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.
As comprehensive distancing,
was equal to or better than
cognitive therapy in two
modest clinical trials.
Several other studies
provide additional support.
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
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.
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.
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
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.,
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
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
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,
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