KANTER et al.


the basis for understanding problem

behavior, are especially cautious to

avoid reifying a descriptive label, such

as major depressive disorder, into

a thing and using it as an explanation

for the symptoms it describes (Follette

& Houts. 1996). Instead, of greater

interest are the patterns of behavior

that lead to the label of depression

being applied and how best to characterize

and alLer these patterns to

improve lives. Toward this end, several

behavior-analytic descriptions

of depression are now available

(Dougher & Hackbert, 1994; Ferster,

1973; Kanter, Cautilli, Busch, &

Baruch, 2005). These descriptions

generally accept Skinner's (e.g., 1953)

view that emotional states, such as

depressed mood, are co-occurring

behavioral responses (elicited unconditioned

reflexes, conditioned reflexes, operant predispositions). To the extent that the various responses labeled depression appear to be integrated, it is because the behaviors are potentiated by common environmental events, occasioned by common discriminanda, or controlled by common consequences. These behavioral interpretations also recognize that depression is characterized by great variability in time course, symptom severity, and correlated conditions.

This paper will focus on two

behavior-analytic treatments for depression

that have emerged: acceptance

and commitment therapy


(ACT; Hayes. Strosahl, & Wilson,

1999) and behavioral activation (BA).

A third behavior-analytic approach,

functional analytic psychotherapy

(FAP; Kohlenberg & Tsai, 1991) has

been used to improve cognitive therapy

for depression (Kanter, Schildcrout,

& Kohlenberg, 2005; Kohlenberg,

Kanter, Bolling, Parker, & Tsai,

2002). FAP is based on a broad

functional analysis of the therapeutic

relationship (e.g., Follette, Naugle, &

Callaghan, 1996) rather than a specific

behavioral model of depression; thus

it will not be described here. Two

current variants of BA exist, BA

(Martell, Addis, & Jacobson, 2OCll)

and brief behavioral activation treatment

for depression (BATD; Lejeuz,

Hopko, & Hopko, 2001). This paper

will focus on BA rather than BATD,

because BA and BATD have recently

been compared and contrasted

(Hopko, Lejuez, Ruggiero, & Eifert,

2003). As we will show, at times ACT

and BA, at the level of function if

not technique, may suggest largely

redundant intervention strategies.

However, at other times the two

treatments differ dramatically and

may in fact present opposing conceptualizations. How, then, is a clinical

behavior analyst to choose between ACT and BA? The body of this paper will compare and contrast these two important treatment approaches. Then, the relevant data on ACT and BA for depression will be presented and discussed. We will end with some thoughts on how and when ACT or BA should be employed clinically in the treatment of depression.

Throughout this article we refer to the ACT (Hayes et al., 1999) and BA (Martell et al., 2001) manuals, although two caveats are required about our focus on manuals. First, both treatments explicitly eschew the cookbook, session-by-session approach that accurately describes some cognitive behavior therapy treatment manuals. Both BA and ACT are principle based, explicitly encouraging the use of any intervention techniques consistent with their underlying principles, whether or not the technique is described in the manual. Thus, there is some danger in comparing the two treatment manuals. We believe we have been sensitive to this danger and have tried to avoid idiosyncratic interpretations of specific techniques without reference to underlying principles. That said, at times we make use

of specific acronyms and techniques presented in the manuals for clinical use, as shorthand encapsulations of key principles.

Second, this paper is organized in

terms of key differences between the



ACT AND BA 163
two manuals. Although we describe

the purported functional impact of

these treatment techniques on client

behavior, the paper is not organized

in terms of these functional processes.

In fact, established functional relations

between specific treatment techniques

and client behaviors for both

BA and ACT largely await experimental

investigation, although much

work is underway in this regard,

particularly for ACT. We encourage

future researchers and authors to

pursue this work and develop these

analyses.

DEPRESSION AND AVOIDANCE

Both ACT and BA conceptualize

depression largely in terms of contextually

controlled avoidance repertoires.

In BA, the relevant history

and context involve direct contingencies

that have shaped and maintained

avoidance behavior through negative

reinforcement. The ACT model,

however, focuses on a verbal context

that dominates over and creates insensitivity

to direct contingencies. We will first discuss ACT’s more complex model and then turn to BA as a contrast. We note that this focus on avoidance is largely a departure from traditional behavioral models of depression that emphasized reductions in positive control rather than increases in aversive control (Lewinsohn, 1974), although Ferster (1973) did emphasize the role of avoidance in his seminal functional analysis of depression. Hayes, Wilson, Gifford, Follette, and Strosahl (1996) have provided a convincing review showing that avoidance may underlie

a host of psychological problems,

including depression, and the specific

relation between avoidance and depression

has received empirical support

as well (reviewed by Ottenbreit

& Dobson, 2004).

ACT

ACT maintains that the fundamental problem in depression is



experiential avoidance: an unwillingness

to remain in contact with

particular private experiences coupled

with attempts to escape or avoid

these experiences (Hayes & Gifford,

1997; Hayes et al., 1996). Experiential

avoidance is not an account of depression

per se; rather, it is posited as

a functional diagnostic category

(Hayes & Follette, 1992) that identifies

a psychological process key to many topographically defined diagnostic categories, including depressive disorders. As pointed out by Zettle (2005a), although the term

experiential avoidance accommodates

both escape and avoidance behavior,



experiential escape may be more

appropriate for depression in that

the depressed individual may more

likely be preoccupied with terminating

psychological events that have

already been experienced and are

currently being endured, such as

guilt, shame, and painful memories

of loss experiences. rather than those

that are anticipated and avoided. We

will use the more general term

experiential avoidance because it is

more consistent with ACT usage.

The problem, according to ACT, is not so much the initial experience of aversive private events-in ACT terminology, clean discomfort (e.g., sadness about not seeing one's children daily after separation from a

spouse)-but that one rigidly follows

rules for living that dictate experiential

avoidance as the necessary response

to such aversive private events. Thus ACT emphasizes that experiential avoidance itself is fueled by a verbal (i.e., rule-governed) process.

Such rules may take many

forms, such as "I can't stand to feel

this way," "Having feelings makes

one weak and vulnerable," or "I need

to be happy." These rules, in the

context of particular aversive private

events, may result in avoidance behavior

that also takes many forms,

such as avoiding seeing one's children

so as to not feel sad and

have thoughts of being a failure as

164 JONATHAN W. KANTER et al.


a parent, oversleeping to escape daytime stress (or undersleeping, if dreams or thoughts while in bed are aversive), overeating to combat loneliness in the evening (or undereating, if eating results in thoughts about being fat, about not having someone to eat with, etc.), rumination to avoid the anxiety that accompanies active problem solving, avoidance of challenging social situations where one

might fail (or going to the party but

passively sitting on the couch all

night), or drinking alcohol excessively to block the pain of grief.

ACT postulates a significant role

for indirect, derived verbal processes

in promoting experiential avoidance. I

For instance, many aversive private

events may be elicited indirectly.

Consider a client for whom the word


loss is in an equivalence relation with

actual painful interpersonal losses

(e.g., death of a parent or experience

with relationships ending badly due

to partner infidelity). The physical

absence of a current significant other

on a Saturday evening (for legitimate

reasons, such as a business trip)

might evoke a verbal response, as in

"He's gone," that is in an equivalence

relation with loss. When this occurs

some of the aversive functions of

actual losses may now be present

(RFT refers to this as a derived

transformation of stimulus functions),

despite the fact that this relationship has not been lost and is not in jeopardy. These aversive private events may now occasion escape behavior, such as frantic calls to the

significant other, binge eating, or

alcohol use, that may contribute to

the demise of the relationship. ACT

posits that this sort of verbal control

over behavior dominates nonverbal

I The model for ACT here is based on

relational frame theory (RFT: Hayes, Barnes-Holmes,

& Roche, 2001), description of which

is beyond the scope of this paper and which is

somewhat controversial within behavior analysis

(e.g., Burgos. 2003; Palmer. 2004; Tonneau.

2001). Our discussion presents the

model simply as described by ACT and RFT.

environmental control, perhaps due,

in this case, to historical operations

that have established losses as particularly

aversive (Dougher & Hackbert,

2000).

According to ACT, despite the fact



that such avoidance tends to maintain

and exacerbate rather than solve

problems in the long run, experiential

avoidance repertoires are maintained

because they are verbally controlled

(rule governed), are successful in the

short run, and block contact with or

create insensitivity to other contingencies

(Hayes & Ju, 1998). For

example, a client reports staying in

bed all day because she "felt depressed,"

lamenting how things

might be different tomorrow if she

feels less depressed. Staying in bed

requires lower response effort than

getting up, getting ready for work,

and going to work. Thus, a direct

escape contingency is involved, but so

too is the verbal rule specifying the

need to feel better before acting

differently. Of course, the decision

to stay in bed until she feels less

depressed also prevents contact with

other contingencies that might lead

to less depression.

BA

BA's model of depression emphasizes

nonverbal processes and appears

to be more parsimonious. The

traditional BA treatment model

viewed the overt behavioral reductions

in depression as a result of loss

of or reductions in response-contingent

positive reinforcement and

viewed the afTective components of

depression as respondent sequelae of

such losses or reductions (Dougher &

Hackbert, 1994; Ferster, 1973; Kanter,

Cautelli, Busch, & Baruch, 2005;

Lewinsohn, 1974). Current BA,

largely based on Ferster (1973),

postulates a greater role for escape

and avoidance from aversive internal

and external stimuli. Ferster further

suggested that the escape-avoidance

repertoire is largely passive, which


ACT AND BA
also leads to a decrease in positive reinforcement relative to what an active repertoire would provide.

Although the topographies of the avoidance repertoires targeted by



ACT and BA are basically the same

(e.g., oversleeping, overeating, rumination, alcohol consumption, and many others), the controlling variables and relevant history postulated are somewhat different. BA contends that aversive private events occur in response to the presentation of punishers or loss of reinforcers. The BA model recognizes that depressed individuals often tact these aversive

private experiences (i.e., emit vocal

responses that are putatively controlled

by internal stimulation), but unlike ACT, no indirect, derived (verbal) processes through which private events become aversive are

specified. Aversive private events are

thought to be elicited by contingencies

that involve loss or deprivation.

Likewise, BA posits no rule-governed

process. Avoidance of aversive

private events is evoked by the events

themselves or by their environmental

determinants or correlates. BA assumes

that direct contact with contingencies

of negative reinforcement

can initially establish and later maintain

avoidance repertoires.2 Verbal

responses are recognized, but these

are often conceptualized as part of

the avoidance repertoire (e.g., mands

2 BA holds that the stimuli that trigger

avoidance responses in depression may be

public or private. However, most of the

examples in the BA manual involve private

stimuli, and the comparison with ACT is more

compelling in terms of private stimuli, so this

will be the focus of this paper. We acknowledge

the traditional view that avoidance is

evoked by public stimuli, and private accompaniments

are correlated with the public

stimuli but are not functionally related to the

avoidance response. Neither BA nor ACT

fully endorses this traditional view; BA does

somewhat but ACT largely appears to have

rejected it in favor of the notion of experiential

avoidance, which highlights a functional relation,

established historically and contextually,

between private stimulation and avoidance

responses.

165
for succor or relief). In comparison,

ACT emphasizes how faulty rules

about the need to change or control

private events promote experiential

avoidance and decrease contact with

external environmental events.

Like ACT, BA holds that avoidance,

even when it works in the short

term, produces additional long-term

problems, because more flexible repertoires

of problem solving and

repertoires based on stable positive

reinforcement are either extinguished,

depotentiated, or never developed.

Both ACT and BA suggest the

clinically relevant problem is not the

initial (albeit aversive) private event,

but that one responds to the event

with avoidance. BA labels these

avoidance patterns secondary coping



behaviors because they are a response

to the initial aversive stimuli but

paradoxically maintain or exacerbate

the depressive episode. Developing

more proactive alternative coping

behaviors to replace these patterns

is the primary focus of BA.
Functional Assessment of Avoidance

in BA and ACT

Any behavior-analytic treatment

should start with functional assessment.

Classical functional analysis, as

in experimental demonstrations of

behavioral control, is generally considered

impossible in outpatient settings.

Nevertheless, clinical behavior

analysts perform quasifunctional

analyses of client behaviors. Given

the somewhat differing conceptualizations

of avoidance by BA and ACT, how does this translate into different assessment strategies? BA provides a structure for detailed assessment of contingencies that maintain the depressive behavior, focusing mostly, as described above, on the role of negative reinforcement in maintaining avoidance. (We note here that BATD adds an emphasis on

positive reinforcement for depressive

behavior.) In practice, functional

assessment explicitly focuses on iden-


  1. JONATHAN W. KANTER et al.

tifying and increasing awareness of

and the difficulties resulting from

avoidance patterns and events that

precede them. In ACT, the first step

is to establish creative hopelessness, in

which there is an explicit focus on

increasing awareness of the futility

of, and the faulty verbal rules that

support, experiential avoidance.

These therapeutic procedures are

not as dissimilar as they might first

appear.

In BA, therapists are taught to



engage in a simple functional assessment,

focusing on contingency-shaped

avoidance behavior. This key technique in BA clearly renders it an advance over earlier BA strategies that targeted pleasant events

and did not involve an idiographic

assessment of function (Kanter, Callaghan,

Landes, Busch, & Brown, 2004). In fact, after over 30 years of cognitive behavioral depression treatment development, behavior analysts may finally rejoice to read the following quote from the BA manual:


Behavior matters. This is the primary motto of

BA, and it is important that the therapist

accept this concept wholeheartedly if they are

10 conduct competent BA....The therapist.

regardless of the technique being used for

a specific intervention, should be asking him~

or herself. "What are the conditions occasioning

this behavior (the context) and what are

the consequences of this behavior for the client

(the function)?" (p. 106)

BA therapists teach their clients to

perform a quasifunctional analysis of

their own out-of-session behavior.

Clients specifically are taught to use

the acronym TRAP: Assess the situational

Trigger, identify one's own aversive private Response to the situation (i.e., anxiety), and finally recognize the Avoidance Pattern that

follows. For example, a TRAP of

a client seen by the first author was as

follows: trigger = meeting someone

at a social event for whom the client

had strong feelings; response

feeling anxious and overwhelmed;

avoidance pattern = not talking

about how she really feels, keeping

the conversation superficial, and

finding a way to escape the conversation

as soon as possible.

In addition to increasing awareness

of avoidance patterns, assessment in

BA also seeks to highlight the futility

of avoidance as a long-term solution

to problems. In this way, BA assessment

bears some resemblance to

ACT's creative hopelessness, which

we describe next. For example, the

BA authors describe the assessment

of a young man who had been

repeatedly driving past his lover's

house to confirm that she is at home

and not out with other men. The

authors state,

We then have a hint at the real goal. to avoid

anxiety. If this is described to the young man.

and he agrees. We have reached an important

first step.... Having learned that his goal is to

be free of the anxiety about his lover seeing

other men, we would then ask: How long does

this freedom from anxiety last? If this is truly

a solution, why must you do the same thing

over and over again? (pp. 131-132)
Repeatedly throughout treatment,

BA therapists are encouraged to

engage in such questioning, to help

their clients recognize the limited

utility, in terms of anything but

short-term negative reinforcement,

of avoidance patterns. The main

difference with ACT is that the BA

therapist has no unique conceptualization

for the role of rules or derived

transformation of stimulus functions

that maintain the problem; thus, the

assessment takes the form of traditional

verbal dialogue about functional

relations among discriminative

stimuli, avoidance behaviors, and

their consequences.

Treatment in ACT, when conducted

in its traditional order, begins

with creative hopelessness. The goal

of this stage is to "draw out the

system" In which the client is

trapped; namely, identifying how

experiential avoidance appears specifically

relevant to his or her struggles.

The "hopelessness" achieved in

creative hopelessness is experiential

ACT AND BA 167

contact with the futility of experiential

avoidance, a growing suspicion

that one's own verbal rules may be

part of the problem rather than

the solution, a confusion about what

to do next, but a sense that it will

be different and counterintuitive.

Through mostly Socratic-style questioning

(e.g., "What do you want?";

"What have you tried?"; and "How

has that worked?"), the client is

guided toward a recognition of the

unworkability of experiential avoidance.

Consider a client seen by the third

author who presented during his fifth

major depressive episode for treatment

to decrease depression and

anxiety, increase self-esteem, improve

his relationship with his wife, and

advance in his career. The initial

assessment revealed that he had tried

numerous treatment approaches including

antidepressants, inpatient

hospitalization, individual therapy,

and couples therapy. He reported

using various personal strategies,

such as deep breathing and, alternatively,

encouraging and berating himself

(trying to tell himself 10 "just let

things go," or "block things out," or

reminding himself of his positive

qualities). Despite these efforts, he

presented for treatment disgusted

with himself for being an incompetent,

unlovable failure. This client identified several verbal self-rules that appeared to promote experiential avoidance as a method for solving life's problems, including, "If you express needs then you'll be seen as an overemotional baby," "emotions can easily become over~

whelming," and "if 1 was perfect (or

at least more self-assured) everything

in my relationships would be okay."

Yet, despite this client's inhibition of

emotional expressivity, attempts to

blunt and block emotions, and moves

to verbally bolster his self-worth,

things had not gotten better. From

an ACT perspective, reviewing the

client's treatment history is an essen-

tial aspect of the assessment, because

it helps the client to make contact

with the fact that his logical and

reasonable attempts to remove depression

have not worked. The next

move is to contact the possibility that

maybe such attempts cannot work.

This is the essence of creative hopelessness.

Most ACT descriptions of how

therapists should conduct creative

hopelessness suggest highlighting the

contradiction between verbal rules

that promote experiential avoidance

and the long-term unworkability of

the accompanying behavior, rather

than simply viewing the interaction

as a functional assessment. For example,

note the following therapist

response to a chronic worrier, who is

first recognizing this discrepancy:

But maybe we are coming to a point in which

the question will be, "Which will you go with?

Your mind or your experience?" Up to now

the answer has been "your mind," but I want

you just to notice also what your experience

tells you about how well that has worked.

(Hayes et al., 1999, p. 97)
Thus, the goal in this phase is for the

client to experience the functional

consequences of avoidance behavior,

which is the same goal as functional

assessment in BA. However, because

the ACT notion of experiential

avoidance emphasizes the role of

verbal rules and derived transformation

of aversive private stimulus

functions in preventing contact with

external environmental events, this

phase does not look like traditional

assessment as in BA. Instead, the

ACT therapist takes caution not to

simply supply additional verbal rules

to describe the client's experience;

rather, the client obtains the awareness,

to the extent possible, experientially.

For an ACT therapist, extended

verbal dialogue, although necessary,

risks inadvertently reinforcing

the notion that verbal solutions to

psychological problems may be

found. As such, these verbal dialogues

are buttressed with or centered

around metaphors or experiential




  1. JONATHAN W. KANTER et al.

exercises that point to a different

"agenda." For instance, the therapist

might note that the client's situation

appears kind of like falling into

quicksand; the natural, sensible thing

to do seems to be to struggle to get

out, but that does not work in

quicksand; it only makes matters

worse.

Thus, it may be the case that ACT

identifies BA's TRAPs over the

course of treatment, but explicit

assessment in ACT, as presented to

the client, focuses on the verbal

context in which experiential avoidance

occurs. ACT clients are asked to

monitor FEAR: Fusion with your

thoughts, Evaluations of your experience,

Avoidance of your experiences,

and Reason given for your

behavior. Note the parallel placement

of avoidance in the TRAP and

FEAR acronyms and how the surrounding

letters shift the focus of

assessment from nonverbal to verbal

variables.

THERAPEUTIC GOALS

One might suggest that therapeutic

goals not only distinguish ACT from

BA but also distinguish ACT from

most, if not all, of the mainstream

medical and psychological community,

including other "third wave"

approaches. Whereas the goal in BA,

simply put, is to reduce the cluster of

responses, both public and private,

collectively labeled as depression,

ACT views efforts to directly change

private events with caution. The caution is based on a concern that these efforts might be co-opted into a generalized experiential avoidance response class. Accordingly, during creative hopelessness especially but throughout treatment, ACT therapists highlight the long-term problems associated with experiential avoidance, notably the narrowing of behavioral repertoires and decreased contact with direct experience.

If not directly reducing the aversive

private events that in part define

depression, what then is the goal in

ACT? The goal of ACT is to increase

contact with direct experience and

create more flexible, value-directed

repertoires that will persist in the

presence of previously avoided private

events, such as those labeled


depression. As told to clients, the goal

is to feel whatever is to be felt as one

commits to and engages in value-directed

behavior (Hayes et al., 1999,

p. 77). By taking this stance against

changing private events and for the

importance of aversive emotions,

ACT has positioned itself in opposition

to mainstream psychiatry and

psychopharmacology as well as cognitive

behavioral psychotherapy,

which has largely adopted the medical

model with its underlying goals

(e.g., reduction of aversive private

symptoms) and assumptions (e.g.,

"the assumption of healthy normality"; Hayes et al., 1999, p. 4).

BA explicitly rejects the medical

model of depression by viewing depression not as an illness but rather

as a direct consequence of learning

history (Jacobson & Gortner, 2000;

Martell et al., 2(01). Nevertheless,

BA authors clearly distinguish the

position of BA from that of ACT:

"Unlike other therapies involving

acceptance. however, BA considers

the experiences of people who are

depressed as experiences worth changing"

(Martell et al., 2001, p.64).

However, in line with the traditional

behavior-analytic position on

private events as causal variables

(Moore. 1980), BA argues that the

best way to achieve such reductions

in aversive private experience is

through overt behavioral activation

(working from the outside in) rather than through attempts at direct manipulation of private experience. Thus, BA clients are taught not to try to reduce private experiences

directly. In addition, even though

BA targets private experience

through overt behavioral activation,

BA by no means others the client the

possibility that aversive private ex-

ACT AND BA

periences can be completely eliminated:

"The goal should not be that

the client be free of depression, as

this cannot be guaranteed. Regardless

of how a person feels they can

engage in activities that have been

important to them" (Martell et al.,

p. 96).


In this regard, BA endorses a position

quite similar to that of ACT, because ACT acknowledges that some private events are changeable. Specifically, ACT therapists acknowledge openly to clients that the quality of private experience, when one is "fused with" and trying to control the experience (e.g., "dirty

discomfort"), is worth changing and

is changeable (Hayes et al., 1999,

p. 136), but is not changeable if one is

trying to change it. Thus, in this way,

ACT and BA arc quite similar. Both

maintain that direct attempts to

change the initial aversive private

experience are potentially problematic, but one can change one's behavioral

response to the initial experience, and this may reduce its aversive quality. ACT therapists, however, are extremely careful to avoid generating additional goals around reducing private experience and increasing rule governance. BA therapists, in contrast,

have no qualms making the point.

In closing, this section focused on

the conceptual stance taken toward

symptom reduction and how this

stance is communicated to the client.

Not yet addressed is the separate

issue of whether the therapies actually

produce symptom reduction, which

is addressed below.


ACCEPTANCE

ACT

Acceptance and interrelated processes such as defusion, mindfulness,

and willingness playa fundamental

role in ACT, and a complete array of

methods is provided in the ACT

manual to engage these processes

(see also Hayes & Wilson, 2003, for

169

discussion of how these processes are interrelated with acceptance). Indeed, their prominence is implied by the position of acceptance in the treatment's title, and the importance of acceptance cannot be overstated. Acceptance techniques are used

throughout treatment; building an acceptance repertoire is seen as an important precursor to value-guided action, which will undoubtedly necessitate the experiencing of distress along the way.

As stated colloquially in the ACT

manual, acceptance is "an active process of feeling feelings as feelings, thinking thoughts as thoughts, remembering memories as memories, and so on" (p. 77). In practice, therapists are encouraged to use the term willingness rather than acceptance because acceptance may imply tolerance or resignation, which is not consistent with the ideal acceptance repertoire, characterized by an active, committed, and nonevaluative approach to previously avoided private

events.

The targets and functions of

ACT's related defusion, acceptance,

and willingness methods vary (Hayes

& Wilson, 2003). In general, the goal

of acceptance is to increase non·

evaluative contact with previously

avoided here-and-now private events.

Because, as stated earlier, ACT posits

that aversive private events are often

verbally derived experiences, many of

the techniques involve altering derived

stimulus functions to facilitate

contact with direct experience. For

example, the milk, milk. milk defusion

technique, in which a negatively

evaluated word or phrase is quickly

repeated for several minutes, appears

to partially extinguish the word's

derived aversive functions, facilitating

acceptance (Masuda, Hayes,

Sackett, & Twohig, 2004). Such

defusion exercises promote discriminations between verbal responses to events and the events themselves and establish these verbal responses as somewhat arbitrary; thus, an

170 JONATHAN W. KANTER et al.

event's verbally derived functions that

promote experiential avoidance may

be extinguished and lead to increased

acceptance of the initial event.

Other techniques. such as the Joe the Bum metaphor, in which the

client is asked to imagine the effort

required to keep Joe the Bum from

a party rather than accepting his

unwanted presence, may be seen as

establishing operations that establish

approach functions and depotentiate

avoidance functions while minimizing

rule governance. Still other exercises.

such as the observer exercise,

a lengthy guided imagery exercise

during which the client is led to

contact a variety of private events to

experience a stable sense of self from

which private events are experienced,

may be seen, at least in part, as

exposure exercises, designed to establish

and maintain contact with a range

of private experiences, although other

interpretations certainly are possible.

ACT and RFT theorists are beginning

to explore interpretations of the functions of these techniques in RFT terminology (e.g., some interventions target contextual variables that control relational responding, whereas others target contextual cues that control the transformation of function given the occurrence of relational responding), but little has been published on this topic to date.

BA

Unlike ACT, in which acceptance

of private experience precedes and

facilitates value-guided action, BA

moves directly to overt action and

assumes that acceptance will follow.

BA therapists teach clients that if

they want to change their depression,

they must accept how they feel and

focus on changing their overt behavior.

This, in turn, will lead to change

in depression. Thus, as in ACT, the

emphasis is on the eponymous term.

in this case activation (discussed next)

rather than acceptance, but acceptance

is clearly promoted by the

treatment. Although no specific acceptance

strategies are specified (with

one exception. mindfulness. described

below), the ability to activate in the

presence of aversive private events

fundamentally entails the acceptance.

at least temporarily. of those aversive

events.


How acceptance functions in the

two treatments is somewhat different.

however. and the distinction between

ACT and BA here is clear and

cogent. In BA. as slated above. the

overall goal is reducing depression.

and the use of acceptance is strategic

in achieving that goal. BA views

depression as a natural result of

difficult life events and "therefore, it

doesn't make sense to try to fight it"

(Martell at al., 2001, p. 93). According to BA, fighting depression by

engaging in avoidance behavior paradoxically

maintains and exacerbates

the depression; thus, the focus is on

countering avoidance behavior and

building active problem-solving repertoires. As relevant to acceptance,

clients are taught to activate themselves

regardless of depressed moods:

"Clients benefit when they can act

while acknowledging that they didn't

feel like acting at the moment"

(p. 93).

In ACT, any attempt to use

acceptance strategies in the service

of reducing the primary aversive

experience of depression functionally

transforms the strategies into experiential avoidance and is to be avoided.

For example, consider a BA client

seen by the first author, who reported

being unable to stop ruminating

about problems she was having at

work. The therapist suggested a mindfulness

exercise to her, in which she goes for a walk and focuses on the physical sensations experienced. The therapist explained that it would potentially help her "to attend to the present moment" and, borrowing ACT parlance, "get some distance from the rumination machine." She then asked if the exercise would also

help her to relax and feel better.

ACT AND BA 171

Because the therapist was conducting

BA, he said that he hoped it would

help her to feel better, because

rumination makes her problems

worse (functionally, rumination is

avoidance) and this alternative might

be enjoyable (by helping her to

contact sources of positive reinforcement).

If the therapist had been

conducting ACT, he would not have

responded with such a reassurance.

Instead, he might have asked her if,

by hoping the exercise would help her

feel better, she was again engaging in

an old emotional control agenda, or

gently asked her if she would like to

repeat the thought "this exercise will

help me feel better" for several

minutes to see what happens to its

functions.


ACTIVATION

BA

In BA, activating clients is the focus of therapy, and the treatment uses the full arsenal of behavioral techniques to achieve behavioral activation, including scheduling behavioral activities, graded homework

assignments, in-session rehearsal and

role playing of targeted behaviors,

therapist modeling of targeted behaviors,

managing situational contingencies

to make initiation and successful

completion of targeted behavior

more likely, problem solving 10 identify specific behavioral targets as solutions to specific problems, and training to overcome skills deficits that interfere with initiation and

maintenance of targeted behaviors.

As mentioned above, the key distinction

between current BA and earlier

forms of behavioral activation for

depression (Hammen & Glass. 1975;

Lewinsohn, 1974: Lewinsohn, Biglan,

& Zeiss, 1976; Lewinsohn & Graf,

1973; Lewinsohn & Libet, 1972) is

that activation is not focused on

increasing pleasant activities per se,

but is targeted toward specific areas

of passivity and avoidance that have

been identified idiographically. Once

target behaviors are identified, attempts

to block avoidance and activate

these alternate behaviors are

also monitored with an eye towards

function. In addition to using the

TRAP acronym to identify avoidance,

clients are taught to "get out of

TRAPs and get on TRAC" by

replacing Avoidance Patterns with

Alternate Coping behaviors.

In addition, clients are taught to

use the acronym ACTION to monitor

ongoing avoidance patterns and

implement changes: Assess how this

behavior serves you, Choose either to

avoid or activate, Try out whatever

behavior has been chosen, Integrate

any new behaviors into a routine,

Observe the outcome, and Never

give up. Note how this acronym

encourages clients to adopt a functional--

experimental approach to evaluating their behavior-to develop

hypotheses about the function of

various behaviors, take action, and

observe the consequences. Taking

such an approach might lead clients

to become better able to describe the

antecedent and consequential stimuli

that control their behavior (i.e., increased

self-awareness) and lead to

the development of accurate verbal

rules (i.e., tracks), which might facilitate

maintenance of treatment gains.

Finally, by ending with "Never give

up," BA attempts to encourage the

persistence of behavior in the face of

obstacles. Pursuit of goal-directed

activity in the face of obstacles is

also emphasized in ACT's values

work, a topic we discuss next.

ACT

ACT includes behavioral activation

as well, but focuses instead on

values and commitment, again emphasizing

verbal over nonverbal processes.

According to ACT, in addition

to a functioning acceptance

repertoire, a set of clearly defined

values and associated goals are essential

prerequisites for guiding activation.

Values, defined in ACT as

172 JONATHAN W. KANTER et al.

"verbally construed global desired

life consequences" (Hayes et al.,

1999, p. 206), may be seen as self-rules

(specifically augmentals) that

strategically take advantage of the

insensitivity to contingencies generated by rule-governed behavior. By

helping clients to identify, create,

and clarify values, and then to make

a verbal commitment to activation in

the service of those values, the ACT

therapist, after having spent much of

treatment dismantling and distancing

from verbal rules that promote emotional

control and derived transformation

of stimulus functions that

support experiential avoidance, now

utilizes these processes in an attempt

to generate high-strength response

classes that will persist in the face of

avoidance contingencies. The difference

is that the focal response classes

consist of overt approach behaviors,

rather than responses that temporarily

terminate or preempt private

events. Indeed, engaging in these

value-directed approach behaviors

often elicits and evokes the very

private events that were previously

avoided-hence, the initial focus on

developing a functioning acceptance

repertoire prior to making a commitment

to behave toward personal

values.

Thus, values take priority over



activation per se in ACT. Like acceptance in BA, activation in ACT is implied and stated as important, but no activation strategies are specified. Instead, the manual (Hayes et al., 1999) states that, as treatment culminates,
ACT takes on the character of traditional

behavior therapy, and virtually any behavior

change technique is acceptable. The difference

is that behavior change goals, guided exposure,

social skills training, modeling, role

playing, couples work, and so on. are integrated

with an ACT perspective. Behavior

change is a kind of willingness exercise,linked

to chosen values. The integration of traditional

behavior therapy and ACT in this phase is

an important topic, but is well beyond the

scope of this book. (p. 258)

As an illustration, consider again

the male client with a history of multiple

depressive episodes described earlier.

One value of his was to be a good

husband, with one specific goal being

to improve his communication with

his wife. Pursuit of this goal necessitated

articulating his needs and feelings

to his wife and apologizing for

and making a commitment to discontinue

certain relationship-weakening

behaviors (e.g., he had previously

belittled his wife as a way of terminating

feelings of vulnerability when

his wife tried to talk to him about

their relationship). Engaging in these

value-directed responses required

that he persist in the face of feelings

of self-doubt and vulnerability and

thoughts that he was an "overemotional

baby" who was unlovable. Not

surprisingly, when he did this his wife

reported experiencing him as more

open, available, and not so closed off,

and both reported increased closeness,

understanding, and positive

contact in the relationship.

In some ways ACT and BA are

similar in that both view simple scheduling of pleasant events as meaningless if it is attempted independent of a larger assessment that delineates idiographic areas of activation.

BA addresses this limitation

and even discusses goals somewhat,

but does not match ACT's technical

or theoretical sophistication with respect

to values, their behavioral

operationalizations, and their role in

therapy. On a case-by-case basis,

however, behavioral activation in

BA and value-guided action in ACT

may look identical, especially for

clients who may already have clear

and well-defined values and may not

need the additional values work

conducted in ACT.

Consider the example immediately

above and how the intervention

could have been conducted from the



TRAP/TRAC and ACTION framework

with the value only implied:

The trigger (T) could have been

a previous discussion initiated by his


ACT AND BA 173
wife about their relationship; the

responses (R) would have been his

feelings of vulnerability, self-doubt,

and negative self-thoughts; the avoidance

patterns (AP) would have been

&.bal he belittled his wife and shut

down as a way of escaping the

feelings: and the alternative coping

(AC) would have been that instead he

initiates the discussion himself, articulates

his needs and feelings during

the discussion, and apologizes for his

past behavior. According to ACTION.

he would have assessed (A)

that his belittling her and shutting

down was making his marriage

worst, chosen (C) instead to activate,

tried out (T) the new behaviors of

discussing feelings and apologizing,

committed to engaging in these behaviors

regularly, thereby integrating

(I) them into a routine, observed (0)

that his wife responded positively to

the new behaviors, and reminded

himself to never give up (N) if and

when she does not respond positively.

An acronym comparison again

summarizes the similarities and differences.

Whereas BA encourages

ACTION, ACT more simply encourages

clients to ACT: Accept your

reactions and be present, Choose

a valued direction, and Take action.

Note that both emphasize choice (but

ACT expands considerably on what

is to be chosen, i.e., values), and both

encourage behavior change in the

form of action. BA's acronym additionally

encourages functional assessment,

now in the context of activation

(the A and 0), whereas ACT's

ACT does not encourage functional

assessment but simply focuses on

acceptance in addition to choosing

values and taking action.

CASE EXAMPLES

To illustrate the similarities and

differences between ACT and BA, we

present two case examples, adapted

from existing writings on ACT and

BA.
ACT

The following ACT case was

adapted from Dougher and Hackbert

(1994, pp. 330-333). The client was

a 23-year-old depressed female college

student, and the treatment goal

was "to help the client achieve

acceptance of her private events while

pursuing those activities and goals

she identified as being important." In

this session (Session 8), the client is

talking about her reaction to a fight

with her nonexclusive boyfriend:


C: We had a fight, and he left, I felt so

angry, so bad. I just couldn't, didn't want

to go through with it. I started to get

really down. I just wanted to get drunk.

... I started to drink, but I'm not much of

a drinker, and when I did, it seemed like

just drinking made me think about it

more.

T: Like trying not to think of pink elephants

makes you think of pink elephants more.

That's true of everything you do to stop

thinking of something or trying not to

have a feeling. It just makes it worse.

C: So, what do you do?

T: Don't try not to have feelings. Have them.

C: Does that work? Will the feelings go away?

T: No, but at least you're not doing anything

to make them worse.

C: Well, how do you get rid of the feelings?

T: You don't. You can'\.

C: What do you do about them?

T: Have them. You want to do something

you can't do. You want not to have

thoughts and feelings. But that can't

happen. you know. You're alive and

they're part of you.

In this transcript, the ACT therapist

clearly goes after the consequences of

experiential avoidance ("it just makes

things worse") and introduces acceptance

as an alternative. An ACT therapist might also introduce a metaphor here to try to move beyond

a literal discussion, Notice also that the therapist did not just go after the link between private events and escape or avoidance, which a BA

therapist might also do, but also

highlighted the verbal rules that

support experiential avoidance-that

feelings should be terminated. There

is little focus on the trigger (the

argument) or, at this point, on

174 JONATHAN W. KANTER et al.
alternative coping behaviors. As values

work has yet to occur at this stage

of ACT, alternative behaviors, other

than acceptance, have yet to be

delineated. A BA therapist might

downplay acceptance here, instead

introducing TRAP and TRAC as

a way to assess the specific situation

and develop alternative coping strategies

that subsume acceptance.

In the following transcript, which

occurs later in therapy (Session 17),

the work has focused on value-guided

activation, and it becomes more

difficult to distinguish between ACT

and BA. In this segment, the client is

talking about a dale with a guy she

met in one of her classes.


C: [Before the date) I was really, uh, starting

to gel nervous and, uh, thinking that, uh,

that it was a mistake to have agreed to go

out with him. I don't know why I was.

you know, so nervous. I have no

confidence. Anyway, I started thinking

about accepting the feelings and the stuff

we talked about, you know, and just got

ready.

T: So you went out?

C: Yeah, and it was pretty good. But the

whole time, I'm like telling myself he

hates me. why am I doing this? What's

the point? You know. But it was good.


Note that the client describes the

problem in terms of anxiety and

a litany of depressotypic thoughts,

defusion from which seems to be part

of a functioning acceptance repertoire

that she has acquired over the course of therapy. This appears to depotentiate the escape response and allows her to go on and enjoy the date. A BA client would be more likely to describe the problem in terms of avoidance and rumination, and the need to stay active in the presence of such feeling and thinking patterns. But the key outcome-engagement in value-directed behavior (activation)-is the same.

At the end of therapy, the client

had terminated the nonexclusive relationship

and was considering taking a job in Washington D.C, a move

consistent with her educational training

and values. In addition, "the

client's depression clearly lifted, although

her affective state was hardly

discussed after the first few weeks of

treatment, and it was never an

explicit goal of therapy" (p. 333).

BA

The BA case was adapted from

Martell et al. (2001, pp. 159-173).

The client was a 21·year·old depressed

female employed as a technician, and the treatment goal was

"teaching her to be more proactive

in order to increase the likelihood

that her behavior could be positively

reinforced." This first transcript is

from Session 4, when the client

described attending a holiday gathering

at her boyfriend's house and

observed his family's happiness and

started thinking about how unhappy

her own family was, which made her

feel sad and lonely.

T: When you were with [his] family and you

started to think about how nice his family

is and how not-so-nice your own is, do

you think you started to disengage a little

bit?

C: [nods in agreement]



T: Did thinking a lot about your own family

ultimately end up with you missing out

on enjoying a good time?

C: Yes. in these situations I'll sit back and

not talk.... And, I'll want to leave.

T: Did you leave?

C: Yes, because of that. and because we were

both tired.

T: You've become very good at avoiding

negative things or getting out of negative

situations-you may not be as good at

getting into more positive situations.

You get into a TRAP. This stands for

Trigger, which, in this case, is your

partner's nice family: Response, which.

in this case, is feeling lousy and lousy

about your own family: and Avoidance-Pattern.

which is when you say you start

wanting to leave the situation... , So the

way to get out of the trap is to use

alternate coping, do something different.

Maybe staying a little longer even though

you feel like leaving, looking around the

room to sec who wore red on Christmas,

or better yet. trying to engage someone in

an interesting conversation. anything

other than sitting and dwelling.
ACT AND BA 175

Here, the therapist clearly goes after

activation. introducing TRAPs and

TRACs. There is no explicit focus on

acceptance (or acceptance-enhancing

techniques) that might be relevant to

the negative thoughts and feelings.

Instead, there is more focus on the

consequences of her passive repertoire

and the possibility of an alternate

repertoire. There is an implied

rule offered: Do anything other than

sitting and ruminating. An ACT

therapist might first implement acceptance

strategies directed toward the private events that preoccupied the client (i.e., the ruminative

thoughts and negative feelings) and willingness to have those thoughts and feelings while choosing not to sit back. The BA therapist went directly after the new behavior and would

likely suggest that the negative private

events will dissipate when an

interesting conversation is achieved.

Notice also how the BA therapist

encourages mindful attending to the

moment during any activation attempt.

which is hinted at in the

comment about seeing how many

people are wearing red.

Later in therapy (Session 16), the

client has been generating ideas for

finding a new job and dealing with

dental problems, but has not been

active in implementing strategies.

T: It seems 10 me that we can look at any of

these life situations as a "trigger." Even

coming 10 therapy and needing to set an

agenda [for the session) is a trigger. Your

response is ... what would you say your

response is?

C: I don't know, .. hopeless.

T: Okay, so you feel hopeless. What do you do?

C: Well, you're telling me I don't do anything.

T: I'm not exactly saying that you don't do

anything. I've seen you work pretty hard

during our therapy. What I am saying is

that your general style is to get very

passive and just complain about problems

but wait until something happens

apart from you that will fix the situation.

Would you agree?

C: Yes, I guess so.

T: So that is your "avoidance pattern" when

it comes 10 these things, So what could


get you back on TRAC, with an alternative

way to cope?

C: Do it no matter how I feel.

T: I think that might be worth a try, so how

can you plan that for this upcoming

week?


C: Well. I need to keep looking for a job,

and I need to gel back 10 see a dentist.

T: Can you write some of these things on an

activity chart and commit to times in the

next few days when you'll do them?

This interaction represents typical

BA-a situational analysis that identifies

avoidance and instruction to

activate instead, The client endorses

feeling hopeless, but, time is not spent

on accepting the feeling and then

acting in the face of it, as might

occur in ACT; the therapist moves

directly to action. Acceptance is

a potential by-product of the goal-directed

action, but there is no deliberate

attempt to foster acceptance,

nor is there a focus on language or

concern about language use that

dictates use of metaphors and experiential

exercises rather than straightforward

talk.

Subsequently the client saw a dentist


(and was prescribed antibiotics)

and interviewed for and accepted

a new job. At the termination session,

the client reported the most important

aspect of therapy was learning to

be active, no matter what she was

feeling.
C: I know that I need to schedule things and

just stick to the schedule, and I'll feel

better, even when I am feeling lousy.

T: So the activity charts have been helpful?

C: Yes, and recognizing when I avoid things.

I know that I just need to keep facing

things, because when I avoid them they

just get worse.


Note that the client clearly endorses

the activation-instead-of-avoidance

rationale. Some acceptance is implied

("I just need to keep facing things"),

but it is a means to another end - feeling

better.
TREATMENT EFFICACY

The history of treatment outcome

studies for BA is a true success story

176 JONATHAN W. KANTER et al.

for behavior analysis. Early research

on Lewinsohn's (1974) original pleasant

events scheduling (PES) was

mixed at best (Blaney, 1981). After

a quiescent period in which PES was

subsumed within larger cognitive

behavioral treatment packages (e.g.,

Lewinsohn's "coping with depression"

and Beck's cognitive therapy,

Beck, Rush, Shaw, & Emery, 1979),

Jacobson et al. (1996) revived interest

in BA with a component analysis of

cognitive therapy. This large study

(152 clients) compared the BA component

of cognitive therapy, BA plus

a partial package of cognitive therapy

targeting automatic thoughts, and

the full cognitive therapy package.

Results suggested that a behavioral

approach to depressive symptoms

was as effective as both cognitive

therapy conditions. There were no

differences in outcome effectiveness

at the end of treatment, despite a large

sample, excellent adherence and competence

by multiple therapists in all conditions, and a clear bias by the study therapists favoring cognitive therapy. More important, these findings were maintained when evaluated

at a 2-year follow-up (Gortner, GolIan,

Dobson, & Jacobson, 1998).

This study sparked the development

of both BATO (see Hopko, Lejuez, LePage, Hopko, & McNeil, 2003; Lejuez, Hopko, & Hopko, 2001; Lejuez, Hopko, LePage, Hopko, & McNeil, 2001) and current BA. A recent randomized trial compared current BA to cognitive therapy, paroxetine, and placebo (Dimidjian et al., in press). Subjects (N = 241)

were randomly assigned, stratified by depression severity, 10 one of the four conditions. At posttreatment, there were no differences between the three active groups for mildly depressed participants. However, BA and medication outperformed cognitive therapy with moderately to severely depressed

participants. Although there

were no differences between BA

and paroxetine, BA had a significantly lower attrition rate. Thus,


BA demonstrated an advantage over

pharmacological treatment by retaining

more clients and matching its

effectiveness without risk for physiological

side effects. Jacobson et al.

(1996) suggested that cognitive therapy's

version of BA performed as well

as full cognitive therapy, but Dimidjian

et al. (in press) offer evidence that

current BA may be a more efficacious

treatment for more severely depressed

clients. However, it should be noted

that in another recently completed

large-scale randomized clinical trial,

cognitive therapy did as well as

a selective serotonin reuptake inhibitor

at post-treatment (DeRubeis et al.,

2005) and was better at preventing

relapse (Hollon et al., 2005).

Two smaller studies on depression

have been conducted using the original version of ACT, called comprehensive distancing (Zettle & Hayes, 1986; Zettle & Rains, 1989). Before we discuss studies that examine comprehensive distancing, it is important to

distinguish it from ACT. Comprehensive

distancing included many features

of ACT. However, it differed in that

creative hopelessness played a relatively

smaller role and, more important,

BA (specifically, PES) was incorporated

towards the end of treatment

rather than the current focus on

values (Zettle, 2005b; Zettle & Hayes,

1989). Lnterestingly, incorporation of

PES included its underlying focus on

reducing depressed feelings, as described

in the comprehensive distancing

manual (Zettle & Hayes, 1989)

used by Zettle and Rains;

One approach which has shown a great deal of

promise in helping individuals like yourself to



feel less depressed [italics added] is to encourage

you to maintain a high activity level,

particularly in doing things you normally

enjoy. Actually what we've focused on so far

in allowing you to avoid getting caught up in

your own thoughts and feelings should free you

up so you’ll have more time and energy to devote

to enjoyable activities [italics added]. (p. 22)
Thus, comprehensive distancing may

be described as a substantial extension

of PES that focused first

ACT AND BA 177

on dismantling the verbal context

that supports experiential avoidance

before engaging in PES. As comprehensive distancing evolved into ACT,

PES and its attached rationale were

replaced by values work, and the

treatment became more consistent.

Zettle and Hayes (1986) compared

duet treatments: comprehensive distancing,

cognitive therapy without

distancing techniques, and full cognitive:

therapy. Eighteen women were

randomly assigned to one of the three

groups, and all clients were treated by

the first author. Despite including

a partial cognitive therapy package to

determine the specific role of distanc109

in cognitive therapy, both cognitive therapy groups were combined

for analysis. Clients treated with

comprehensive distancing reported

significantly less believability of

thoughts at posttreatment and significantly less depression at a 2-month follow-up compared to clients in the aggregate cognitive therapy condition (see also Zettle & Hayes, 1987).

This study was followed by a comparison of comprehensive distancing

and cognitive therapy in a group

therapy setting (Zettle & Rains,

1989). Forty-five women participated

and, similar to Zettle and Hayes

(986), three treatment conditions

were included: comprehensive distancing, cognitive therapy without

distancing, and full cognitive therapy;

all groups were led by the first

author. Unlike the previous study,

however, the cognitive therapy

groups were not aggregated for analysis. All groups demonstrated significant decreases in depression, but no differences in treatment efficacy were found at either posttreatment or 2-month follow-up.

Thus, taken together, there is a small data set suggesting that an early and approximate version of ACT tested better than cognitive therapy when administered individually and a comparatively larger study

that reported no significant differences when conducted in a group

selling. All clients in both studies

were women, and all were treated by

Robert Zettle; thus generalizations to

men and to other therapists less

connected with the development of

the treatment remain unresolved issues. With regards to ACT, to date

there is no randomized outcome research published that has examined

its efficacy with respect to depressive

clients. Thus, it seems that BA clearly

holds an advantage over ACT in

terms of published efficacy for the

treatment of depression. However,

several trials of both ACT and BA

for depression (including large-scale

efficacy trials of BA adapted for

primary-care settings) are underway

or have not yet been published, and

we expect the database to grow

considerably for both treatments over

the next few years. Unfortunately not

much of this research will be behavior analytic. 3

That said, it must also be stated

that ACT holds an advantage over

BA in terms of several other mental

health problems. ACT has been

tested for workplace stress management, psychotic symptoms, mathematics anxiety, polysubstance-abusing opiate addicts, chronic smokers, and social anxiety (reviewed in Hayes et al., 2006; Hayes, Masuda, Bissett,

Luoma, & Guerrero, 2004). Several

of these studies have included measures of depression. An ACT-based

group intervention decreased depression for self-harming clients who had

been diagnosed with borderline personality disorder compared to a treatment-as-usual control (Gratz & Gunderson, In press). Chronic pain patients, acting as their own controls and receiving ACT-consistent interventions, demonstrated reduced levels of depression that were maintained at a 3-month follow-up

_______________________________________

J Readers may also want to consider research

on process mediators of outcome in

comprehensive distancing (Hayes, Luoma,

Bond, Masuda, & Lillis, 2006; Zettle & Hayes,

1986; Zettle & Rains, 1989) and BA (Jacobson

et al., 1996).

178 JONATHAN W. KANTER et al.
(McCracken, Vowles, & Eccleston,

2(05). A multiple baseline within-subject

design demonstrated reductions

in depression among obsessive-compulsive

clients (Twohig, Hayes. &

Masuda, in press). Finally, a noncontrolled

study reported similar reductions

in depression among parents of

children who had been diagnosed

with autism given ACT-based group

support (Blackledge & Hayes, in

press). BA, in turn, has been studied

as a treatment for posttraumatic

stress disorder in a case study (Mulick

& Naugle, 2004) and a smallgroup

design (Jakupak et al., in

press).

SUMMARYAND

TREATMENT IMPLICATIONS

In addition to the text below,

Table 1 provides a brief synopsis of

the similarities and differences between

ACT and BA outlined in this

paper. (Cognitive therapy, although

not the focus of this paper, is included

as an additional point of reference

because it is the psychosocial treatment

for depression that has the

largest empirical database.) In BA,

clients are told, "Activate and you

will feel better" and are provided with

instructions for how to do so. Initial

compliance with these rules will hopefully

lead to stable contact with

positive, natural reinforcement,

which should then maintain the behavior

and the rule following. According

to the taxonomy of rule following described by Hayes (Hayes et al., 1999; Hayes & Ju, 1998), rule following in BA moves from pliance (rule following because of socially mediated consequences) and ineffective tracking (following because of a correspondence between the rule and the natural consequences---in BA's conceptualization of depression, the natural consequence being avoidance or escape) to more effective

tracking (following a rule because,

more often than not, it successfully

leads to positive reinforcement). The

desired outcome is for the specific

tracks (e.g., as identified in the

TRAP/TRAC analyses) to become

largely contingency governed as natural

consequences are contacted,

thus, also supporting the general rule

(i.e., "To feel better activate using

TRAP/TRAC analyses"). It is hoped

that this result will be prophylactic

against future depression.

From an ACT perspective, there is

potential concern that strengthening

such rule following might unwittingly

contribute to a generalized response

class of following verbal rules that

specify emotional control. Accordingly,

across the full duration of

therapy, ACT seeks to weaken attempts

at verbal control of private

events; this includes eliminating

changing private events as an explicit

goal of treatment. The purpose of

ACT is similar to that of BA in that

clients should make contact with

contingencies in their current environment.

The hope is that, when

attempts to control private events

are suspended and values are clearly

discriminated, (a) engagement in

overt behavior, as specified in rules

derived from values, will be potentiated

(augmenting), and (b) the client

will be more sensitive to the direct

consequences of this behavior, such

that (c) rules that are formed will be

more accurate and adaptive (tracking).

Thus, ACT differs from BA on

theoretical grounds for three reasons.

First, as stated earlier, BA can be

seen as reinforcing verbal processes

that support the control of aversive

private events. Second, according to

ACT, verbally controlled behavior

leads to insensitivity to changes in

schedules of reinforcement and may

reduce the value of reinforcers. That

is, the same way that values may act

as augmentals that increase the

strength of reinforcers, an avoidance-

control agenda may act as an

augmental that reduces the value of

reinforcers that are associated with

the occurrence of negative private


ACT AND BA 179
TABLE I: A summary of the similarities and differences among behavioral activation, acceptance and commitment therapy, and cognitive therapy

Therapist

conceptual

stancea

Therapist

verbal


behavior to

c1ienta

Symptom change
Comparative Efficacy




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