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



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Behavioral activation

Feelings of sadness can be changed and changed most effectively by changing behavior.

Hypothesized mechanism of action is direct reinforcement contingent on behavior scheduled for activation.


We are going to try and change how you are feeling by working from the outside in because this is where we are likely to have the greatest amount of success.


Decreases depressive symptoms.

Has done as well as or better than the full cognitive therapy package (that includes activation) in two large randomized clinical trials. These findings support activation as sufficient treatment.

Acceptance and commitment

Therapy
Working toward a goal of changing sad feelings may further the emotional control agenda and rigid rule governance that fuel experiential avoidance, the primary barrier to living a values-based life. The therapist works to diminish the verbal link between feeling better and living better, with a decrease in experiential avoidance as the proposed mechanism of action (i.e., an experiential avoidance mediational model).
Attempts to change sadness have not worked for you. A new strategy is needed. Willingness is an alternative; are you willing to have sadness and go where you choose to go in life? If you do so your sadness may decrease, but there is no guarantee, it may not.

Decreases depressive

symptoms.

As comprehensive distancing,

was equal to or better than

cognitive therapy in two

modest clinical trials.

Several other studies

provide additional support.

Cognitive therapy

Sad feelings can be

changed and changed

most effectively by

changing the client's

thoughts. The therapist

works from the inside

out, with a change in the

content of thoughts (or

schemas) as the proposed mechanism of

action (i.e., u cognitive

mediational model).

How you appraise a situation is critical to how you feel and act. Negative thinking leads to negative mood states and maladaptive behaviors. We are going to try and change how you are feeling by changing how you think about and interpret situations.


Decreases depressive

symptoms.

Efficacy supported in

several large randomized clinical trials. The necessity of cognitive techniques called into question by BA findings.




aFor simplicity we focus on sadness, the cardinal symptom of depression and a clear aversive

private event, to best highlight similarities und differences in these domains.

_____________________________________________________________________________________________________


events (e.g., when a client reports

having had a positive social encounter

but indicates that it was "a

failure" because he did not feel happy

as it occurred or afterward). In other

words, verbal processes may prevent

and disrupt contact with environmental

contingencies that BA suggests

will reinforce and maintain
behaviors alternative to avoidance.

Third, even when environmental contingencies

that support active and

goal-directed behavior are contacted,

ACT would consider such contact to

be limited and risk for relapse substantial

as long as underlying verbal

processes that support experiential

avoidance are not addressed. Even


180 JONATHAN W. KANTER et al.

an active and goal-directed life will still inevitably supply aversive private experiences that will trigger experiential avoidance.

among the treatments. The need for

additional data addressing the active



For this reason, ACT permits the success of activation and exposure treatments but only to a degree. For example, a young college student who strictly follows the rule, "If I avoid emotional expression, then I

will not be humiliated, which is

good," may find himself in a specific

social situation in which emotional

expression is encouraged and supported.

Eventually, the person may

learn to disclose emotions in this

setting. From an ACT perspective,

a new rule has not been established;

rather, the old rule has been elaborated

into "If I avoid emotional expression, then I will not be humiliated, which is good but since Situation A will not bring humiliation I can express emotion." According to ACT, this may be what BA achieves. This appears to be at least a half step forward from an ACT perspective, in that this rule is less rigid and inflexible than the original, consistent with the ACT notion that experiential avoidance becomes especially problematic when it results in significantly reduced behavioral flexibility

(i.e., large portions of the client's repertoire are centered around it). However, this half step forward might lead to a full step backward if the underlying control agenda has simply been reinforced and not weakened. In other words, risk for relapse might be higher. This conceptual concern is not supported by the

available long-term follow-up data

on BA (or cognitive therapy for that

matter), which suggest that changes

are relatively robust. It is not entirely

clear at the present time how ACT

would conceptually account for the

positive and persisting effects of BA

and cognitive therapy, but BA can

conceptually account for the effects

of ACT, cognitive therapy, and BA

by emphasizing the sufficiency of

activation, the common thread

ingredients of change in these treatments is apparent.

The preceding paragraph also

prompts questioning whether ACT's additional verbal strategies are necessary. Efficacy data based on group designs aside, theoretically the

choice to use BA or ACT for a depressed client may rest on the role of verbal behavior in a client's problems. Unfortunately, technologies for the assessment of the role of derived stimulus relations and control by verbal rules in individual cases do not yet exist (see Hayes & Follette, 1992, for a full discussion of this

issue). ACT authors frequently highlight

the apparent ubiquity of verbal behavior (e.g., "Humans swim in a sea of talking, listening, planning, and reasoning," Hayes, Blackledge,

& Barnes-Holmes, 2001, p. 3) as justification for ACT's use, but such broad generalizations are difficult to support empirically. Indeed, a basic premise of behavior analysis has been

that most controlling variables are

not globally applicable, should be

determined experimentally, and are

not to be assumed from common

sense and experience. Furthermore,

another premise has been that a particular

focus on verbal behavior and

other private events, although they

seem causal from the perspective of

common sense, may in fact detract

from a proper functional assessment

of environmental variables (e.g.,

Skinner, 1953).

There is certainly solid experimental

support for many of the basic

processes (rule-governed behavior,

derived stimulus relations, transformation

of stimulus functions) invoked

by ACT and described by

RFT (Hayes, Barnes-Holmes, &

Roche, 200 1), and this support is

growing. Nonetheless, RFT research

preparations do not successfully address

the ubiquity of verbal behavior,

the question of whether a particular

client problem is best conceptualized

ACT AND BA 181


as verbal, or the question of whether

a particular overt behavioral stream

is functionally connected to the private

verbal behavioral stream that

preceded it. RFT theorists acknowledge

the difficulty determining whether

nonverbal behavior is verbally

mediated or contingency shaped on

a behavior-by-behavior basis (Hayes.

Gifford, Townsend, & Barnes·

Holmes, 2001); only a full documentation of the relevant histories involved

will reveal the actual sources

of control, and of course the distinction

is somewhat arbitrary, in that

most clinically relevant behavior is

multiply controlled.

Given multiple sources of control,

it may be more appropriate to take

a pragmatic stance and ask if targeting

verbal variables over other variables

will lead to enhanced outcomes

for particular clients. Unfortunately.

there is little research to guide this line

of questioning. The problem is compounded

by the repeated finding

that most cognitive and behavioral

treatments for depression appear

to perform equivalently (Gloaguen,

Conraux, Cucherat, & Blackburn,

1998), and considerable evidence exists

to support the notion that nonspecific

factors (i.e., provision of a clear treatment rationale with a set of associated techniques offered in the context of a solid therapeutic relationship) are more important in

treatment than are specific differences

as discussed in this article (Ilardi &

Craighead, 1994).

Addis and Jacobson (1996) provide

some potentially relevant information

about clients for whom BA mayor may not work. Examining the data from the component analysis of cognitive therapy (Jacobson et al.,

1996), they found that outcome in BA was positively correlated with client response to the BA rationale and early activation assignments, suggesting the importance of events that happen early in treatment. In addition. clients who endorsed more reasons for depression (assessed with

the Reasons for Depression self-report

questionnaire by Addis, Truax,

& Jacobson, 1996), especially reasons

that pointed to depression as a character

trait or depression in response

to existential issues, tended to have

poorer outcomes in BA.

Extrapolating from these data, it

might be suggested that clients receive


ACT if they present with high

experiential avoidance4 and many

reasons for depression, especially

reasons that place the cause of depression

in characterological or existential

domains, because ACT directly

targets verbal reason giving

(with cognitive defusion strategies)

and existential issues (with values

identification and clarification). In

addition to using self-report questionnaires,

we suggest that the clinician perform some informal assessment to identify the level of fusion with evaluating thoughts and conceptual categories, the level of experiential

avoidance (core unacceptable

emotions, thoughts, memories, etc.;

what are the consequences of having

such experiences that the client is

unwilling to risk) versus overt behavioral

avoidance, and the level of identified values and value-directed behavior. This recommendation may point toward ACT with potentially more difficult clients (those with high fusion, high experiential avoidance,

and low values), but this simple

heuristic is contradicted by BA's

recently demonstrated success with

severely depressed rather than mildly

depressed individuals (Dimidjian et

al., in press).

These recommendations are almost

entirely based on theory, group design

research. and correlations between

questionnaires. Single-case de-

_______________________________________ 4Because the most well-used measure: or

ACT processes. the Acceptance and Action

Questionnaire (Hayes, Strosahl, et al., 2004).

has been defined not only as a measure or

experiential avoidance but as a broad measure

of multiple ACT processes, the development

or more specific measures of experiential

avoidance per se may be fruitful.

182 JONATHAN W. KANTER et al.
signs are sorely needed in this area.

Neither ACT nor BA has provided

much of these data for depression

(but see Twohig, Hayes, & Masuda,

in press). Furthermore, neither have

provided much in the form of component

analyses, to determine which

of their multiple treatment techniques

or components are empirically justifiable,

when to employ them, and for

which client problems. Lastly, there is

little research guidance on how to

conduct functional assessments of the

relevant verbal and nonverbal variables

that would guide case conceptualization.

Thus, the choice to use ACT or BA, for now, may ultimately rely on clinician preference and familiarity, or perhaps clinician values,

and the dangers of relying on clinical

judgment are clear (Dawes, 1994;

Dawes, Faust, & Meehl, 1989; Tversky & Kahneman, 1974). This is a somewhat sad state of affairs, but by no means are ACT or BA treatment developers to blame; the

field of behavior analysis as a whole

has not addressed the particulars of

treatment for outpatient depression.

Assuming a lack of a clear rationale

for applying either therapy,

starting treatments for depression

with BA may be justifiable for a few

reasons. First, conservatively speaking,

the recent, large, and well-designed

BA studies lend it clear

empirical support as traditionally defined

(although the accumulation of

ACT evidence from a variety of

sources is compelling). Second,

whereas both ACT and BA have

been formatted as relatively short-term

treatments (e.g., 16 to 20 sessions), because the theoretical rationale and treatment procedures for BA are both less complex than ACT, it would be expected that it would be

easier to train and conduct BA

(although such a supposition has yet

to be empirically tested). Third,

practically speaking, it would appear

to be far easier and even productive

to switch from a BA to an ACT

rationale than vice versa. That is, if

BA is ineffective, the failure of these

early attempts to activate without

addressing the internal change agenda

(and its supporting verbal context)

are ripe material for creative hopelessness.

In fact, as per functional

analytic psychotherapy (Kohlenberg

& Tsai, 1991), because these failures

occurred during therapy they may

make creative hopelessness even more

powerful than otherwise. Again, however,

we have no data suggesting the

utility of ACT with BA treatment

failures.

It may be the case that BA is more

appropriate, not for easier (less depressed)

clients, but for clients with

simpler goals; namely, to feel better.

For example, it is probably easier to

conduct BA in the context of other

symptom-reduction approaches (e.g.,

medications). Of course, one can use

ACT with clients on medications, but

the rationale becomes trickier and

harder to implement. ACT therapists

in this situation face the dilemma of

trying to change a client in ways the

client may not have bargained for. It

is our experience that some clients

will not achieve creative hopelessness,

and persistent attempts to target it

may frustrate the client and create

ruptures in the therapeutic relationship

(see Castonguay, Goldfried,

Wiser, Raue, & Hayes, 1996, for

a demonstration of how rigid adherence

to a particular strategy in cognitive therapy led to similar problems). Thus, if the case is relatively pure depression, the client wants

simply to feel better, and there is

a short time frame, then the use of

ACT's values identification and elaborate

acceptance and mindfulness

technologies may be incommensurate

with overall treatment goals.

Nevertheless, ACT has captivated

many therapists because the work

offers much more than techniques for

symptom reduction. For example,

Hayes et al. (1999) note that ACT,

as part of a larger effort focused on

the RFT analysis of human language

and cognition, broadly targets hu-

ACT AND BA 183

man consciousness and suffering and

"is perhaps the most important psychological

task we face as a species"

(po 287). Applied to depression treatment,

this vision at the least mandates

not only status as an empirically

supported treatment based on

acute-treatment outcomes but superior

relapse prevention and quality-of-

life data as well, and perhaps data

based on idiographic measures of

commitment to and activation in

valued life domains. This will be no

easy task, especially given cognitive

therapy's demonstrated success at

achieving relapse prevention, at

least compared to pharmacotherapy

(DeRubeis et al., 2005), and given

BA's possible superiority over cognitive

therapy. Given ACT's grand

vision, it will be interesting to sec if

it can outperform BA in this arena.

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