Cognitive Behavior Therapy (Core Principles for Practice) || Acceptance and Cognitive Behavior Therapy

Acceptance and CognitiveBehavior Therapy

14Chapter

Kelly G. WilsonMaureen K. FlynnMichael BordieriStephanie Nassar

Nadia LucasKerry Whiteman

Acceptance is both old and new in cognitive behavior therapy

(CBT). As the CBT family has grown and evolved, acceptance

has become both a more explicit and more prominent focus of treatment.

Two significant bodies of evidence make this shift sensible. First, there is

an emerging and diverse body of evidence suggestive of the benefits of

acceptance (and the harm or risk, or both, posed by nonacceptance). This

data comes to us from a broad range of sources, including basic experi-

mental research, survey research, experimental psychopathology, and

clinical trials research.

A second body of evidence that has come increasingly to the fore is

data challenging long-held assumptions about processes responsible for

change within the broad family of CBT interventions. These challenges

call into question both the necessity and utility of interventions aimed at

direct alteration of negative cognition and emotional arousal. Evidence

suggests that difficult cognition and emotion are often persistent and that

this persistence does not preclude meaningful recovery.

Although there is considerable theoretical diversity among CBT

treatment developers, including the potential role of acceptance, they

are united by their respect for evidence. Theory and evidence are

currently converging in a way that heightens the role of acceptance

377

Cognitive Behavior Therapy: Core Principles for PracticeEdited by William O’Donohue and Jane E. Fisher

Copyright © 2012 John Wiley & Sons, Inc.

and increases the importance of theoretical and empirical clarity on the

nature and role of acceptance in human suffering.

In this review of acceptance in CBT, we will examine definitions of

the acceptance and describe its basic research evidence and that of its

counterpart, experiential avoidance. We will also briefly review the use

of acceptance in the CBT family historically and its relationship to

other principles used in CBT. Finally, we will offer some ideas for future

research directions.

Defining Acceptance

Expanded treatment of the concept of acceptance, or its converse,

experiential avoidance, can be found in current versions of CBT that

are highly focused on acceptance as a treatment component. Acceptance

and commitment therapy (ACT), for example, holds that ‘‘acceptance

processes involve taking an intentionally open, receptive, non-

judgmental posture with respect to various aspects of experience’’

(Wilson & DuFrene, 2009, p. 46). Similarly, Robins, Schmidt, and Linehan

(2004) have discussed acceptance in dialectical behavior therapy (DBT)

in the form of radical acceptance:

Radical acceptance is the fully open experience of what is, entering into reality

just as it is, at this moment. Fully open acceptance is without constrictions,

and without distortion, without judgment, without evaluation, and without

attempts to keep an experience or to get rid of it. (p. 39)

Acceptance, in this definition, again emphasizes the lack of evalua-

tion as well as openness to experience. Robins and colleagues also note

that attempts to hold on to or reject an experience are counter to

acceptance.

Experiential avoidance is a term that mirrors experiential acceptance.

Experiential avoidance involves attempts to attenuate, postpone, escape,

or avoid private experiences, such as thoughts, emotions, memories,

bodily sensations, and behavioral predispositions. Although these avoi-

dant repertoires often reduce unwanted thoughts and emotions over the

short term, they are potentially disabling over the long term, at least

under some circumstances (Allen, McHugh, & Barlow, 2008; S. C. Hayes,

Wilson, Gifford, Follette, & Strosahl, 1996).

378 Cognitive Behavior Therapy

Acceptance-Oriented Clinical Intervention

Acceptance-oriented clinical interventions can be quite varied among the

current crop of CBTs. At times, the intervention might be as simple as

coaching openness to experience while engaged in an in vivo exposure

session for anxiety. Acceptance might also be coached in the context of an

exercise involving imaginal exposure. This coaching might be as straight-

forward as simply asking the client if they could accept discomfort, even

momentarily, in the service of moving ahead in treatment. Mindfulness-

based treatments virtually always contain significant acceptance compo-

nents. Equanimity is a core component of mindfulness. Clients are asked

in the mindfulness exercises to ‘‘just notice’’ thoughts and emotions that

arise. This is in marked contrast to more typical struggles with negative

cognition and emotion.

Also, some treatments, such as ACT use many metaphors to facilitate

acceptance. For example, the paradox of control is sometimes illustrated

in ACT using the physical metaphor of the finger trap. Finger traps, for

those unfamiliar, are small woven straw tubes. If one places one’s index

fingers in the ends of the tube and pulls, the trap gets tighter. The harder

you pull, the tighter the trap becomes. If you pull hard enough, you can

get out, but it is quite destructive. There is another way out of the trap,

however. If you push your finger into the trap and move them around a

bit, the trap becomes less tight and the fingers can actually be removed

quite easily. A client might be asked if anxiety, for example, is not a bit

like that trap. The more one struggles with anxiety, the more anxious one

becomes. Clients are then invited to explore anxiety in that same way.

Empirical Support for Acceptance asa Psychological Principle

There is an accumulating body of basic and applied research that exam-

ines the effects of acceptance and avoidance on a number of different

variables. Some variants of avoidance, such as thought suppression, have

been studied for decades (Abramowitz, Tolin, & Street, 2001). However,

the volume of research has grown dramatically in recent years. In

particular, growth of interest among members of the broad CBT treat-

ment development community has been enormous. What follows is a

brief review of the literature, including basic and clinical research.

Acceptance and Cognitive Behavior Therapy 379

Thought Suppression

One of themostobviousways toavoid unpleasant thoughts and emotions is

to attempt to directly suppress those experiences. Several studies have

demonstrated that direct instruction to avoid thinking a specific thought

such as ‘‘do not think of a white bear,’’ enhances the probability of thoughts

of white bears upon release from the instruction (Lavy & van den Hout,

1990; D. Wegner, 1992; D. M. Wegner & Erber, 1992; D. M. Wegner,

Schneider, Carter, & White, 1987; D. M. Wegner, Schneider, Knutson, &

McMahon, 1991; cf., Clark, Ball, & Pape, 1991). When thought suppression

occurs in particular contexts, those contextual features can cue and exac-

erbate this rebound effect (D. M. Wegner et al., 1991).

Longer-term studies havedemonstrated thathigh levels of suppression

predict depression especially when combined with stressful circumstances

(Wenzlaff & Luxton, 2003). This data may be of particular relevance for

clinical conditions since stressful circumstances are precisely the sort of

contexts in which suppression is both likely to occur and likely to fail as a

coping strategy. Multiple studies show that thought suppression is associ-

ated with other clinically relevant issues, such as substance use, anxiety,

obsession thinking, posttraumatic stress disorder (PTSD), depression, and

borderline personality disorder (BPD) (Chapman, Specht, & Cellucci, 2005;

Rassin, Merckelbach, & Muris, 2000). Suppression has also been linked to

higher rates of failure in smoking cessation (Haaga & Allison, 1994;

Salkovskis & Reynolds, 1994; Toll, Sobell, Wagner, & Sobell, 2001), greater

self-harm behaviors for individuals with BPD (Chapman et al., 2005), and

increased intrusive thoughts among burn victims and car crash victims

(Bryant & Harvey, 1995; Lawrence, Fauerbach, & Munster, 1996).

Experiential Avoidance

A variety of studies have examined experiential avoidance through the lens

of the acceptance and action questionnaire (A. M. Hayes et al., 2004). The

acceptance and action questionnaire is a measure that assesses experiential

avoidance and ability to engage in values-consistent action even when

distressing thoughts and emotions are present (Bond et al., 2011; A. M.

Hayes et al., 2004). Higher levels of experiential avoidance correlates

positively with depression, anxiety, lower quality of life, specific phobias,

self-deceiving positivity, and avoidant coping (A. M. Hayes et al., 2004).

Pooling from 32 studies investigating experiential avoidance, S. C.

Hayes, Luoma, Bond, Masuda, and Lillis (2006) conducted a meta-analysis


to examine the relationship between experiential avoidance and mental

health and life quality. The meta-analysis revealed that lower levels of

experiential avoidance were correlated with less disability, decreased like-

lihood of a psychiatric diagnosis, fewer prescription analgesics and health-

care visits related to pain, better job performance, and better work status

(S. C. Hayes et al., 2006).

Expressive Writing

The expressive writing experimental paradigm has a number of features

that overlap with the concepts of acceptance and avoidance. Expressive

writing typically involves instructing participants to ‘‘really let go and

explore your very deepest emotions and thoughts’’ (Pennebaker, 1994,

p. 3). This paradigm is not precisely an acceptance-based protocol (it was

initially driven by the general theory of inhibition). It employs however,

components of experiential acceptance, particularly toward emotionally

upsetting and traumatic events (Pennebaker & Beall, 1986).

Participants in emotional disclosure writing preparations have expe-

rienced numerous psychological and physiological benefits as compared

to control condition participants who wrote about emotionally neutral

topics. The wide array of benefits associated with expressive writing

include improved mood; enhanced social communication; better college

adjustment; increased student grade point averages; improved working

memory; reduced blood pressure and heart rate; increased immune, lung,

and liver function; fewer physician visits and days in the hospital; fewer

reported health problems; and fewer days out of work and days un-

employed after job loss (for reviews, see Baikie & Wilhelm, 2005; Corter &

Petrie, 2011; Frattaroli, 2006; Pennebaker & Chung, 2011).

Given the beneficial results of expressive writing commonly found

among healthy participants, exploration of this paradigm was applied

to broader populations. Frattaroli (2006) published the largest meta-

analysis with an inclusion criteria of all randomized expressive writing

experiments (N ¼ 146). Employing a random effects approach, Frattaroli

(2006) found a significant and positive average r-effect size of .075

(d ¼ .15) for emotional disclosure—an effect size, which is comparable

to effect sizes seen in psychotherapy and common medical interventions

(for example, aspirin for heart attack prevention).

Although not all evidence is supportive, the salutary impact across

many studies and many populations suggests a robust positive impact of

this method of cultivating openness to experience. Areas in which we see


discordant data, as in the acceptance and suppression literature, present

challenges to the research community to determine the conditions under

which acceptance is likely to be beneficial, benign, or even harmful.

Acceptance Versus Other Coping Strategies

Experimental evidence suggests that suppression may be particularly likely

to fail under stressful circumstances and furthermore that suppression may

sensitize individuals to noxious stimuli in their environment. In a cold-

pressor pain task, suppression of pain caused slower recovery and also

caused subjects to rate an innocuous buzzer more negatively (Cioffi &

Holloway, 1993).

Clinical researchers within CBT have also begun to investigate the

impact of suppression and acceptance. Several studies have examined the

role of acceptance during a carbon dioxide inhalation challenge (Eifert &

Heffner, 2003; Feldner, Zvolensky, Eifert, & Spira, 2003; Levitt, Brown,

Orsillo, & Barlow, 2004). Reactivity to a gas challenge has been suggested

as a marker for anxiety disorders (Zvolensky & Eifert, 2001). Prospective

analyses have shown that individuals high in experiential avoidance

report greater levels of anxiety and affective distress during a CO2

challenge than those with low levels of experiential avoidance (Feldner

et al., 2003). When participants have been instructed to accept and notice

emotional and bodily states, rather than suppress, they have demon-

strated less behavioral avoidance, reported less intense fear, lower levels

of subjective anxiety, and greater willingness to participate in a subse-

quent CO2 inhalation as compared to those instructed to suppress or

control reactions (for example, Eifert & Heffner, 2003; Levitt et al., 2004).

Acceptance-centered coping strategies have been shown to be more

effective than control-based strategies such as suppression and cognitive

restructuring, for pain and distress tolerance in a cold-pressor task

(Masedo & Esteve, 2007), coping with intrusive thoughts and anxiety

(Marcks & Woods, 2007), and coping with food cravings and consump-

tion for individuals with a high susceptibility to the presence of desirable

foods (Forman et al., 2007).

Some recent data appears to run counter, at least in part, to these

findings. Hofmann and colleagues tested brief instructions for reappraisal,

acceptance, or suppression of anxiety provoked by an impromptu speech

(Hofmann, Heering, Sawyer, & Asnaani, 2009). As expected, suppression

instructions produced the highest arousal and the highest self-reported

anxiety. Both reappraisal and acceptance instructions were more


effective than suppression instructions at producing lower physiological

arousal. Hofmann and colleagues go on to suggest that ‘‘the reappraisal

strategy was more effective for moderating subjective feelings of anxiety

than attempts to suppress or accept the emotional experience.’’ The

difference between the acceptance and reappraisal condition, however,

was quite small and nonsignificant (Hofmann, Glombiewski, Asnaani, &

Sawyer, 2010, p. 393). Only the reappraisal and the suppression condi-

tion showed significantly different subjective distress and there was no

difference among conditions on the participants’ willingness to persist in

the anxiety provoking speech task.

A second study by Szasz, Szentagotai, and Hoffmann (2001) again

tested the impact of reappraisal, acceptance, and suppression coping

instructions on angry arousal and task persistence. Reappraisal instructions

outperformed both acceptance and suppression instructions on both self-

reported experience of anger and persistence in a frustrating task. Accep-

tance failed to outperform suppression on either measure (Szasz et al.,

2001).

The absence of differences in subjective distress or emotional arousal

of any sort is not particularly damning, since acceptance is not done to

lessen subjective distress—even though it sometimes does (e.g., Eifert &

Heffner, 2003; Levitt et al., 2004). While experiential avoidance has been

found to be a robust predictor of many sorts of distress (S. C. Hayes et al.,

1996), it does not follow empirically or theoretically that teaching accep-

tance will necessarily reduce distress. We do not have good evidence at this

point in time as to contextual factors that do and do not produce reductions

in subjective distress. It is also worth noting that setting reduction in

subjective distress as an intervention goal is problematic, since acceptance

of distress to reduce distress is simply not acceptance.

A more troubling finding in both of these studies is the absence of

any demonstrated benefit for acceptance instructions on task persistence.

Acceptance-oriented interventions are specifically intended to improve

behavioral performances and willingness to engage in difficult tasks.

Willingness to participate in distressing tasks has been shown in numer-

ous studies with cold pressor and CO2 gas challenge (for example, Eifert &

Heffner, 2003; Guti�errez, Luciano, Rodr�ıguez, & Fink, 2004; Levitt et al.,

2004). It is possible that these findings are the result of the extremely brief

instructional sets and the relative oddity of acceptance strategies.

Reappraisal and suppression strategies may simply require less instruc-

tion or practice than acceptance strategies because they are more com-

monly used. Parameters such as brief versus long instruction and practice


versus no practice conditions may shed light on why these effects are

found in some studies and not in others.

A Historical Overview of Acceptance in CBT

While acceptance has received increased attention as an active treatment

mechanism in recent years, it is not a new concept within the cognitive

behavioral tradition. Acceptance has been included within CBT inter-

ventions from their inception in the 1960s. Beginning with early pioneers

in the development of CBT and moving to more contemporary psycho-

therapy models within the CBT family, this section will review the use of

acceptance as a treatment component.

Acceptance in Traditional CBT

The first person in the CBT community to incorporate acceptance as a

major component in treatment was Albert Ellis. Ellis’s use of acceptance

in rational emotive therapy (RET) was shaped by reading the work

philosophers and his own clinical experience (Ellis & Robb, 1994).

RET encourages unconditional acceptance of self and others and empha-

sizes the evaluation of thoughts, feelings, and behaviors rather than

personhood. According to RET, people develop psychological difficulties

by nonacceptance, and the change strategies used in RET are designed to

teach acceptance and build tolerance (Ellis & Robb, 1994).

Within Beck’s cognitive model, acceptance has been acknowledged as

a more minor treatment component. Dozois and Beck (2010) assert,

‘‘Some notions of acceptance have, for some time, played a role (albeit

a minor one relative to direct cognitive change strategies) in cognitive

therapy’’ (p. 31). For example, acceptance is implicitly present in the

rationale for exposure work because a client must accept a certain amount

of discomfort or anxiety to participate in the exposure itself. It is important

to note, however, that Beck does not view acceptance as a mechanism of

change in the model. Within the Beckian model, ‘‘the primary objective of

promoting the acceptance of internal experiences in CT is to bring about

cognitive change and symptom relief’’ (Dozois & Beck, 2010, p. 39).

Increased Emphasis of Acceptance Within the CBT Family

While elements of acceptance have existed in CBT since its inception,

acceptance has become a much more prominent feature within emerging


CBT variants. Some models incorporate acceptance while maintaining

the traditional focus on changes in cognitive content (e.g., Wells, 1995).

Others have suggested that acceptance is an important change process

independent of facilitating change in cognitive content (e.g., S. C. Hayes,

Strosahl, & Wilson, 1999; Teasdale et al., 2000). Although these newer

variants of CBT contain many of the elements and sensibilities of

traditional CBT, they differ in that they all consider acceptance processes

as a central mechanism of clinically meaningful change.

Acceptance-Based Behavior Therapies

Many interventions have been developed that introduce acceptance pro-

cesses to existing protocols. Acceptance-based behavior therapies (ABBTs)

are an extension of traditional behavioral and cognitive behavioral treat-

ments that integrate acceptance-based components within existing empir-

ically supported treatment technologies (that is,CBT; seeRoemer & Orsillo,

2009). There is initial evidence of efficacy of AABTs for generalized anxiety

disorder (Orsillo, Roemer, & Barlow, 2003; Roemer, Orsillo, & Salters-

Pedneault, 2008) with both process measures and participant self-reports

suggestive of acceptance processes as active mechanisms of change.

Acceptance and Commitment Therapy

Acceptance and commitment therapy (ACT) is a contemporary contextual

behavioral model that uses acceptance processes to encourage contact with

avoidedexperiences in theserviceofguiding individuals towardamoreactive

and vital way of living (see S. C. Hayes et al., 1999; S. C. Hayes, Strosahl, &

Wilson, 2011). There is a growing body of empirical support for ACT across a

wide range of both clinical and nonclinical difficulties, including psychosis

(Bach & Hayes, 2002; Gaudiano & Herbert, 2006), chronic pain (Dahl &

Lundgren,2006),depression (Zettle&Rains,1989), andpanicdisorder (Eifert

& Heffner, 2003). In several recent meta-analyses, ACT has displayed small to

moderate effect sizes when compared to established active treatments sug-

gesting that it is at least as effective as existing treatment technologies (S. C.

Hayes et al., 2006; €Ost, 2008; Powers, V€ording, & Emmelkamp, 2009). In

addition, ACT enjoys emerging evidence of active mechanisms of change tied

to the psychological flexibility model, which includes acceptance as a core

mechanism (S. C. Hayes et al., 2006; Ruiz, 2010).

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT), another member of the contempo-

rary CBT family, is a treatment modality that targets acceptance and


mindfulness skills, emotion regulation, distress tolerance, and interpersonal

effectiveness skills (Linehan, 1993). There is a substantial body of research to

support the efficacy of using DBT to help individuals diagnosed with

borderline personality disorder (Kliem, Kroger, & Kosfelder, 2010; Linehan,

1993; Linehan & Dexter-Mazza, 2007).

Integrative Behavioral Couples Therapy

Integrative behavioral couples therapy (IBCT) (Christensen, Jacobson, &

Babcock, 1995; Christensen & Jacobson 1996) evolved from traditional

behavioral couples therapy (TBCT) (Jacobson & Margolin, 1979), which

strongly emphasized that intimacy is built in the relationship by the

couple accepting each other and their behavior rather than being focused

solely on behavior change. IBCT also helps each partner notice and accept

their own emotional states as they arise in the couples’ interactions. IBCT

enjoys equal evidence of efficacy with traditional behavioral couples

therapy (Christensen, Atkins, Berns, Wheeler, Baucom, & Simpson,

2004; Jacobson, Christensen, Prince, Cordova, & Eldridge, 2000) with

acceptance processes shown to mediate relationship satisfaction (Doss,

Thum, Sevier, Atkins, & Christensen, 2005).

Meta-Cognitive Therapy

Meta-cognitive therapy (MCT) (Wells, 2000) is a therapeutic model that

focuses on attentional process change as a mechanism to change the

relationship with thoughts rather than thoughts themselves. MCT incor-

porates acceptance components as a means of changing attentional

processes. Two recent randomized controlled trials have shown promis-

ing efficacy for MCT (Simons, Schneider, & Herpertz-Dahlmann, 2006;

Wells et al., 2010). MCT also enjoys evidence of efficacy for the treatment

of depression (Wells et al., 2009), generalized anxiety disorder (Wells &

King, 2006), and obsessive-compulsive disorder (Fisher & Wells, 2008).

Mindfulness-Based Cognitive Therapy

Mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teas-

dale, 2002) is based on mindfulness-based stress reduction (Kabat-Zinn,

1982). Within MBCT, clients are taught mindfulness meditation, involv-

ing an open and nonjudgmental posture with respect to negative cogni-

tion, emotion, and bodily states. Research has shown that MBCT is

particularly effective in helping currently symptomatic patients with

chronic or treatment resistant depression, as well as in promoting relapse

prevention for those with recurrent depression (Barnhofer et al., 2009;


Eisendrath et al., 2008; Kenny & Williams, 2007; Ma & Teasdale, 2004;

Segal et al., 2010; Teasdale et al., 2000).

The Relationship of Acceptance to Other Principles in CBT

Acceptance is compatible and sometimes inherently used in conjunction

with other principles used in CBT and has had an increased role in

developing variants of CBT. The following section describes the relation-

ship between acceptance and other principles in CBT and also implica-

tions for acceptance with respect to these principles, given the emerging

evidence.

Relaxation

Depending on the purpose to which relaxation is put, it has the potential

to be a component of an acceptance-based treatment strategy or it could

be used at cross-purposes with an acceptance-based strategy. If relaxation

is employed as a method of distraction from, or for reducing, difficult

emotional and cognitive responses it could potentially undermine accep-

tance interventions. However, some, such as Borkovec have found that

relaxation facilitates arousal when used in conjunction with exposure

(Hazlett-Stevens & Borkovec, 2001). Thus, relaxation has the potential to

be cast in the psychoeducation of clients as a method of opening up to

difficult experiences rather than reducing or eliminating them.

Emotional Regulation

Emotion regulation involves the modulation of emotional experience

(Chambers, Gullone, & Allen, 2009). In some regards, emotion regulation

appears to run contrary to acceptance. However, the language of emotion

regulation has been used among a variety of individuals within the array of

emerging CBTs that are acceptance-oriented (e.g., Brown, Lejuez, Kahler,

Strong, & Zvolensky, 2005; Linehan, 1993; Syzdek, Addis, & Martell,

2010). Generally speaking, maladaptive emotion regulation is considered

a factor in psychological difficulties, whereas adaptive emotion regulation

is linked to psychological well-being (Moses & Barlow, 2006).

Mindfulness has been conceptualized as a possible adaptive form of

emotion regulation (Chambers et al., 2009; A. M. Hayes & Feldman, 2004).

As noted in A. M. Hayes & Feldman (2004), avoidance and overengagement


in emotional experience are two maladaptive ways that people engage

emotions. Mindfulness is aimed at practicing openness to experience with-

out pushing it away (avoidance) or clinging to it (overengagement).

Exposure

The place of acceptance in exposure-based treatments has often been as a

means to facilitate exposure and therefore fear reduction (Dozois & Beck,

2010). Behavior therapists have long assumed that fear reduction was the

mechanism of change in these treatments. However, in a recent review of

the evidence, Craske and colleagues found little evidence for the habitu-

ation hypothesis and relatively strong evidence that the fear reduction

was not necessary for clinical gains (Craske et al., 2008). They concluded

that ‘‘neither the degree by which fear reduces nor the ending fear level

predict therapeutic outcome’’ (Craske et al., 2008, p. 5).

While acceptance may continue to play an important role in facili-

tating exposure, there may be an additional role for acceptance given the

persistence of fear among some individuals. Unless these findings are

refuted, which seems unlikely given the breadth of Craske and col-

leagues’ review, psychoeducation should include a discussion of the

potential persistence of strong emotional responses for some. Refocusing

psychoeducation away from a symptom reduction treatment agenda to a

treatment agenda more focused on quality of life and increased flexibility

appears appropriate, given the current evidence.

Cognitive Restructuring

Cognitive restructuring is rooted in the theory that cognitions plays a

causal role in behavior and emotion; thus by changing thoughts, behav-

ior and emotion will change. According to some CBT theorists, ‘‘all CBT

treatment protocols are firmly rooted within the basic CBT approach,

which assumes that maladaptive cognitions are causally linked to emo-

tional distress, and that changing those cognitions results in improvement

of emotional distress and maladaptive behaviors’’ (Hofmann et al., 2010,

p. 322). Although cognitive therapy has an extremely strong database

supporting its efficacy in both acute and long-term outcomes for depres-

sion (Vittengl, Clark, Dunn, & Jarrett, 2007; Dobson, 1989), the additive

benefits of interventions challenging cognition have come increasingly

into question. In a comprehensive review of the literature on logicora-

tional strategies, Longmore and Worrell (2007) found little evidence that


cognitive interventions improved the impact of treatment or that cogni-

tive change is necessary for clinical improvement.

In recent study by Jarrett and colleagues, both depressive sympto-

mology as well as negative cognitive content were assessed over the

course of treatment and during follow-up (Jarrett, Vittengl, Doyle, &

Clark, 2007). They found that changes in cognitive content during and

following therapy were large and enduring, but not predictive of depres-

sive symptomology. Where change in cognitive content was found,

‘‘contrary to the primacy hypothesis in its most basic form, regression

analyses showed that reductions in depressive symptoms accounted for

changes in cognitive content rather than the other way around’’ (Jarrett

et al., 2007, p. 12).

These findings bear an interesting similarity to the evidence emerg-

ing regarding the fear reduction hypothesis in exposure-based treat-

ments. It appears that changes in negative thinking, like fear, may be

quite persistent among some individuals and also, that the persistence of

these difficult cognitions does not preclude recovery meaningful recov-

ery. This evidence suggests, as with exposure, a potential place for

teaching acceptance, rather than refutation.

Some evidence that bears on this idea comes from mindfulness-

based interventions. First, MBCT has been found to be particularly

useful for individuals with multiple episodes of depression. Second,

Segal and colleagues randomized individuals who had been success-

fully treated with antidepressant medication (ADM) to ongoing ADM, a

placebo, or an 8-week course of MBCT (Segal et al., 2010). Among

remitters with symptom flurries, MBCT produced outcomes equal to

ongoing ADM and markedly superior to a placebo (Segal et al., 2010).

Taken together, this data is suggestive of the importance of examining

acceptance-oriented strategies, particularly for persistent depressive

symptoms.

Behavioral Activation

Behavioral activation involves a systematic approach to facilitate client

engagement in activities that have been neglected, but are potentially

reinforcing. Although acceptance has not been highlighted as central to

behavioral activation, it has been recognized as implicit. In some regards,

as with exposure-based treatments, engagement in activities even when

cognition and emotion are quite negative involves an exercise in accep-

tance (Martell & Atkins, 2006).


Research Issues and Unresolved IssuesRegarding Acceptance

The literature on acceptance in CBT has been undergoing extraordinary

growth. This change in the content of CBT has co-occurred with a change

in the focus of CBT treatment research. We are beginning to see a shift

from research focused primarily on outcome to an increased focus on

both the components and processes necessary for those outcomes. Evi-

dence is converging that suggests that many sorts of distressing cognition

and emotion will persist even when treatment is successful. Furthermore,

some instability in remission appears to put individuals at risk for

subsequent diagnosable episodes. Among other groups, it is quite typical

for symptoms to persist in at least some residual, if not profound, form (for

example, chronic pain, schizophrenia). Explicitly teaching acceptance in

the face of persistent difficulties makes theoretical sense and supplies us

with testable hypotheses.

Suppression predicts a variety of difficulties in survey research, in

experimental psychopathology, and in clinical trials. Evidence is less clear

on strategies that do not involve suppression, but instead involve some

sort of refutation or restructuring of cognition. To be clear, CBT has never

advocated suppression. However, many logicorational strategies set cli-

ents in a somewhat adversarial relationship with thoughts and emotions,

as they gather evidence to refute or reframe thought and emotion. Given

the very robust evidence base for therapies containing these interven-

tions, suspending their use and or their teaching would be unwise in the

extreme.

Forexample, consider the individuals whorecovered in Dimidjianand

colleagues’ comparison of CT and BA for depression (Dimidjian et al.,

2006). At 2-year follow-up, CT showed a marginally higher survival rate

than those in the behavioral activation condition (Dobson et al., 2008).

However, this finding for the whole sample of recovered individuals takes

nothing away from the equivalence of outcomes for BA and CT among

moderately depressed individuals and the superiority of BA among severely

depressed individuals over the course of acute treatment (Dimidjian et al.,

2006).

Hollon, in writing about Jacobson and colleagues’ (1996) component

analysis of CBT, showing no additive benefit of cognitive interventions,

suggested that ‘‘if these findings are replicated, they . . . call into question

the notion that cognitive therapy works, when it works, by virtue of using


cognitive change strategies to produce change in belief’’ (Hollon, 2000,

p. 1). This replication has occurred under watchful eyes of adherents of the

core cognitive hypothesis, including Hollon himself (Dimidjian et al.,

2006). Time has indeed come to very carefully examine the value of

challenging cognitive content.

These findings, along with findings regarding the persistence of

difficult emotion and cognition among many clinical populations sets

the stage for close examination of acceptance-based treatments. In

particular, there is a need to examine, empirically and theoretically,

when and for whom direct cognitive and emotional change strategies are

useful and likewise, where acceptance might be more useful.

It is incumbent on therapies to lift the evidentiary burden that justifies

their use, and that burden includes components, outcomes, and processes

(Kazdin, 2007). It is worth noting the successes some very, very simple

treatments have produced, including relatively pure behavioral activation

and relatively pure mindfulness interventions (Dimidjian et al., 2006;

Hofmann et al., 2010). All complex treatment strategies, including those

such as ACT and DBT, as well as traditional CBT variants, share the burden

of demonstrating the necessity of treatment components as well as the

mechanism through which they produce outcomes.

Training complex treatments is costly, and if we find that we can

leave out elements in our treatment, we ought to be happy. Simpler

treatment equates to more disseminable and less expensive treatment.

Simpler treatment translates to a greater likelihood that we will be able to

train the delivery of these treatments to nonprofessionals and paraprofes-

sionals, saving our more expensive and highly trained providers for

individuals who are nonresponsive to simpler interventions.

The abundance of process research that is currently under way

makes it more likely that these questions will be answered promptly.

To provide an example, in €Ost’s (2008) critical review of the literature on

emerging CBTs, including ACT, FAP, and DBT (but strangely not includ-

ing any of the emergent mindfulness-based cognitive therapies), he

found a nearly identical effect size as was seen in Hayes and colleagues’

meta-analysis (S. C. Hayes et al., 2006). Hayes, in preparation of a meta-

analysis of meditational analyses, examined €Ost’s data set and contacted

all senior authors of the traditional CBT and ACT studies. Only one of the

14 traditional CBT trials had any analyzed meditational data (Clark et al.,

2006). This data remains unpublished to date, whereas 8 of the 14 ACT

trials had meditational data either analyzed, under review, in press, or in

print (S. C. Hayes, personal communication, 2011). This provides an


example of the sort of attention to mediators and moderators of change

Kazdin suggests in his 2007 call to arms.

Members of the CBT treatment development community, for all the

differences among its broad family of therapies and theories, share a great

respect for evidence. Many of our treatments emerged quite directly from

an understanding of basic learning processes. Having amassed a large

body of evidence demonstrating the efficacy of our treatments, it is time

for the CBT treatment development community to return to a focus on

processes of change and to the deep connection between basic and

applied science that gave birth to evidence-based psychological practices.

Key Readings

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Psychology, 64, 1152–1168.

Williams, J. C., & Lynn, S. J. (2010). Acceptance: An historical and conceptual

review. Imagination, Cognition, & Personality, 30, 5–56.

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