Acceptance and Commitment Therapy andBehavioral Activation for the Treatment of Depression:

Description and Comparison

Jonathan W. Kanter and David E. BaruchUniversity of Wisconsin–Milwaukee

Scott T. GaynorWestern Michigan University

The field of clinical behavior analysis is growing rapidly and has the potential to affect andtransform mainstream cognitive behavior therapy. To have such an impact, the field mustprovide a formulation of and intervention strategies for clinical depression, the ‘‘common cold’’of outpatient populations. Two treatments for depression have emerged: acceptance andcommitment therapy (ACT) and behavioral activation (BA). At times ACT and BA may suggestlargely redundant intervention strategies. However, at other times the two treatments differdramatically and may present opposing conceptualizations. This paper will compare andcontrast these two important treatment approaches. Then, the relevant data will be presentedand discussed. We will end with some thoughts on how and when ACT or BA should beemployed clinically in the treatment of depression.

Key words: clinical behavior analysis, depression, psychotherapy, acceptance and commit-ment therapy, behavioral activation

The field of clinical behavior anal-ysis is growing rapidly. After begin-nings documented in this journal(Dougher, 1993; Dougher & Hack-bert, 1994) and elsewhere (Dougher,2000), it has become an integral partof a ‘‘third wave’’ of behavior ther-apy (Hayes, 2004; O’Donohue, 1998)that has the potential not only toinfluence but also to transform main-stream cognitive behavior therapy inmeaningful and permanent ways.

To have such an impact, the fieldmust provide a formulation of andintervention strategies for clinical de-pression, the ‘‘common cold’’ of out-patient populations. The phenome-non of depression currently is parsedinto several diagnostic categories bythe Diagnostic and Statistical Manualof Mental Disorders (DSM-IV-TR;American Psychiatric Association,

2000). The most common diagnosis,major depressive disorder, is appliedwhen an individual reports a combi-nation of feelings of sadness, loss ofinterest in activities, sleep and appe-tite changes, guilt and hopelessness,fatigue or restlessness, concentrationproblems, and suicidal ideation thatpersist for most of the day, nearlyevery day, for at least 2 weeks.Epidemiological data from a largerepresentative U.S. sample indicatea lifetime prevalence rate for majordepressive disorder of 16% (and anannual prevalence rate of 7%), whichsuggests that over 30 million Amer-icans will struggle with diagnosabledepression during their lifetimes(Kessler, McGonagle, Swartz, Blazer,& Nelson, 1993). The costs of de-pression are significant, not only forthose who are suffering but alsobecause of the high economic burdenof depression, much of which isattributed to work-related absentee-ism and lost productivity (Greenberget al., 2003).

Clinical behavior analysts, histori-cally skeptical of using the DSM as

We thank Douglas Woods and GregorySchramka for helpful reviews of this manu-script.

Address correspondence to Jonathan W.Kanter, Assistant Professor and PsychologyClinic Coordinator, P.O. Box 413, Milwaukee,Wisconsin 53201 (e-mail: jkanter@uwm.edu).

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

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the basis for understanding problembehavior, are especially cautious toavoid reifying a descriptive label, suchas major depressive disorder, intoa thing and using it as an explanationfor the symptoms it describes (Follette& Houts, 1996). Instead, of greaterinterest are the patterns of behaviorthat lead to the label of depressionbeing applied and how best to char-acterize and alter these patterns toimprove lives. Toward this end, sev-eral behavior-analytic descriptionsof depression are now available(Dougher & Hackbert, 1994; Ferster,1973; Kanter, Cautilli, Busch, &Baruch, 2005). These descriptionsgenerally accept Skinner’s (e.g., 1953)view that emotional states, such asdepressed mood, are co-occurringbehavioral responses (elicited uncon-ditioned reflexes, conditioned reflexes,operant predispositions). To the ex-tent that the various responses labeleddepression appear to be integrated, itis because the behaviors are potenti-ated by common environmentalevents, occasioned by common dis-criminanda, or controlled by com-mon consequences. These behavioralinterpretations also recognize thatdepression is characterized by greatvariability in time course, symptomseverity, and correlated conditions.

This paper will focus on twobehavior-analytic treatments for de-pression that have emerged: accep-tance and commitment therapy(ACT; Hayes, Strosahl, & Wilson,1999) and behavioral activation (BA).A third behavior-analytic approach,functional analytic psychotherapy(FAP; Kohlenberg & Tsai, 1991) hasbeen used to improve cognitive ther-apy for depression (Kanter, Schild-crout, & Kohlenberg, 2005; Kohlen-berg, Kanter, Bolling, Parker, & Tsai,2002). FAP is based on a broadfunctional analysis of the therapeuticrelationship (e.g., Follette, Naugle, &Callaghan, 1996) rather than a specificbehavioral model of depression; thusit will not be described here. Twocurrent variants of BA exist, BA

(Martell, Addis, & Jacobson, 2001)and brief behavioral activation treat-ment for depression (BATD; Lejeuz,Hopko, & Hopko, 2001). This paperwill focus on BA rather than BATD,because BA and BATD have recentlybeen compared and contrasted(Hopko, Lejuez, Ruggiero, & Eifert,2003). As we will show, at times ACTand BA, at the level of function ifnot technique, may suggest largelyredundant intervention strategies.However, at other times the twotreatments differ dramatically andmay in fact present opposing con-ceptualizations. How, then, is a clini-cal behavior analyst to choose be-tween ACT and BA? The body of thispaper will compare and contrast thesetwo important treatment approaches.Then, the relevant data on ACT andBA for depression will be presentedand discussed. We will end with somethoughts on how and when ACT orBA should be employed clinically inthe treatment of depression.

Throughout this article we refer tothe ACT (Hayes et al., 1999) and BA(Martell et al., 2001) manuals, al-though two caveats are requiredabout our focus on manuals. First,both treatments explicitly eschewthe cookbook, session-by-session ap-proach that accurately describes somecognitive behavior therapy treatmentmanuals. Both BA and ACT areprinciple based, explicitly encouragingthe use of any intervention techniquesconsistent with their underlying prin-ciples, whether or not the technique isdescribed in the manual. Thus, thereis some danger in comparing thetwo treatment manuals. We believewe have been sensitive to this dangerand have tried to avoid idiosyncraticinterpretations of specific techniqueswithout reference to underlying prin-ciples. That said, at times we make useof specific acronyms and techniquespresented in the manuals for clinicaluse, as shorthand encapsulations ofkey principles.

Second, this paper is organized interms of key differences between the

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two manuals. Although we describethe purported functional impact ofthese treatment techniques on clientbehavior, the paper is not organizedin terms of these functional processes.In fact, established functional rela-tions between specific treatment tech-niques and client behaviors for bothBA and ACT largely await experi-mental investigation, although muchwork is underway in this regard,particularly for ACT. We encouragefuture researchers and authors topursue this work and develop theseanalyses.

DEPRESSION AND AVOIDANCE

Both ACT and BA conceptualizedepression largely in terms of con-textually controlled avoidance reper-toires. In BA, the relevant historyand context involve direct contingen-cies that have shaped and maintainedavoidance behavior through nega-tive reinforcement. The ACT model,however, focuses on a verbal contextthat dominates over and creates in-sensitivity to direct contingencies. Wewill first discuss ACT’s more complexmodel and then turn to BA asa contrast. We note that this focuson avoidance is largely a departurefrom traditional behavioral models ofdepression that emphasized reduc-tions in positive control rather thanincreases in aversive control (Lewin-sohn, 1974), although Ferster (1973)did emphasize the role of avoidancein his seminal functional analysis ofdepression. Hayes, Wilson, Gifford,Follette, and Strosahl (1996) haveprovided a convincing review show-ing that avoidance may underliea host of psychological problems,including depression, and the specificrelation between avoidance and de-pression has received empirical sup-port as well (reviewed by Ottenbreit& Dobson, 2004).

ACT

ACT maintains that the funda-mental problem in depression is

experiential avoidance: an unwilling-ness to remain in contact withparticular private experiences cou-pled with attempts to escape or avoidthese experiences (Hayes & Gifford,1997; Hayes et al., 1996). Experientialavoidance is not an account of de-pression per se; rather, it is posited asa functional diagnostic category(Hayes & Follette, 1992) that identi-fies a psychological process key tomany topographically defined diag-nostic categories, including depres-sive disorders. As pointed out byZettle (2005a), although the termexperiential avoidance accommodatesboth escape and avoidance behavior,experiential escape may be moreappropriate for depression in thatthe depressed individual may morelikely be preoccupied with terminat-ing psychological events that havealready been experienced and arecurrently being endured, such asguilt, shame, and painful memoriesof loss experiences, rather than thosethat are anticipated and avoided. Wewill use the more general termexperiential avoidance because it ismore consistent with ACT usage.

The problem, according to ACT,is not so much the initial experienceof aversive private events—in ACTterminology, clean discomfort (e.g.,sadness about not seeing one’s chil-dren daily after separation from aspouse)—but that one rigidly followsrules for living that dictate experien-tial avoidance as the necessary re-sponse to such aversive privateevents. Thus ACT emphasizes thatexperiential avoidance itself is fueledby a verbal (i.e., rule-governed) pro-cess. Such rules may take manyforms, such as ‘‘I can’t stand to feelthis way,’’ ‘‘Having feelings makesone weak and vulnerable,’’ or ‘‘I needto be happy.’’ These rules, in thecontext of particular aversive privateevents, may result in avoidance be-havior that also takes many forms,such as avoiding seeing one’s child-ren so as to not feel sad andhave thoughts of being a failure as

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a parent, oversleeping to escapedaytime stress (or undersleeping, ifdreams or thoughts while in bed areaversive), overeating to combat lone-liness in the evening (or undereating,if eating results in thoughts aboutbeing fat, about not having someoneto eat with, etc.), rumination to avoidthe anxiety that accompanies activeproblem solving, avoidance of chal-lenging social situations where onemight fail (or going to the party butpassively sitting on the couch allnight), or drinking alcohol excessive-ly to block the pain of grief.

ACT postulates a significant rolefor indirect, derived verbal processesin promoting experiential avoidance.1

For instance, many aversive privateevents may be elicited indirectly.Consider a client for whom the wordloss is in an equivalence relation withactual painful interpersonal losses(e.g., death of a parent or experiencewith relationships ending badly dueto partner infidelity). The physicalabsence of a current significant otheron a Saturday evening (for legitimatereasons, such as a business trip)might evoke a verbal response, as in‘‘He’s gone,’’ that is in an equivalencerelation with loss. When this occurssome of the aversive functions ofactual losses may now be present(RFT refers to this as a derivedtransformation of stimulus func-tions), despite the fact that thisrelationship has not been lost and isnot in jeopardy. These aversive pri-vate events may now occasion escapebehavior, such as frantic calls to thesignificant other, binge eating, oralcohol use, that may contribute tothe demise of the relationship. ACTposits that this sort of verbal controlover behavior dominates nonverbal

environmental control, perhaps due,in this case, to historical operationsthat have established losses as partic-ularly aversive (Dougher & Hack-bert, 2000).

According to ACT, despite the factthat such avoidance tends to main-tain and exacerbate rather than solveproblems in the long run, experientialavoidance repertoires are maintainedbecause they are verbally controlled(rule governed), are successful in theshort run, and block contact with orcreate insensitivity to other contin-gencies (Hayes & Ju, 1998). Forexample, a client reports staying inbed all day because she ‘‘felt de-pressed,’’ lamenting how thingsmight be different tomorrow if shefeels less depressed. Staying in bedrequires lower response effort thangetting up, getting ready for work,and going to work. Thus, a directescape contingency is involved, but sotoo is the verbal rule specifying theneed to feel better before actingdifferently. Of course, the decisionto stay in bed until she feels lessdepressed also prevents contact withother contingencies that might leadto less depression.

BA

BA’s model of depression empha-sizes nonverbal processes and ap-pears to be more parsimonious. Thetraditional BA treatment modelviewed the overt behavioral reduc-tions in depression as a result of lossof or reductions in response-contin-gent positive reinforcement andviewed the affective components ofdepression as respondent sequelae ofsuch losses or reductions (Dougher &Hackbert, 1994; Ferster, 1973; Kan-ter, Cautelli, Busch, & Baruch, 2005;Lewinsohn, 1974). Current BA,largely based on Ferster (1973),postulates a greater role for escapeand avoidance from aversive internaland external stimuli. Ferster furthersuggested that the escape–avoidancerepertoire is largely passive, which

1 The model for ACT here is based onrelational frame theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001), description of whichis beyond the scope of this paper and which issomewhat controversial within behavior anal-ysis (e.g., Burgos, 2003; Palmer, 2004; Ton-neau, 2001). Our discussion presents themodel simply as described by ACT and RFT.

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also leads to a decrease in positivereinforcement relative to what anactive repertoire would provide.

Although the topographies of theavoidance repertoires targeted byACT and BA are basically the same(e.g., oversleeping, overeating, rumi-nation, alcohol consumption, andmany others), the controlling vari-ables and relevant history postulatedare somewhat different. BA contendsthat aversive private events occur inresponse to the presentation of pun-ishers or loss of reinforcers. The BAmodel recognizes that depressed in-dividuals often tact these aversiveprivate experiences (i.e., emit vocalresponses that are putatively con-trolled by internal stimulation), butunlike ACT, no indirect, derived(verbal) processes through whichprivate events become aversive arespecified. Aversive private events arethought to be elicited by contingen-cies that involve loss or deprivation.

Likewise, BA posits no rule-gov-erned process. Avoidance of aversiveprivate events is evoked by the eventsthemselves or by their environmentaldeterminants or correlates. BA as-sumes that direct contact with con-tingencies of negative reinforcementcan initially establish and later main-tain avoidance repertoires.2 Verbalresponses are recognized, but theseare often conceptualized as part ofthe avoidance repertoire (e.g., mands

for succor or relief). In comparison,ACT emphasizes how faulty rulesabout the need to change or controlprivate events promote experientialavoidance and decrease contact withexternal environmental events.

Like ACT, BA holds that avoid-ance, even when it works in the shortterm, produces additional long-termproblems, because more flexible re-pertoires of problem solving andrepertoires based on stable positivereinforcement are either extinguished,depotentiated, or never developed.Both ACT and BA suggest theclinically relevant problem is not theinitial (albeit aversive) private event,but that one responds to the eventwith avoidance. BA labels theseavoidance patterns secondary copingbehaviors because they are a responseto the initial aversive stimuli butparadoxically maintain or exacerbatethe depressive episode. Developingmore proactive alternative copingbehaviors to replace these patternsis the primary focus of BA.

Functional Assessment of Avoidancein BA and ACT

Any behavior-analytic treatmentshould start with functional assess-ment. Classical functional analysis, asin experimental demonstrations ofbehavioral control, is generally con-sidered impossible in outpatient set-tings. Nevertheless, clinical behavioranalysts perform quasifunctionalanalyses of client behaviors. Giventhe somewhat differing conceptuali-zations of avoidance by BA andACT, how does this translate intodifferent assessment strategies? BAprovides a structure for detailedassessment of contingencies thatmaintain the depressive behavior,focusing mostly, as described above,on the role of negative reinforcementin maintaining avoidance. (We notehere that BATD adds an emphasis onpositive reinforcement for depressivebehavior.) In practice, functionalassessment explicitly focuses on iden-

2 BA holds that the stimuli that triggeravoidance responses in depression may bepublic or private. However, most of theexamples in the BA manual involve privatestimuli, and the comparison with ACT is morecompelling in terms of private stimuli, so thiswill be the focus of this paper. We acknowl-edge the traditional view that avoidance isevoked by public stimuli, and private accom-paniments are correlated with the publicstimuli but are not functionally related to theavoidance response. Neither BA nor ACTfully endorses this traditional view; BA doessomewhat but ACT largely appears to haverejected it in favor of the notion of experientialavoidance, which highlights a functional re-lation, established historically and contextual-ly, between private stimulation and avoidanceresponses.

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tifying and increasing awareness ofand the difficulties resulting fromavoidance patterns and events thatprecede them. In ACT, the first stepis to establish creative hopelessness, inwhich there is an explicit focus onincreasing awareness of the futilityof, and the faulty verbal rules thatsupport, experiential avoidance.These therapeutic procedures arenot as dissimilar as they might firstappear.

In BA, therapists are taught toengage in a simple functional assess-ment, focusing on contingency-shaped avoidance behavior. Thiskey technique in BA clearly rendersit an advance over earlier BA strat-egies that targeted pleasant eventsand did not involve an idiographicassessment of function (Kanter, Call-aghan, Landes, Busch, & Brown,2004). In fact, after over 30 years ofcognitive behavioral depression treat-ment development, behavior analystsmay finally rejoice to read the fol-lowing quote from the BA manual:

Behavior matters. This is the primary motto ofBA, and it is important that the therapistaccept this concept wholeheartedly if they areto conduct competent BA. …The therapist,regardless of the technique being used fora specific intervention, should be asking him-or herself, ‘‘What are the conditions occasion-ing this behavior (the context) and what arethe consequences of this behavior for the client(the function)?’’ (p. 106)

BA therapists teach their clients toperform a quasifunctional analysis oftheir own out-of-session behavior.Clients specifically are taught to usethe acronym TRAP: Assess the situ-ational Trigger, identify one’s ownaversive private Response to thesituation (i.e., anxiety), and finallyrecognize the Avoidance Pattern thatfollows. For example, a TRAP ofa client seen by the first author was asfollows: trigger 5 meeting someoneat a social event for whom the clienthad strong feelings; response 5feeling anxious and overwhelmed;avoidance pattern 5 not talkingabout how she really feels, keeping

the conversation superficial, andfinding a way to escape the conver-sation as soon as possible.

In addition to increasing awarenessof avoidance patterns, assessment inBA also seeks to highlight the futilityof avoidance as a long-term solutionto problems. In this way, BA assess-ment bears some resemblance toACT’s creative hopelessness, whichwe describe next. For example, theBA authors describe the assessmentof a young man who had beenrepeatedly driving past his lover’shouse to confirm that she is at homeand not out with other men. Theauthors state,

We then have a hint at the real goal, to avoidanxiety. If this is described to the young man,and he agrees, we have reached an importantfirst step. … Having learned that his goal is tobe free of the anxiety about his lover seeingother men, we would then ask: How long doesthis freedom from anxiety last? If this is trulya solution, why must you do the same thingover and over again? (pp. 131–132)

Repeatedly throughout treatment,BA therapists are encouraged toengage in such questioning, to helptheir clients recognize the limitedutility, in terms of anything butshort-term negative reinforcement,of avoidance patterns. The maindifference with ACT is that the BAtherapist has no unique conceptuali-zation for the role of rules or derivedtransformation of stimulus functionsthat maintain the problem; thus, theassessment takes the form of tradi-tional verbal dialogue about func-tional relations among discriminativestimuli, avoidance behaviors, andtheir consequences.

Treatment in ACT, when con-ducted in its traditional order, beginswith creative hopelessness. The goalof this stage is to ‘‘draw out thesystem’’ in which the client istrapped; namely, identifying howexperiential avoidance appears spe-cifically relevant to his or her strug-gles. The ‘‘hopelessness’’ achieved increative hopelessness is experiential

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contact with the futility of experien-tial avoidance, a growing suspicionthat one’s own verbal rules may bepart of the problem rather thanthe solution, a confusion about whatto do next, but a sense that it willbe different and counterintuitive.Through mostly Socratic-style ques-tioning (e.g., ‘‘What do you want?’’;‘‘What have you tried?’’; and ‘‘Howhas that worked?’’), the client isguided toward a recognition of theunworkability of experiential avoid-ance.

Consider a client seen by the thirdauthor who presented during his fifthmajor depressive episode for treat-ment to decrease depression andanxiety, increase self-esteem, improvehis relationship with his wife, andadvance in his career. The initialassessment revealed that he had triednumerous treatment approaches in-cluding antidepressants, inpatienthospitalization, individual therapy,and couples therapy. He reportedusing various personal strategies,such as deep breathing and, alterna-tively, encouraging and berating him-self (trying to tell himself to ‘‘just letthings go,’’ or ‘‘block things out,’’ orreminding himself of his positivequalities). Despite these efforts, hepresented for treatment disgustedwith himself for being an incompe-tent, unlovable failure. This clientidentified several verbal self-rulesthat appeared to promote experien-tial avoidance as a method forsolving life’s problems, including,‘‘If you express needs then you’ll beseen as an overemotional baby,’’‘‘emotions can easily become over-whelming,’’ and ‘‘if I was perfect (orat least more self-assured) everythingin my relationships would be okay.’’Yet, despite this client’s inhibition ofemotional expressivity, attempts toblunt and block emotions, and movesto verbally bolster his self-worth,things had not gotten better. Froman ACT perspective, reviewing theclient’s treatment history is an essen-tial aspect of the assessment, because

it helps the client to make contactwith the fact that his logical andreasonable attempts to remove de-pression have not worked. The nextmove is to contact the possibility thatmaybe such attempts cannot work.This is the essence of creative hope-lessness.

Most ACT descriptions of howtherapists should conduct creativehopelessness suggest highlighting thecontradiction between verbal rulesthat promote experiential avoidanceand the long-term unworkability ofthe accompanying behavior, ratherthan simply viewing the interactionas a functional assessment. For ex-ample, note the following therapistresponse to a chronic worrier, who isfirst recognizing this discrepancy:

But maybe we are coming to a point in whichthe question will be, ‘‘Which will you go with?Your mind or your experience?’’ Up to nowthe answer has been ‘‘your mind,’’ but I wantyou just to notice also what your experiencetells you about how well that has worked.(Hayes et al., 1999, p. 97)

Thus, the goal in this phase is for theclient to experience the functionalconsequences of avoidance behavior,which is the same goal as functionalassessment in BA. However, becausethe ACT notion of experientialavoidance emphasizes the role ofverbal rules and derived transforma-tion of aversive private stimulusfunctions in preventing contact withexternal environmental events, thisphase does not look like traditionalassessment as in BA. Instead, theACT therapist takes caution not tosimply supply additional verbal rulesto describe the client’s experience;rather, the client obtains the aware-ness, to the extent possible, experien-tially. For an ACT therapist, extend-ed verbal dialogue, although neces-sary, risks inadvertently reinforcingthe notion that verbal solutions topsychological problems may befound. As such, these verbal dia-logues are buttressed with or centeredaround metaphors or experiential

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exercises that point to a different‘‘agenda.’’ For instance, the therapistmight note that the client’s situationappears kind of like falling intoquicksand; the natural, sensible thingto do seems to be to struggle to getout, but that does not work inquicksand; it only makes mattersworse.

Thus, it may be the case that ACTidentifies BA’s TRAPs over thecourse of treatment, but explicitassessment in ACT, as presented tothe client, focuses on the verbalcontext in which experiential avoid-ance occurs. ACT clients are asked tomonitor FEAR: Fusion with yourthoughts, Evaluations of your expe-rience, Avoidance of your experi-ences, and Reason given for yourbehavior. Note the parallel placementof avoidance in the TRAP andFEAR acronyms and how the sur-rounding letters shift the focus ofassessment from nonverbal to verbalvariables.

THERAPEUTIC GOALS

One might suggest that therapeuticgoals not only distinguish ACT fromBA but also distinguish ACT frommost, if not all, of the mainstreammedical and psychological commu-nity, including other ‘‘third wave’’approaches. Whereas the goal in BA,simply put, is to reduce the cluster ofresponses, both public and private,collectively labeled as depression,ACT views efforts to directly changeprivate events with caution. Thecaution is based on a concern thatthese efforts might be co-opted intoa generalized experiential avoidanceresponse class. Accordingly, duringcreative hopelessness especially butthroughout treatment, ACT thera-pists highlight the long-term prob-lems associated with experientialavoidance, notably the narrowing ofbehavioral repertoires and decreasedcontact with direct experience.

If not directly reducing the aversiveprivate events that in part define

depression, what then is the goal inACT? The goal of ACT is to increasecontact with direct experience andcreate more flexible, value-directedrepertoires that will persist in thepresence of previously avoided pri-vate events, such as those labeleddepression. As told to clients, the goalis to feel whatever is to be felt as onecommits to and engages in value-directed behavior (Hayes et al., 1999,p. 77). By taking this stance againstchanging private events and for theimportance of aversive emotions,ACT has positioned itself in opposi-tion to mainstream psychiatry andpsychopharmacology as well as cog-nitive behavioral psychotherapy,which has largely adopted the medi-cal model with its underlying goals(e.g., reduction of aversive privatesymptoms) and assumptions (e.g.,‘‘the assumption of healthy normali-ty’’; Hayes et al., 1999, p. 4).

BA explicitly rejects the medicalmodel of depression by viewing de-pression not as an illness but ratheras a direct consequence of learninghistory (Jacobson & Gortner, 2000;Martell et al., 2001). Nevertheless,BA authors clearly distinguish theposition of BA from that of ACT:‘‘Unlike other therapies involvingacceptance, however, BA considersthe experiences of people who aredepressed as experiences worth chang-ing’’ (Martell et al., 2001, p. 64).However, in line with the tradi-tional behavior-analytic position onprivate events as causal variables(Moore, 1980), BA argues that thebest way to achieve such reductionsin aversive private experience isthrough overt behavioral activation(working from the outside in) ratherthan through attempts at directmanipulation of private experience.Thus, BA clients are taught not totry to reduce private experiencesdirectly. In addition, even thoughBA targets private experiencethrough overt behavioral activation,BA by no means offers the client thepossibility that aversive private ex-

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periences can be completely elimi-nated: ‘‘The goal should not be thatthe client be free of depression, asthis cannot be guaranteed. Regard-less of how a person feels they canengage in activities that have beenimportant to them’’ (Martell et al.,p. 96).

In this regard, BA endorses a posi-tion quite similar to that of ACT,because ACT acknowledges thatsome private events are changeable.Specifically, ACT therapists ac-knowledge openly to clients that thequality of private experience, whenone is ‘‘fused with’’ and trying tocontrol the experience (e.g., ‘‘dirtydiscomfort’’), is worth changing andis changeable (Hayes et al., 1999,p. 136), but is not changeable if one istrying to change it. Thus, in this way,ACT and BA are quite similar. Bothmaintain that direct attempts tochange the initial aversive privateexperience are potentially problemat-ic, but one can change one’s behav-ioral response to the initial experi-ence, and this may reduce its aversivequality. ACT therapists, however, areextremely careful to avoid generatingadditional goals around reducingprivate experience and increasing rulegovernance. BA therapists, in con-trast, have no qualms making thepoint.

In closing, this section focused onthe conceptual stance taken towardsymptom reduction and how thisstance is communicated to the client.Not yet addressed is the separateissue of whether the therapies actuallyproduce symptom reduction, whichis addressed below.

ACCEPTANCE

ACT

Acceptance and interrelated pro-cesses such as defusion, mindfulness,and willingness play a fundamentalrole in ACT, and a complete array ofmethods is provided in the ACTmanual to engage these processes(see also Hayes & Wilson, 2003, for

discussion of how these processes areinterrelated with acceptance). Indeed,their prominence is implied by theposition of acceptance in the treat-ment’s title, and the importance ofacceptance cannot be overstated.Acceptance techniques are usedthroughout treatment; building anacceptance repertoire is seen as animportant precursor to value-guidedaction, which will undoubtedly ne-cessitate the experiencing of distressalong the way.

As stated colloquially in the ACTmanual, acceptance is ‘‘an activeprocess of feeling feelings as feelings,thinking thoughts as thoughts, re-membering memories as memories,and so on’’ (p. 77). In practice,therapists are encouraged to use theterm willingness rather than accep-tance because acceptance may implytolerance or resignation, which is notconsistent with the ideal acceptancerepertoire, characterized by an active,committed, and nonevaluative ap-proach to previously avoided privateevents.

The targets and functions ofACT’s related defusion, acceptance,and willingness methods vary (Hayes& Wilson, 2003). In general, the goalof acceptance is to increase non-evaluative contact with previouslyavoided here-and-now private events.Because, as stated earlier, ACT positsthat aversive private events are oftenverbally derived experiences, many ofthe techniques involve altering de-rived stimulus functions to facilitatecontact with direct experience. Forexample, the milk, milk, milk defu-sion technique, in which a negativelyevaluated word or phrase is quicklyrepeated for several minutes, appearsto partially extinguish the word’sderived aversive functions, facilitat-ing acceptance (Masuda, Hayes,Sackett, & Twohig, 2004). Suchdefusion exercises promote discrimi-nations between verbal responsesto events and the events themselvesand establish these verbal responsesas somewhat arbitrary; thus, an

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event’s verbally derived functions thatpromote experiential avoidance maybe extinguished and lead to increasedacceptance of the initial event.

Other techniques, such as the Joethe Bum metaphor, in which theclient is asked to imagine the effortrequired to keep Joe the Bum froma party rather than accepting hisunwanted presence, may be seen asestablishing operations that establishapproach functions and depotentiateavoidance functions while minimiz-ing rule governance. Still other ex-ercises, such as the observer exercise,a lengthy guided imagery exerciseduring which the client is led tocontact a variety of private events toexperience a stable sense of self fromwhich private events are experienced,may be seen, at least in part, asexposure exercises, designed to estab-lish and maintain contact with a rangeof private experiences, although otherinterpretations certainly are possible.ACT and RFT theorists are begin-ning to explore interpretations of thefunctions of these techniques in RFTterminology (e.g., some interventionstarget contextual variables that con-trol relational responding, whereasothers target contextual cues thatcontrol the transformation of func-tion given the occurrence of relation-al responding), but little has beenpublished on this topic to date.

BA

Unlike ACT, in which acceptanceof private experience precedes andfacilitates value-guided action, BAmoves directly to overt action andassumes that acceptance will follow.BA therapists teach clients that ifthey want to change their depression,they must accept how they feel andfocus on changing their overt behav-ior. This, in turn, will lead to changein depression. Thus, as in ACT, theemphasis is on the eponymous term,in this case activation (discussed next)rather than acceptance, but accep-tance is clearly promoted by the

treatment. Although no specific ac-ceptance strategies are specified (withone exception, mindfulness, describedbelow), the ability to activate in thepresence of aversive private eventsfundamentally entails the acceptance,at least temporarily, of those aversiveevents.

How acceptance functions in thetwo treatments is somewhat different,however, and the distinction betweenACT and BA here is clear andcogent. In BA, as stated above, theoverall goal is reducing depression,and the use of acceptance is strategicin achieving that goal. BA viewsdepression as a natural result ofdifficult life events and ‘‘therefore, itdoesn’t make sense to try to fight it’’(Martell at al., 2001, p. 93). Accord-ing to BA, fighting depression byengaging in avoidance behavior par-adoxically maintains and exacerbatesthe depression; thus, the focus is oncountering avoidance behavior andbuilding active problem-solving rep-ertoires. As relevant to acceptance,clients are taught to activate them-selves regardless of depressed moods:‘‘Clients benefit when they can actwhile acknowledging that they didn’tfeel like acting at the moment’’(p. 93).

In ACT, any attempt to useacceptance strategies in the serviceof reducing the primary aversiveexperience of depression functionallytransforms the strategies into experi-ential avoidance and is to be avoided.For example, consider a BA clientseen by the first author, who reportedbeing unable to stop ruminatingabout problems she was having atwork. The therapist suggested a mind-fulness exercise to her, in which shegoes for a walk and focuses on thephysical sensations experienced. Thetherapist explained that it wouldpotentially help her ‘‘to attend tothe present moment’’ and, borrowingACT parlance, ‘‘get some distancefrom the rumination machine.’’ Shethen asked if the exercise would alsohelp her to relax and feel better.

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Because the therapist was conductingBA, he said that he hoped it wouldhelp her to feel better, becauserumination makes her problemsworse (functionally, rumination isavoidance) and this alternative mightbe enjoyable (by helping her tocontact sources of positive reinforce-ment). If the therapist had beenconducting ACT, he would not haveresponded with such a reassurance.Instead, he might have asked her if,by hoping the exercise would help herfeel better, she was again engaging inan old emotional control agenda, orgently asked her if she would like torepeat the thought ‘‘this exercise willhelp me feel better’’ for severalminutes to see what happens to itsfunctions.

ACTIVATION

BA

In BA, activating clients is thefocus of therapy, and the treatmentuses the full arsenal of behavioraltechniques to achieve behavioral ac-tivation, including scheduling behav-ioral activities, graded homeworkassignments, in-session rehearsal androle playing of targeted behaviors,therapist modeling of targeted behav-iors, managing situational contin-gencies to make initiation and suc-cessful completion of targeted be-havior more likely, problem solvingto identify specific behavioral targetsas solutions to specific problems, andtraining to overcome skills deficitsthat interfere with initiation andmaintenance of targeted behaviors.As mentioned above, the key distinc-tion between current BA and earlierforms of behavioral activation fordepression (Hammen & Glass, 1975;Lewinsohn, 1974; Lewinsohn, Biglan,& Zeiss, 1976; Lewinsohn & Graf,1973; Lewinsohn & Libet, 1972) isthat activation is not focused onincreasing pleasant activities per se,but is targeted toward specific areasof passivity and avoidance that havebeen identified idiographically. Once

target behaviors are identified, at-tempts to block avoidance and acti-vate these alternate behaviors arealso monitored with an eye towardsfunction. In addition to using theTRAP acronym to identify avoid-ance, clients are taught to ‘‘get out ofTRAPs and get on TRAC’’ byreplacing Avoidance Patterns withAlternate Coping behaviors.

In addition, clients are taught touse the acronym ACTION to moni-tor ongoing avoidance patterns andimplement changes: Assess how thisbehavior serves you, Choose either toavoid or activate, Try out whateverbehavior has been chosen, Integrateany new behaviors into a routine,Observe the outcome, and Nevergive up. Note how this acronymencourages clients to adopt a func-tional–experimental approach to eval-uating their behavior—to develophypotheses about the function ofvarious behaviors, take action, andobserve the consequences. Takingsuch an approach might lead clientsto become better able to describe theantecedent and consequential stimulithat control their behavior (i.e., in-creased self-awareness) and lead tothe development of accurate verbalrules (i.e., tracks), which might facil-itate maintenance of treatment gains.Finally, by ending with ‘‘Never giveup,’’ BA attempts to encourage thepersistence of behavior in the face ofobstacles. Pursuit of goal-directedactivity in the face of obstacles isalso emphasized in ACT’s valueswork, a topic we discuss next.

ACT

ACT includes behavioral activa-tion as well, but focuses instead onvalues and commitment, again em-phasizing verbal over nonverbal pro-cesses. According to ACT, in addi-tion to a functioning acceptancerepertoire, a set of clearly definedvalues and associated goals are es-sential prerequisites for guiding acti-vation. Values, defined in ACT as

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‘‘verbally construed global desiredlife consequences’’ (Hayes et al.,1999, p. 206), may be seen as self-rules (specifically augmentals) thatstrategically take advantage of theinsensitivity to contingencies generat-ed by rule-governed behavior. Byhelping clients to identify, create,and clarify values, and then to makea verbal commitment to activation inthe service of those values, the ACTtherapist, after having spent much oftreatment dismantling and distancingfrom verbal rules that promote emo-tional control and derived transfor-mation of stimulus functions thatsupport experiential avoidance, nowutilizes these processes in an attemptto generate high-strength responseclasses that will persist in the face ofavoidance contingencies. The differ-ence is that the focal response classesconsist of overt approach behaviors,rather than responses that temporar-ily terminate or preempt privateevents. Indeed, engaging in thesevalue-directed approach behaviorsoften elicits and evokes the veryprivate events that were previouslyavoided—hence, the initial focus ondeveloping a functioning acceptancerepertoire prior to making a commit-ment to behave toward personalvalues.

Thus, values take priority overactivation per se in ACT. Likeacceptance in BA, activation inACT is implied and stated as impor-tant, but no activation strategies arespecified. Instead, the manual (Hayeset al., 1999) states that, as treatmentculminates,

ACT takes on the character of traditionalbehavior therapy, and virtually any behaviorchange technique is acceptable. The differenceis that behavior change goals, guided expo-sure, social skills training, modeling, roleplaying, couples work, and so on, are in-tegrated with an ACT perspective. Behaviorchange is a kind of willingness exercise, linkedto chosen values. The integration of tradition-al behavior therapy and ACT in this phase isan important topic, but is well beyond thescope of this book. (p. 258)

As an illustration, consider againthe male client with a history of multi-ple depressive episodes described ear-lier. One value of his was to be a goodhusband, with one specific goal beingto improve his communication withhis wife. Pursuit of this goal necessi-tated articulating his needs and feel-ings to his wife and apologizing forand making a commitment to dis-continue certain relationship-weaken-ing behaviors (e.g., he had previouslybelittled his wife as a way of termi-nating feelings of vulnerability whenhis wife tried to talk to him abouttheir relationship). Engaging in thesevalue-directed responses requiredthat he persist in the face of feelingsof self-doubt and vulnerability andthoughts that he was an ‘‘overemo-tional baby’’ who was unlovable. Notsurprisingly, when he did this his wifereported experiencing him as moreopen, available, and not so closed off,and both reported increased close-ness, understanding, and positivecontact in the relationship.

In some ways ACT and BA aresimilar in that both view simplescheduling of pleasant events asmeaningless if it is attempted inde-pendent of a larger assessment thatdelineates idiographic areas of acti-vation. BA addresses this limitationand even discusses goals somewhat,but does not match ACT’s technicalor theoretical sophistication with re-spect to values, their behavioraloperationalizations, and their role intherapy. On a case-by-case basis,however, behavioral activation inBA and value-guided action in ACTmay look identical, especially forclients who may already have clearand well-defined values and may notneed the additional values workconducted in ACT.

Consider the example immediatelyabove and how the interventioncould have been conducted from theTRAP/TRAC and ACTION frame-work with the value only implied:The trigger (T) could have beena previous discussion initiated by his

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wife about their relationship; theresponses (R) would have been hisfeelings of vulnerability, self-doubt,and negative self-thoughts; the avoid-ance patterns (AP) would have beenthat he belittled his wife and shutdown as a way of escaping thefeelings; and the alternative coping(AC) would have been that instead heinitiates the discussion himself, ar-ticulates his needs and feelings duringthe discussion, and apologizes for hispast behavior. According to AC-TION, he would have assessed (A)that his belittling her and shuttingdown was making his marriageworse, chosen (C) instead to activate,tried out (T) the new behaviors ofdiscussing feelings and apologizing,committed to engaging in these be-haviors regularly, thereby integrating(I) them into a routine, observed (O)that his wife responded positively tothe new behaviors, and remindedhimself to never give up (N) if andwhen she does not respond positively.

An acronym comparison againsummarizes the similarities and dif-ferences. Whereas BA encouragesACTION, ACT more simply en-courages clients to ACT: Accept yourreactions and be present, Choosea valued direction, and Take action.Note that both emphasize choice (butACT expands considerably on whatis to be chosen, i.e., values), and bothencourage behavior change in theform of action. BA’s acronym addi-tionally encourages functional assess-ment, now in the context of activa-tion (the A and O), whereas ACT’sACT does not encourage functionalassessment but simply focuses onacceptance in addition to choosingvalues and taking action.

CASE EXAMPLES

To illustrate the similarities anddifferences between ACT and BA, wepresent two case examples, adaptedfrom existing writings on ACT andBA.

ACT

The following ACT case wasadapted from Dougher and Hackbert(1994, pp. 330–333). The client wasa 23-year-old depressed female col-lege student, and the treatment goalwas ‘‘to help the client achieveacceptance of her private events whilepursuing those activities and goalsshe identified as being important.’’ Inthis session (Session 8), the client istalking about her reaction to a fightwith her nonexclusive boyfriend:

C: We had a fight, and he left, I felt soangry, so bad. I just couldn’t, didn’t wantto go through with it. I started to getreally down. I just wanted to get drunk.… I started to drink, but I’m not much ofa drinker, and when I did, it seemed likejust drinking made me think about itmore.

T: Like trying not to think of pink elephantsmakes you think of pink elephants more.That’s true of everything you do to stopthinking of something or trying not tohave 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’t.C: What do you do about them?T: Have them. You want to do something

you can’t do. You want not to havethoughts and feelings. But that can’thappen, you know. You’re alive andthey’re part of you.

In this transcript, the ACT therapistclearly goes after the consequences ofexperiential avoidance (‘‘it just makesthings worse’’) and introduces accep-tance as an alternative. An ACTtherapist might also introduce a met-aphor here to try to move beyonda literal discussion. Notice also thatthe therapist did not just go after thelink between private events andescape or avoidance, which a BAtherapist might also do, but alsohighlighted the verbal rules thatsupport experiential avoidance—thatfeelings should be terminated. Thereis little focus on the trigger (theargument) or, at this point, on

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alternative coping behaviors. As val-ues work has yet to occur at this stageof ACT, alternative behaviors, otherthan acceptance, have yet to bedelineated. A BA therapist mightdownplay acceptance here, insteadintroducing TRAP and TRAC asa way to assess the specific situationand develop alternative coping strat-egies that subsume acceptance.

In the following transcript, whichoccurs later in therapy (Session 17),the work has focused on value-guidedactivation, and it becomes moredifficult to distinguish between ACTand BA. In this segment, the client istalking about a date with a guy shemet in one of her classes.

C: [Before the date] I was really, uh, startingto get nervous and, uh, thinking that, uh,that it was a mistake to have agreed to goout with him. I don’t know why I was,you know, so nervous. I have noconfidence. Anyway, I started thinkingabout accepting the feelings and the stuffwe talked about, you know, and just gotready.

T: So you went out?C: Yeah, and it was pretty good. But the

whole time, I’m like telling myself hehates me, why am I doing this? What’sthe point? You know. But it was good.

Note that the client describes theproblem in terms of anxiety anda litany of depressotypic thoughts,defusion from which seems to be partof a functioning acceptance reper-toire that she has acquired over thecourse of therapy. This appears todepotentiate the escape response andallows her to go on and enjoy thedate. A BA client would be morelikely to describe the problem interms of avoidance and rumination,and the need to stay active in thepresence of such feeling and thinkingpatterns. But the key outcome—engagement in value-directed behav-ior (activation)—is the same.

At the end of therapy, the clienthad terminated the nonexclusive re-lationship and was considering tak-ing a job in Washington D.C., a moveconsistent with her educational train-

ing and values. In addition, ‘‘theclient’s depression clearly lifted, al-though her affective state was hardlydiscussed after the first few weeks oftreatment, and it was never anexplicit goal of therapy’’ (p. 333).

BA

The BA case was adapted fromMartell et al. (2001, pp. 159–173).The client was a 21-year-old de-pressed female employed as a techni-cian, and the treatment goal was‘‘teaching her to be more proactivein order to increase the likelihoodthat her behavior could be positivelyreinforced.’’ This first transcript isfrom Session 4, when the clientdescribed attending a holiday gather-ing at her boyfriend’s house andobserved his family’s happiness andstarted thinking about how unhappyher own family was, which made herfeel sad and lonely.

T: When you were with [his] family and youstarted to think about how nice his familyis and how not-so-nice your own is, doyou think you started to disengage a littlebit?

C: [nods in agreement]T: Did thinking a lot about your own family

ultimately end up with you missing outon enjoying a good time?

C: Yes, in these situations I’ll sit back andnot 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 negativesituations—you may not be as good atgetting into more positive situations. …You get into a TRAP. This stands forTrigger, which, in this case, is yourpartner’s nice family; Response, which,in this case, is feeling lousy and lousyabout your own family; and Avoidance-Pattern, which is when you say you startwanting to leave the situation. … So theway to get out of the trap is to usealternate coping, do something different.Maybe staying a little longer even thoughyou feel like leaving, looking around theroom to see who wore red on Christmas,or better yet, trying to engage someone inan interesting conversation, anythingother than sitting and dwelling.

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Here, the therapist clearly goes afteractivation, introducing TRAPs andTRACs. There is no explicit focus onacceptance (or acceptance-enhancingtechniques) that might be relevant tothe negative thoughts and feelings.Instead, there is more focus on theconsequences of her passive reper-toire and the possibility of an alter-nate repertoire. There is an impliedrule offered: Do anything other thansitting and ruminating. An ACTtherapist might first implement ac-ceptance strategies directed towardthe private events that preoccupiedthe client (i.e., the ruminativethoughts and negative feelings) andwillingness to have those thoughtsand feelings while choosing not to sitback. The BA therapist went directlyafter the new behavior and wouldlikely suggest that the negative pri-vate events will dissipate when aninteresting conversation is achieved.Notice also how the BA therapistencourages mindful attending to themoment during any activation at-tempt, which is hinted at in thecomment about seeing how manypeople are wearing red.

Later in therapy (Session 16), theclient has been generating ideas forfinding a new job and dealing withdental problems, but has not beenactive in implementing strategies.

T: It seems to me that we can look at any ofthese life situations as a ‘‘trigger.’’ Evencoming to therapy and needing to set anagenda [for the session] is a trigger. Yourresponse is … what would you say yourresponse 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 hardduring our therapy. What I am saying isthat your general style is to get verypassive and just complain about prob-lems but wait until something happensapart 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 to these things. So what could

get you back on TRAC, with an alterna-tive 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 upcomingweek?

C: Well, I need to keep looking for a job,and I need to get back to see a dentist.

T: Can you write some of these things on anactivity chart and commit to times in thenext few days when you’ll do them?

This interaction represents typicalBA—a situational analysis that iden-tifies avoidance and instruction toactivate instead. The client endorsesfeeling hopeless, but, time is not spenton accepting the feeling and thenacting in the face of it, as mightoccur in ACT; the therapist movesdirectly to action. Acceptance isa potential by-product of the goal-directed action, but there is no de-liberate attempt to foster acceptance,nor is there a focus on language orconcern about language use thatdictates use of metaphors and expe-riential exercises rather than straight-forward talk.

Subsequently the client saw a den-tist (and was prescribed antibiotics)and interviewed for and accepteda new job. At the termination session,the client reported the most impor-tant aspect of therapy was learning tobe active, no matter what she wasfeeling.

C: I know that I need to schedule things andjust stick to the schedule, and I’ll feelbetter, 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 facingthings, because when I avoid them theyjust get worse.

Note that the client clearly endorsesthe activation-instead-of-avoidancerationale. 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 outcomestudies for BA is a true success story

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for behavior analysis. Early researchon Lewinsohn’s (1974) original pleas-ant events scheduling (PES) wasmixed at best (Blaney, 1981). Aftera quiescent period in which PES wassubsumed within larger cognitivebehavioral treatment packages (e.g.,Lewinsohn’s ‘‘coping with depres-sion’’ and Beck’s cognitive therapy,Beck, Rush, Shaw, & Emery, 1979),Jacobson et al. (1996) revived interestin BA with a component analysis ofcognitive therapy. This large study(152 clients) compared the BA com-ponent of cognitive therapy, BA plusa partial package of cognitive therapytargeting automatic thoughts, andthe full cognitive therapy package.Results suggested that a behavioralapproach to depressive symptomswas as effective as both cognitivetherapy conditions. There were nodifferences in outcome effectivenessat the end of treatment, despite a largesample, excellent adherence and com-petence by multiple therapists in allconditions, and a clear bias by thestudy therapists favoring cognitivetherapy. More important, these find-ings were maintained when evaluatedat a 2-year follow-up (Gortner, Gol-lan, Dobson, & Jacobson, 1998).

This study sparked the develop-ment of both BATD (see Hopko,Lejuez, LePage, Hopko, & McNeil,2003; Lejuez, Hopko, & Hopko, 2001;Lejuez, Hopko, LePage, Hopko, &McNeil, 2001) and current BA. Arecent randomized trial comparedcurrent BA to cognitive therapy,paroxetine, and placebo (Dimidjianet al., in press). Subjects (N 5 241)were randomly assigned, stratified bydepression severity, to one of the fourconditions. At posttreatment, therewere no differences between the threeactive groups for mildly depressedparticipants. However, BA and med-ication outperformed cognitive ther-apy with moderately to severely de-pressed participants. Although therewere no differences between BAand paroxetine, BA had a signi-ficantly lower attrition rate. Thus,

BA demonstrated an advantage overpharmacological treatment by retain-ing more clients and matching itseffectiveness without risk for physio-logical side effects. Jacobson et al.(1996) suggested that cognitive ther-apy’s version of BA performed as wellas full cognitive therapy, but Dimid-jian et al. (in press) offer evidence thatcurrent BA may be a more efficacioustreatment for more severely depressedclients. However, it should be notedthat in another recently completedlarge-scale randomized clinical trial,cognitive therapy did as well asa selective serotonin reuptake inhibi-tor at posttreatment (DeRubeis et al.,2005) and was better at preventingrelapse (Hollon et al., 2005).

Two smaller studies on depressionhave been conducted using the origi-nal version of ACT, called compre-hensive distancing (Zettle & Hayes,1986; Zettle & Rains, 1989). Before wediscuss studies that examine compre-hensive distancing, it is important todistinguish it from ACT. Comprehen-sive distancing included many featuresof ACT. However, it differed in thatcreative hopelessness played a relative-ly smaller role and, more important,BA (specifically, PES) was incorpo-rated towards the end of treatmentrather than the current focus onvalues (Zettle, 2005b; Zettle & Hayes,1989). Interestingly, incorporation ofPES included its underlying focus onreducing depressed feelings, as de-scribed in the comprehensive distanc-ing manual (Zettle & Hayes, 1989)used by Zettle and Rains:

One approach which has shown a great deal ofpromise in helping individuals like yourself tofeel less depressed [italics added] is to encour-age you to maintain a high activity level,particularly in doing things you normallyenjoy. Actually what we’ve focused on so farin allowing you to avoid getting caught up inyour own thoughts and feelings should free youup so you’ll have more time and energy to devoteto enjoyable activities [italics added]. (p. 22)

Thus, comprehensive distancing maybe described as a substantial ex-tension of PES that focused first

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on dismantling the verbal contextthat supports experiential avoidancebefore engaging in PES. As compre-hensive distancing evolved into ACT,PES and its attached rationale werereplaced by values work, and thetreatment became more consistent.

Zettle and Hayes (1986) comparedthree treatments: comprehensive dis-tancing, cognitive therapy withoutdistancing techniques, and full cogni-tive therapy. Eighteen women wererandomly assigned to one of the threegroups, and all clients were treated bythe first author. Despite includinga partial cognitive therapy package todetermine the specific role of distanc-ing in cognitive therapy, both cogni-tive therapy groups were combinedfor analysis. Clients treated withcomprehensive distancing reportedsignificantly less believability ofthoughts at posttreatment and signif-icantly less depression at a 2-monthfollow-up compared to clients in theaggregate cognitive therapy condition(see also Zettle & Hayes, 1987).

This study was followed by a com-parison of comprehensive distancingand cognitive therapy in a grouptherapy setting (Zettle & Rains,1989). Forty-five women participatedand, similar to Zettle and Hayes(1986), three treatment conditionswere included: comprehensive dis-tancing, cognitive therapy withoutdistancing, and full cognitive therapy;all groups were led by the firstauthor. Unlike the previous study,however, the cognitive therapygroups were not aggregated for anal-ysis. All groups demonstrated signif-icant decreases in depression, but nodifferences in treatment efficacy werefound at either posttreatment or 2-month follow-up.

Thus, taken together, there isa small data set suggesting that anearly and approximate version ofACT tested better than cognitivetherapy when administered individu-ally and a comparatively larger studythat reported no significant differ-ences when conducted in a group

setting. All clients in both studieswere women, and all were treated byRobert Zettle; thus generalizations tomen and to other therapists lessconnected with the development ofthe treatment remain unresolved is-sues. With regards to ACT, to datethere is no randomized outcome re-search published that has examinedits efficacy with respect to depressiveclients. Thus, it seems that BA clearlyholds an advantage over ACT interms of published efficacy for thetreatment of depression. However,several trials of both ACT and BAfor depression (including large-scaleefficacy trials of BA adapted forprimary-care settings) are underwayor have not yet been published, andwe expect the database to growconsiderably for both treatments overthe next few years. Unfortunately notmuch of this research will be behav-ior analytic.3

That said, it must also be statedthat ACT holds an advantage overBA in terms of several other mentalhealth problems. ACT has beentested for workplace stress manage-ment, psychotic symptoms, mathe-matics anxiety, polysubstance-abus-ing opiate addicts, chronic smokers,and social anxiety (reviewed in Hayeset al., 2006; Hayes, Masuda, Bissett,Luoma, & Guerrero, 2004). Severalof these studies have included mea-sures of depression. An ACT-basedgroup intervention decreased depres-sion for self-harming clients who hadbeen diagnosed with borderline per-sonality disorder compared to a treat-ment-as-usual control (Gratz & Gun-derson, in press). Chronic painpatients, acting as their own controlsand receiving ACT-consistent inter-ventions, demonstrated reduced lev-els of depression that were main-tained at a 3-month follow-up

3 Readers may also want to consider re-search on process mediators of outcome incomprehensive distancing (Hayes, Luoma,Bond, Masuda, & Lillis, 2006; Zettle & Hayes,1986; Zettle & Rains, 1989) and BA (Jacobsonet al., 1996).

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(McCracken, Vowles, & Eccleston,2005). A multiple baseline within-subject design demonstrated reduc-tions in depression among obsessive-compulsive clients (Twohig, Hayes, &Masuda, in press). Finally, a noncon-trolled study reported similar reduc-tions in depression among parents ofchildren who had been diagnosedwith autism given ACT-based groupsupport (Blackledge & Hayes, inpress). BA, in turn, has been studiedas a treatment for posttraumaticstress disorder in a case study (Mu-lick & Naugle, 2004) and a small-group design (Jakupak et al., inpress).

SUMMARY ANDTREATMENT IMPLICATIONS

In addition to the text below,Table 1 provides a brief synopsis ofthe similarities and differences be-tween ACT and BA outlined in thispaper. (Cognitive therapy, althoughnot the focus of this paper, is includedas an additional point of referencebecause it is the psychosocial treat-ment for depression that has thelargest empirical database.) In BA,clients are told, ‘‘Activate and youwill feel better’’ and are provided withinstructions for how to do so. Initialcompliance with these rules will hope-fully lead to stable contact withpositive, natural reinforcement,which should then maintain the be-havior and the rule following. Ac-cording to the taxonomy of rulefollowing described by Hayes (Hayeset al., 1999; Hayes & Ju, 1998), rulefollowing in BA moves from pliance(rule following because of sociallymediated consequences) and ineffec-tive tracking (following because ofa correspondence between the ruleand the natural consequences—inBA’s conceptualization of depression,the natural consequence being avoid-ance or escape) to more effectivetracking (following a rule because,more often than not, it successfullyleads to positive reinforcement). The

desired outcome is for the specifictracks (e.g., as identified in theTRAP/TRAC analyses) to becomelargely contingency governed as nat-ural consequences are contacted,thus, also supporting the general rule(i.e., ‘‘To feel better activate usingTRAP/TRAC analyses’’). It is hopedthat this result will be prophylacticagainst future depression.

From an ACT perspective, there ispotential concern that strengtheningsuch rule following might unwittinglycontribute to a generalized responseclass of following verbal rules thatspecify emotional control. Accord-ingly, across the full duration oftherapy, ACT seeks to weaken at-tempts at verbal control of privateevents; this includes eliminatingchanging private events as an explicitgoal of treatment. The purpose ofACT is similar to that of BA in thatclients should make contact withcontingencies in their current envi-ronment. The hope is that, whenattempts to control private eventsare suspended and values are clearlydiscriminated, (a) engagement inovert behavior, as specified in rulesderived from values, will be potenti-ated (augmenting), and (b) the clientwill be more sensitive to the directconsequences of this behavior, suchthat (c) rules that are formed will bemore accurate and adaptive (track-ing).

Thus, ACT differs from BA ontheoretical grounds for three reasons.First, as stated earlier, BA can beseen as reinforcing verbal processesthat support the control of aversiveprivate events. Second, according toACT, verbally controlled behaviorleads to insensitivity to changes inschedules of reinforcement and mayreduce the value of reinforcers. Thatis, the same way that values may actas augmentals that increase thestrength of reinforcers, an avoid-ance-control agenda may act as anaugmental that reduces the value ofreinforcers that are associated withthe occurrence of negative private

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events (e.g., when a client reportshaving had a positive social encoun-ter but indicates that it was ‘‘afailure’’ because he did not feel happyas it occurred or afterward). In otherwords, verbal processes may preventand disrupt contact with environ-mental contingencies that BA sug-gests will reinforce and maintain

behaviors alternative to avoidance.Third, even when environmental con-tingencies that support active andgoal-directed behavior are contacted,ACT would consider such contact tobe limited and risk for relapse sub-stantial as long as underlying verbalprocesses that support experientialavoidance are not addressed. Even

TABLE 1

A summary of the similarities and differences among behavioral activation,acceptance and commitment therapy, and cognitive therapy

Behavioral activationAcceptance and commitment

therapy Cognitive therapy

Therapistconceptualstancea

Feelings of sadnesscan be changedand changed mosteffectively bychanging behavior.Hypothesizedmechanism ofaction is directreinforcementcontingent onbehavior scheduledfor activation.

Working toward a goal ofchanging sad feelings mayfurther the emotionalcontrol agenda and rigidrule governance that fuelexperiential avoidance, theprimary barrier to livinga values-based life. Thetherapist works to diminishthe verbal link betweenfeeling better and livingbetter, with a decrease inexperiential avoidance asthe proposed mechanismof action (i.e., anexperiential avoidancemediational model).

Sad feelings can bechanged and changedmost effectively bychanging the client’sthoughts. The therapistworks from the insideout, with a change in thecontent of thoughts (orschemas) as the proposed mechanism ofaction (i.e., a cognitivemediational model).

Therapistverbalbehavior toclienta

We are going to tryand change howyou are feeling byworking from theoutside in becausethis is where weare likely to havethe greatestamount of success.

Attempts to change sadnesshave not worked for you.A new strategy is needed.Willingness is analternative; are you willingto have sadness and gowhere you choose to go inlife? If you do so yoursadness may decrease, butthere is no guarantee, itmay not.

How you appraise asituation is critical tohow you feel and act.Negative thinking leadsto negative mood statesand maladaptivebehaviors. We are goingto try and change howyou are feeling bychanging how you thinkabout and interpretsituations.

Symptomchange

Decreases depressivesymptoms.

Decreases depressivesymptoms.

Decreases depressivesymptoms.

Comparativeefficacy

Has done as well asor better than thefull cognitivetherapy package(that includesactivation) in twolarge randomizedclinical trials.These findingssupport activationas sufficienttreatment.

As comprehensive distancing,was equal to or better thancognitive therapy in twomodest clinical trials.Several other studiesprovide additional support.

Efficacy supported inseveral largerandomized clinicaltrials. The necessity ofcognitive techniquescalled into question byBA findings.

aFor simplicity we focus on sadness, the cardinal symptom of depression and a clear aversiveprivate event, to best highlight similarities and differences in these domains.

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an active and goal-directed life willstill inevitably supply aversive privateexperiences that will trigger experien-tial avoidance.

For this reason, ACT permits thesuccess of activation and exposuretreatments but only to a degree. Forexample, a young college studentwho strictly follows the rule, ‘‘If Iavoid emotional expression, then Iwill not be humiliated, which isgood,’’ may find himself in a specificsocial situation in which emotionalexpression is encouraged and sup-ported. Eventually, the person maylearn to disclose emotions in thissetting. From an ACT perspective,a new rule has not been established;rather, the old rule has been elabo-rated into ‘‘If I avoid emotionalexpression, then I will not be humil-iated, which is good but since Situa-tion A will not bring humiliation Ican express emotion.’’ According toACT, this may be what BA achieves.This appears to be at least a half stepforward from an ACT perspective, inthat this rule is less rigid and in-flexible than the original, consistentwith the ACT notion that experien-tial avoidance becomes especiallyproblematic when it results in signif-icantly reduced behavioral flexibility(i.e., large portions of the client’srepertoire are centered around it).However, this half step forwardmight lead to a full step backward ifthe underlying control agenda hassimply been reinforced and notweakened. In other words, risk forrelapse might be higher. This concep-tual concern is not supported by theavailable long-term follow-up dataon BA (or cognitive therapy for thatmatter), which suggest that changesare relatively robust. It is not entirelyclear at the present time how ACTwould conceptually account for thepositive and persisting effects of BAand cognitive therapy, but BA canconceptually account for the effectsof ACT, cognitive therapy, and BAby emphasizing the sufficiency ofactivation, the common thread

among the treatments. The need foradditional data addressing the activeingredients of change in these treat-ments is apparent.

The preceding paragraph alsoprompts questioning whether ACT’sadditional verbal strategies arenecessary. Efficacy data based ongroup designs aside, theoretically thechoice to use BA or ACT for a de-pressed client may rest on the role ofverbal behavior in a client’s prob-lems. Unfortunately, technologies forthe assessment of the role of derivedstimulus relations and control byverbal rules in individual cases donot yet exist (see Hayes & Follette,1992, for a full discussion of thisissue). ACT authors frequently high-light the apparent ubiquity of verbalbehavior (e.g., ‘‘Humans swim ina sea of talking, listening, planning,and reasoning,’’ Hayes, Blackledge,& Barnes-Holmes, 2001, p. 3) asjustification for ACT’s use, but suchbroad generalizations are difficult tosupport empirically. Indeed, a basicpremise of behavior analysis has beenthat most controlling variables arenot globally applicable, should bedetermined experimentally, and arenot to be assumed from commonsense and experience. Furthermore,another premise has been that a par-ticular focus on verbal behavior andother private events, although theyseem causal from the perspective ofcommon sense, may in fact detractfrom a proper functional assessmentof environmental variables (e.g.,Skinner, 1953).

There is certainly solid experimen-tal support for many of the basicprocesses (rule-governed behavior,derived stimulus relations, transfor-mation of stimulus functions) in-voked by ACT and described byRFT (Hayes, Barnes-Holmes, &Roche, 2001), and this support isgrowing. Nonetheless, RFT researchpreparations do not successfully ad-dress the ubiquity of verbal behavior,the question of whether a particularclient problem is best conceptualized

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as verbal, or the question of whethera particular overt behavioral streamis functionally connected to the pri-vate verbal behavioral stream thatpreceded it. RFT theorists acknowl-edge the difficulty determining wheth-er nonverbal behavior is verballymediated or contingency shaped ona behavior-by-behavior basis (Hayes,Gifford, Townsend, & Barnes-Holmes, 2001); only a full documen-tation of the relevant histories in-volved will reveal the actual sourcesof control, and of course the distinc-tion is somewhat arbitrary, in thatmost clinically relevant behavior ismultiply controlled.

Given multiple sources of control,it may be more appropriate to takea pragmatic stance and ask if target-ing verbal variables over other vari-ables will lead to enhanced outcomesfor particular clients. Unfortunately,there is little research to guide this lineof questioning. The problem is com-pounded by the repeated findingthat most cognitive and behavioraltreatments for depression appearto perform equivalently (Gloaguen,Cottraux, Cucherat, & Blackburn,1998), and considerable evidence ex-ists to support the notion that non-specific factors (i.e., provision ofa clear treatment rationale with a setof associated techniques offered in thecontext of a solid therapeutic re-lationship) are more important intreatment than are specific differencesas discussed in this article (Ilardi &Craighead, 1994).

Addis and Jacobson (1996) providesome potentially relevant informa-tion about clients for whom BAmay or may not work. Examiningthe data from the component analysisof cognitive therapy (Jacobson et al.,1996), they found that outcome inBA was positively correlated withclient response to the BA rationaleand early activation assignments,suggesting the importance of eventsthat happen early in treatment. Inaddition, clients who endorsed morereasons for depression (assessed with

the Reasons for Depression self-re-port questionnaire by Addis, Truax,& Jacobson, 1996), especially reasonsthat pointed to depression as a char-acter trait or depression in responseto existential issues, tended to havepoorer outcomes in BA.

Extrapolating from these data, itmight be suggested that clients re-ceive ACT if they present with highexperiential avoidance4 and manyreasons for depression, especiallyreasons that place the cause of de-pression in characterological or exis-tential domains, because ACT di-rectly targets verbal reason giving(with cognitive defusion strategies)and existential issues (with valuesidentification and clarification). Inaddition to using self-report ques-tionnaires, we suggest that the clini-cian perform some informal assess-ment to identify the level of fusionwith evaluating thoughts and concep-tual categories, the level of experien-tial avoidance (core unacceptableemotions, thoughts, memories, etc.;what are the consequences of havingsuch experiences that the client isunwilling to risk) versus overt behav-ioral avoidance, and the level ofidentified values and value-directedbehavior. This recommendation maypoint toward ACT with potentiallymore difficult clients (those with highfusion, high experiential avoidance,and low values), but this simpleheuristic is contradicted by BA’srecently demonstrated success withseverely depressed rather than mildlydepressed individuals (Dimidjian etal., in press).

These recommendations are almostentirely based on theory, group de-sign research, and correlations be-tween questionnaires. Single-case de-

4 Because the most well-used measure ofACT processes, the Acceptance and ActionQuestionnaire (Hayes, Strosahl, et al., 2004),has been defined not only as a measure ofexperiential avoidance but as a broad measureof multiple ACT processes, the developmentof more specific measures of experientialavoidance per se may be fruitful.

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signs are sorely needed in this area.Neither ACT nor BA has providedmuch of these data for depression(but see Twohig, Hayes, & Masuda,in press). Furthermore, neither haveprovided much in the form of com-ponent analyses, to determine whichof their multiple treatment techniquesor components are empirically justifi-able, when to employ them, and forwhich client problems. Lastly, there islittle research guidance on how toconduct functional assessments of therelevant verbal and nonverbal vari-ables that would guide case concep-tualization. Thus, the choice to useACT or BA, for now, may ultimatelyrely on clinician preference and fa-miliarity, or perhaps clinician values,and the dangers of relying on clinicaljudgment are clear (Dawes, 1994;Dawes, Faust, & Meehl, 1989;Tversky & Kahneman, 1974). Thisis a somewhat sad state of affairs,but by no means are ACT or BAtreatment developers to blame; thefield of behavior analysis as a wholehas not addressed the particulars oftreatment for outpatient depression.

Assuming a lack of a clear ratio-nale for applying either therapy,starting treatments for depressionwith BA may be justifiable for a fewreasons. First, conservatively speak-ing, the recent, large, and well-de-signed BA studies lend it clearempirical support as traditionally de-fined (although the accumulation ofACT evidence from a variety ofsources is compelling). Second,whereas both ACT and BA havebeen formatted as relatively short-term treatments (e.g., 16 to 20sessions), because the theoretical ra-tionale and treatment procedures forBA are both less complex than ACT,it would be expected that it would beeasier to train and conduct BA(although such a supposition has yetto be empirically tested). Third,practically speaking, it would appearto be far easier and even productiveto switch from a BA to an ACTrationale than vice versa. That is, if

BA is ineffective, the failure of theseearly attempts to activate withoutaddressing the internal change agen-da (and its supporting verbal context)are ripe material for creative hope-lessness. In fact, as per functionalanalytic psychotherapy (Kohlenberg& Tsai, 1991), because these failuresoccurred during therapy they maymake creative hopelessness even morepowerful than otherwise. Again, how-ever, we have no data suggesting theutility of ACT with BA treatmentfailures.

It may be the case that BA is moreappropriate, not for easier (less de-pressed) clients, but for clients withsimpler goals; namely, to feel better.For example, it is probably easier toconduct BA in the context of othersymptom-reduction approaches (e.g.,medications). Of course, one can useACT with clients on medications, butthe rationale becomes trickier andharder to implement. ACT therapistsin this situation face the dilemma oftrying to change a client in ways theclient may not have bargained for. Itis our experience that some clientswill not achieve creative hopelessness,and persistent attempts to target itmay frustrate the client and createruptures in the therapeutic relation-ship (see Castonguay, Goldfried,Wiser, Raue, & Hayes, 1996, fora demonstration of how rigid adher-ence to a particular strategy incognitive therapy led to similar prob-lems). Thus, if the case is relativelypure depression, the client wantssimply to feel better, and there isa short time frame, then the use ofACT’s values identification and elab-orate acceptance and mindfulnesstechnologies may be incommensuratewith overall treatment goals.

Nevertheless, ACT has captivatedmany therapists because the workoffers much more than techniques forsymptom reduction. For example,Hayes et al. (1999) note that ACT,as part of a larger effort focused onthe RFT analysis of human languageand cognition, broadly targets hu-

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man consciousness and suffering and‘‘is perhaps the most important psy-chological task we face as a species’’(p. 287). Applied to depression treat-ment, this vision at the least man-dates not only status as an empiri-cally supported treatment based onacute-treatment outcomes but supe-rior relapse prevention and quality-of-life data as well, and perhaps databased on idiographic measures ofcommitment to and activation invalued life domains. This will be noeasy task, especially given cognitivetherapy’s demonstrated success atachieving relapse prevention, atleast compared to pharmacotherapy(DeRubeis et al., 2005), and givenBA’s possible superiority over cogni-tive therapy. Given ACT’s grandvision, it will be interesting to see ifit can outperform BA in this arena.

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