Integrating Acceptance-based Integrating Acceptance-based Behavior Therapy into Behavior Therapy into

Exposure-based therapyExposure-based therapyfor PTSDfor PTSD

AcknowledgmentsAcknowledgments

Susan Orsillo, PhDSusan Orsillo, PhDSuffolk UniversitySuffolk University

Lizabeth Roemer, PhDLizabeth Roemer, PhDUniversity of Massachusetts, BostonUniversity of Massachusetts, Boston

The third wave The third wave

Behavior TherapyBehavior Therapy Cognitive TherapyCognitive Therapy Acceptance-based modelsAcceptance-based models

Acceptance and Commitment Therapy (ACT)Acceptance and Commitment Therapy (ACT) Mindfulness-based Cognitive Therapy (MBCT)Mindfulness-based Cognitive Therapy (MBCT) Acceptance-based Behavior Therapy for GADAcceptance-based Behavior Therapy for GAD Dialectical Behavior Therapy (DBT)Dialectical Behavior Therapy (DBT) Integrative Behavioral Couple Therapy (IBCT)Integrative Behavioral Couple Therapy (IBCT) Behavioral Activation (BA)Behavioral Activation (BA) Functional Analytic Psychotherapy (FAP)Functional Analytic Psychotherapy (FAP) Mindfulness-based Relapse Prevention (MBRP)Mindfulness-based Relapse Prevention (MBRP)

An etiological model of PTSDAn etiological model of PTSD

Generalized psychological vulnerabilityGeneralized psychological vulnerability Generalized biological vulnerabilityGeneralized biological vulnerability Experience of traumaExperience of trauma

Developed by classical conditioningDeveloped by classical conditioning Maintained by operant conditioningMaintained by operant conditioning

Anxious apprehensionAnxious apprehension Avoidance or numbing of emotional responseAvoidance or numbing of emotional response Moderated by social support and ability to copeModerated by social support and ability to cope

(Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)(Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)

Evidence-based psychological Evidence-based psychological treatments for PTSDtreatments for PTSD

General aimsGeneral aims Extinction of conditioned fear and anxiety Extinction of conditioned fear and anxiety

responses through repeated, non-reinforced responses through repeated, non-reinforced exposure to CSexposure to CS

Development of alternative, competing Development of alternative, competing responses to anxiety and fearresponses to anxiety and fear

Emphasis on symptom reduction through Emphasis on symptom reduction through mastery experiences and internal control mastery experiences and internal control strategiesstrategies

Evidence-based treatmentsEvidence-based treatments

Exposure TherapyExposure Therapy Anxiety Management Training (AMT)Anxiety Management Training (AMT) Combination treatmentsCombination treatments

(Foa, Keane & Friedman, 2000; Keane et al, 2006; Roth & Fonagy, (Foa, Keane & Friedman, 2000; Keane et al, 2006; Roth & Fonagy, 2005)2005)

Exposure TherapyExposure Therapy

Patient is guided through a vivid remembering of Patient is guided through a vivid remembering of the trauma until extinction occursthe trauma until extinction occurs

Goal is to reduce avoidance of anxiety and Goal is to reduce avoidance of anxiety and promote control/mastery over trauma-related promote control/mastery over trauma-related cuescues

(Foa and Rothbaum, 1998)(Foa and Rothbaum, 1998)

Anxiety Management TrainingAnxiety Management Training

Package of behavioral and cognitive Package of behavioral and cognitive strategies to reduce and control anxietystrategies to reduce and control anxiety Progressive muscle relaxationProgressive muscle relaxation Diaphragmatic breathingDiaphragmatic breathing Cognitive restructuringCognitive restructuring Communication skills trainingCommunication skills training Time managementTime management Anger management/assertion trainingAnger management/assertion training

(Meichenbaum, 1994)(Meichenbaum, 1994)

Combination treatmentsCombination treatments Package of CT, exposure and emotion Package of CT, exposure and emotion

regulation skillsregulation skills Essential components of CTEssential components of CT

Self-monitoringSelf-monitoring Identification and labeling of thoughts and Identification and labeling of thoughts and

associated emotionsassociated emotions Cognitive restructuringCognitive restructuring

Changing the content of a ‘dysfunctional’ cognition Changing the content of a ‘dysfunctional’ cognition through logical analysisthrough logical analysis

Hypothesis testingHypothesis testing Conducting behavioral experiments to evaluate the Conducting behavioral experiments to evaluate the

validity of dysfunctional thoughtsvalidity of dysfunctional thoughts

Combination treatmentsCombination treatments

Cognitive Processing Therapy (CPT)Cognitive Processing Therapy (CPT) Written exposure trialsWritten exposure trials cognitive restructuring of trauma related erroneous cognitive restructuring of trauma related erroneous

cognitions and schemas, particularly regarding safety, cognitions and schemas, particularly regarding safety, trust, power, control, self-esteem and intimacytrust, power, control, self-esteem and intimacy

STAIRSSTAIRS Emotion regulation and distress tolerance skillsEmotion regulation and distress tolerance skills Prolonged exposureProlonged exposure CSA related PTSDCSA related PTSD

(Resick et al. 2002; Cloitre et al., 2002)(Resick et al. 2002; Cloitre et al., 2002)

The good news about EBTs for PTSDThe good news about EBTs for PTSD

Treatments are efficacious when compared to Treatments are efficacious when compared to TAU, wait list control and active placebo TAU, wait list control and active placebo treatmentstreatments 67% of completers no longer meet criteria for PTSD67% of completers no longer meet criteria for PTSD 56% of intent-to-treat patients no longer meet criteria 56% of intent-to-treat patients no longer meet criteria

for PTSD for PTSD Exposure and CBT are generally equally Exposure and CBT are generally equally

efficaciousefficacious

(Bradley, 2005)(Bradley, 2005)

Limitations of current treatmentsLimitations of current treatments

44% of intent-to-treat patients continue to meet 44% of intent-to-treat patients continue to meet criteria for PTSD criteria for PTSD (Bradley, 2005)(Bradley, 2005)

Using DSM criteria as treatment outcome may Using DSM criteria as treatment outcome may not be relevant to clinically significant changenot be relevant to clinically significant change

Generalization of findings limited by study Generalization of findings limited by study exclusion rates averaging 30%exclusion rates averaging 30% Co-morbid Axis I disorderCo-morbid Axis I disorder Current substance abuseCurrent substance abuse Suicidal ideation or behaviorSuicidal ideation or behavior

More limitationsMore limitations

Relative lack of effectiveness researchRelative lack of effectiveness research RCTs generally compare monotherapies and not RCTs generally compare monotherapies and not

multimodal therapiesmultimodal therapies lack of evidence regarding long-term lack of evidence regarding long-term

maintenance of gainsmaintenance of gains Vast majority of community sample patients do Vast majority of community sample patients do

not receive EBTsnot receive EBTs Due to lack of disseminationDue to lack of dissemination Due to lack of treatment acceptance by patientsDue to lack of treatment acceptance by patients

And still moreAnd still more

Lowest effect sizes for patients with combat-Lowest effect sizes for patients with combat-related PTSD compared to other traumasrelated PTSD compared to other traumas

Focus on symptom reduction and not functional Focus on symptom reduction and not functional improvementimprovement Interpersonal relationshipsInterpersonal relationships Vocational functioningVocational functioning General quality of lifeGeneral quality of life

Limitations specific to CBTLimitations specific to CBT

Relatively difficult to train therapists to Relatively difficult to train therapists to adherence adherence (Kohlenberg, 2004; Dimidjian et al, 2006)(Kohlenberg, 2004; Dimidjian et al, 2006)

Emphasis on control and mastery strategies can Emphasis on control and mastery strategies can have paradoxical effect in anxiety disorders have paradoxical effect in anxiety disorders (Roemer & Borkovec, 1994)(Roemer & Borkovec, 1994)

Limitations specific to exposureLimitations specific to exposure

Requires memory of a specific trauma eventRequires memory of a specific trauma event May have low acceptability to patients and May have low acceptability to patients and

providersproviders PTSD patients have more negative attitudes PTSD patients have more negative attitudes

toward emotional expressiontoward emotional expression Exposure less effective for patients:Exposure less effective for patients:

High levels of anger at pre-treatmentHigh levels of anger at pre-treatment High levels of avoidance at pre-treatmentHigh levels of avoidance at pre-treatment Perpetrators of harm who experience guilt/shame as Perpetrators of harm who experience guilt/shame as

primary symptomsprimary symptoms

Potential limitations of standard Potential limitations of standard therapies for OIF/OEF veteranstherapies for OIF/OEF veterans

Stigma associated with mental health careStigma associated with mental health care Reluctance to participate in exposureReluctance to participate in exposure Presence of co-morbid conditionsPresence of co-morbid conditions Lack of a single traumatic eventLack of a single traumatic event Associated feelings of guilt, loss, anger, Associated feelings of guilt, loss, anger,

sadness, griefsadness, grief Potential for iatrogenic effects of exposurePotential for iatrogenic effects of exposure

The challenge in treating OIF/OEF The challenge in treating OIF/OEF veteransveterans

How do we provide secondary prevention?How do we provide secondary prevention? Proper treatment may help prevent the development Proper treatment may help prevent the development

or progression of symptoms, or progression of symptoms, or the underlying or the underlying mechanisms leading to pathologymechanisms leading to pathology (Zatzick et al. 2004)(Zatzick et al. 2004)

what are these mechanisms?what are these mechanisms? What is the natural course of resilience, remission What is the natural course of resilience, remission

and recovery? and recovery? (Bonanno 2004)(Bonanno 2004) How can we use current treatments in secondary How can we use current treatments in secondary

prevention?prevention? How can we adapt or elaborate on these treatments How can we adapt or elaborate on these treatments

for use with recently returned veterans?for use with recently returned veterans?

Spectrum of Post-Spectrum of Post-Deployment Deployment

Mental Disorders (N = Mental Disorders (N = 46,571)46,571)

DisorderDisorder N N % %

PTSDPTSD 20,63820,63844%44%

Drug AbuseDrug Abuse 17,76817,76838%38%

DepressionDepression 14,317 14,317 31%31%

Neurotic DisordersNeurotic Disorders 11,48111,48125%25%Affective PsychosisAffective Psychosis 7,460 7,46016%16%Alcohol DependenceAlcohol Dependence 3,116 3,116 7% 7%Acute Stress ReactionAcute Stress Reaction 1,327 1,327 3% 3%

VHA Office of Public Health and Environmental Hazards, February 14, 2006VHA Office of Public Health and Environmental Hazards, February 14, 2006

The cautionary tale of Critical Incident The cautionary tale of Critical Incident Stress Debriefing (CISD)Stress Debriefing (CISD)

Intervention intended as secondary prevention Intervention intended as secondary prevention for occupational trauma exposure for occupational trauma exposure (Mitchell 1983;1993)(Mitchell 1983;1993)

Proprietary; dramatic claims of effectiveness Proprietary; dramatic claims of effectiveness Basic assumptions Basic assumptions

Exposure to traumatic stressor is sufficient to cause Exposure to traumatic stressor is sufficient to cause symptoms that can escalate to a pathological symptoms that can escalate to a pathological conditioncondition

Early and proximal intervention involving emotional Early and proximal intervention involving emotional catharsis (exposure) is prophylacticcatharsis (exposure) is prophylactic

CISD proceduresCISD procedures

FormatFormat Group administrationGroup administration Delivered by a mental health provider assisted by Delivered by a mental health provider assisted by

non-professional peersnon-professional peers Conducted in one 2-3 hour session within 24-72 hours Conducted in one 2-3 hour session within 24-72 hours

of traumatic eventof traumatic event Mandatory attendance customaryMandatory attendance customary Non-attendees or drop-outs typically retrieved by peer Non-attendees or drop-outs typically retrieved by peer

facilitatorfacilitator

CISD treatment protocolCISD treatment protocol

Introduction of the debriefingIntroduction of the debriefing Statement of facts regarding the traumatic eventStatement of facts regarding the traumatic event Disclosure of thoughts regarding the eventDisclosure of thoughts regarding the event Disclosure of emotional reactions, with focus on Disclosure of emotional reactions, with focus on

strong negative affectsstrong negative affects Specification of possible symptomsSpecification of possible symptoms Education regarding consequences of trauma Education regarding consequences of trauma

exposureexposure Planned re-entry to social environmentPlanned re-entry to social environment(Mitchell & Everly, 1993)(Mitchell & Everly, 1993)

CISD outcome researchCISD outcome research

No clinically significant improvement for participants at No clinically significant improvement for participants at long-term follow-uplong-term follow-up

Slight but statistically significant worsening on outcome Slight but statistically significant worsening on outcome measures for those accepting debriefingmeasures for those accepting debriefing

Preference for informal sources of support and Preference for informal sources of support and assistance correlated strongly with improved outcomeassistance correlated strongly with improved outcome

Those with highest levels of both avoidance and intrusive Those with highest levels of both avoidance and intrusive recollection deteriorated most after debriefing; recovery recollection deteriorated most after debriefing; recovery better among those not receiving treatment better among those not receiving treatment (Mayou et al. (Mayou et al. 2000)2000)

““CISD is inert at best and iatrogenic at worst”CISD is inert at best and iatrogenic at worst” (Lohr et al. (Lohr et al. 2003)2003)

An etiological model of PTSDAn etiological model of PTSD

Generalized psychological vulnerabilityGeneralized psychological vulnerability Generalized biological vulnerabilityGeneralized biological vulnerability Experience of traumaExperience of trauma

Developed by classical conditioningDeveloped by classical conditioning Maintained by operant conditioningMaintained by operant conditioning

Anxious apprehensionAnxious apprehension Avoidance or numbing of emotional responseAvoidance or numbing of emotional response Moderated by social support and Moderated by social support and ability to copeability to cope

(Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)(Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)

Approaches to providing secondary Approaches to providing secondary preventionprevention

Watch and waitWatch and wait Respect the natural course of recovery among the Respect the natural course of recovery among the

resilientresilient SupportSupport naturally occurring restorative factors in naturally occurring restorative factors in

patient’s lifepatient’s life Provide supportive treatments that do not interfere Provide supportive treatments that do not interfere

with natural resilience and are not iatrogenicwith natural resilience and are not iatrogenic WellnessWellness

Provide treatments that Provide treatments that enhanceenhance naturally occurring naturally occurring restorative factors restorative factors

Example: Behavioral Activation (BA)Example: Behavioral Activation (BA)

Secondary prevention approachesSecondary prevention approaches

RehabilitationRehabilitation Support naturally occurring curative factors in Support naturally occurring curative factors in

patient’s life +patient’s life + Provide treatments that Provide treatments that prevent or inhibit pathological prevent or inhibit pathological

mechanismsmechanisms implicated in the development and implicated in the development and maintenance of psychological distressmaintenance of psychological distress

Experiential avoidanceExperiential avoidance Co-morbid conditions that serve the function of experiential Co-morbid conditions that serve the function of experiential

avoidance, especially SUDs and ruminationavoidance, especially SUDs and rumination

Acceptance-based Behavior Therapy Acceptance-based Behavior Therapy (ABT)(ABT)

Standard therapiesStandard therapies Based on a conditioning model of PTSDBased on a conditioning model of PTSD Aim is to reduce fear and anxiety through extinctionAim is to reduce fear and anxiety through extinction Coupled with strategies to change trauma-related thought Coupled with strategies to change trauma-related thought

contentcontent

An alternative modelAn alternative model PTSD can be understood as a disorder of PTSD can be understood as a disorder of experiential avoidanceexperiential avoidance

(Hayes et al. 1999)(Hayes et al. 1999) Aim is to improve quality of lifeAim is to improve quality of life Coupled with strategies to change the process of cognition Coupled with strategies to change the process of cognition

rather than the contentrather than the content

((Orsillo & Batten 2005; Batten et al. 2005; Follette et al. 2004)Orsillo & Batten 2005; Batten et al. 2005; Follette et al. 2004)

Experiential avoidanceExperiential avoidance

Attempts to change the form or frequency of Attempts to change the form or frequency of internal events (thoughts, feelings, memories, internal events (thoughts, feelings, memories, sensations) sensations) (Hayes et al. 1996)(Hayes et al. 1996)

EA contributes to the development and EA contributes to the development and maintenance of various forms of maintenance of various forms of psychopathology, particularly anxiety disorderspsychopathology, particularly anxiety disorders

Anxiety Anxiety disordersdisorders develop when individuals are develop when individuals are unwilling to experience anxiety (and associated unwilling to experience anxiety (and associated thoughts, images, distressing emotions)thoughts, images, distressing emotions)

A variety of external and internal control strategies are A variety of external and internal control strategies are utilized to alleviate distress via escape and avoidanceutilized to alleviate distress via escape and avoidance Behavioral avoidance of situations and cues (CS) that elicit Behavioral avoidance of situations and cues (CS) that elicit

unwanted internal states (CR)unwanted internal states (CR) Cognitive control strategies to avoid unwanted statesCognitive control strategies to avoid unwanted states

Thought suppressionThought suppression Worried rumination Worried rumination Distraction Distraction

Internal and external control strategies are negatively Internal and external control strategies are negatively reinforcedreinforced

External control strategies generalizeExternal control strategies generalize lead to disengagement with the naturally rewarding lead to disengagement with the naturally rewarding

contingencies in the environment contingencies in the environment Internal control strategies generalizeInternal control strategies generalize

Become rigid and inflexibleBecome rigid and inflexible Lead to narrowing of attentionLead to narrowing of attention

Control strategies maintain distress / cause rebound Control strategies maintain distress / cause rebound

Thought suppressionThought suppression Effortful suppression of thoughtsEffortful suppression of thoughts

Initially relieves distressInitially relieves distress Has paradoxical long-term effect with rebound of Has paradoxical long-term effect with rebound of

avoided imageryavoided imagery Leads to escalating efforts to control and master Leads to escalating efforts to control and master

thoughts and imagerythoughts and imagery Thought suppression associated with negative tx Thought suppression associated with negative tx

outcome outcome (CSA, rape, MVA, Gulf War, urban violence)(CSA, rape, MVA, Gulf War, urban violence)

Behavioral therapies have been adapted to Behavioral therapies have been adapted to specifically target experiential avoidance as a specifically target experiential avoidance as a core feature of pathologycore feature of pathology

(Borkovec et al. 2004)(Borkovec et al. 2004)

Acceptance-based Behavior Therapies Acceptance-based Behavior Therapies (ABT)(ABT)

Acceptance and Commitment Therapy (ACT)Acceptance and Commitment Therapy (ACT) (Hayes et (Hayes et al. 1999, 2004; Eifert & Forsyth, 2005)al. 1999, 2004; Eifert & Forsyth, 2005)

Mindfulness-based Cognitive Therapy (MBCT)Mindfulness-based Cognitive Therapy (MBCT) (Segal et (Segal et al. 2002)al. 2002)

Acceptance-based Behavior Therapy for GADAcceptance-based Behavior Therapy for GAD (Roemer& Orsillo, 2004, 2005)(Roemer& Orsillo, 2004, 2005)

Dialectical Behavior Therapy (DBT)Dialectical Behavior Therapy (DBT) (Linehan, 1993)(Linehan, 1993) Integrative Behavioral Couple Therapy (IBCT)Integrative Behavioral Couple Therapy (IBCT)

(Jacobson & Christensen, 1996)(Jacobson & Christensen, 1996) Behavioral Activation (BA)Behavioral Activation (BA) (Jacobson et al. 1996; Dimidjian et (Jacobson et al. 1996; Dimidjian et

al. 2006)al. 2006) Functional Analytic Psychotherapy (FAP)Functional Analytic Psychotherapy (FAP) (Kohlenberg & (Kohlenberg &

Tsai, 1991; Kohlenberg et al. 2004) Tsai, 1991; Kohlenberg et al. 2004) Mindfulness-based Relapse Prevention (MBRP)Mindfulness-based Relapse Prevention (MBRP)

(Marlatt et al. 2005)(Marlatt et al. 2005)

Acceptance-based Behavior Therapy Acceptance-based Behavior Therapy (ABT)(ABT)

Basic assumptionsBasic assumptions Treatment componentsTreatment components Treatment strategies and techniquesTreatment strategies and techniques

ABT assumptionsABT assumptions

Emotions are just emotions; thoughts are just Emotions are just emotions; thoughts are just thoughts; memories are just memoriesthoughts; memories are just memories

Emotions are information; not good or badEmotions are information; not good or bad Control of internal events is not an optionControl of internal events is not an option Control is the problem, not the solutionControl is the problem, not the solution

Similarities to Exposure/CBTSimilarities to Exposure/CBT

Both consider avoidance to be a core feature of Both consider avoidance to be a core feature of pathologypathology

Both advocate approach as an integral treatment Both advocate approach as an integral treatment strategystrategy

Differences from Exposure/CBTDifferences from Exposure/CBT

Approach and avoidanceApproach and avoidance Approach behaviors are inherently valuable Approach behaviors are inherently valuable Approach behaviors are pragmatically valuable in Approach behaviors are pragmatically valuable in

order to reengage with natural reinforcers and expand order to reengage with natural reinforcers and expand domains of functioningdomains of functioning

Emphasis on clinically valued change rather than Emphasis on clinically valued change rather than symptom reduction symptom reduction

DifferencesDifferences

AttentionAttention CBT emphasizes directing attention toward stimuli CBT emphasizes directing attention toward stimuli

associated with disorder (or distract from)associated with disorder (or distract from) ABT emphasizes directing attention broadly toward ABT emphasizes directing attention broadly toward

flow of experienceflow of experience

DifferencesDifferences

Cognition – radically different understanding of Cognition – radically different understanding of the role of cognition in development and the role of cognition in development and treatment of disorderstreatment of disorders Cognitions are causal vs. cognitions are responsesCognitions are causal vs. cognitions are responses Importance of content vs. importance of functionImportance of content vs. importance of function Goal to change content vs. goal to change Goal to change content vs. goal to change

relationship to one’s own thoughts and feelingsrelationship to one’s own thoughts and feelings

DifferencesDifferences

Control within the CBT frameworkControl within the CBT framework Lack of perceived control and unpredictability strongly Lack of perceived control and unpredictability strongly

associated with distress (Mineka et al. 2006)associated with distress (Mineka et al. 2006) Control/predictability can be increasedControl/predictability can be increased by by

Attending to thoughts and associated emotionsAttending to thoughts and associated emotions Changing thoughts from irrational to rationalChanging thoughts from irrational to rational Through process of logical analysis and behavioral Through process of logical analysis and behavioral

experimentationexperimentation

DifferencesDifferences

Control within the ABT frameworkControl within the ABT framework Efforts to exert internal control maintain distressEfforts to exert internal control maintain distress Thoughts and emotions are transitory experiences of Thoughts and emotions are transitory experiences of

the mind and bodythe mind and body Treatment provides experiential learning of Treatment provides experiential learning of

acceptanceacceptance rather than control rather than control Distress naturally wanes as a consequence of not Distress naturally wanes as a consequence of not

being escalated by control strategies (e.g., MBCT)being escalated by control strategies (e.g., MBCT)

ABT treatment componentsABT treatment components

Overarching goalsOverarching goals Target experiential avoidance and expand Target experiential avoidance and expand

experiential acceptanceexperiential acceptance Target associated behavioral restrictions and expand Target associated behavioral restrictions and expand

engagement with valued life goals and activitiesengagement with valued life goals and activities

1. Psychoeducation1. Psychoeducation 2. Assessment2. Assessment 3. Experiential acceptance3. Experiential acceptance 4. Valued action4. Valued action

1. Psychoeducation1. Psychoeducation

Role of emotions as informationRole of emotions as information (Linehan 1993) (Linehan 1993)

Limits and costs of control strategies Limits and costs of control strategies (Roemer & (Roemer & Orsilllo 2004)Orsilllo 2004)

Importance of approach and emotional Importance of approach and emotional engagement in therapy sessions engagement in therapy sessions (Jaycox et al. 1998)(Jaycox et al. 1998)

2. Assessment2. Assessment

General assessmentGeneral assessment Symptom review and diagnostic assessmentSymptom review and diagnostic assessment Self-report measuresSelf-report measures

PTSDPTSD AnxietyAnxiety depressiondepression

Self-report functional measuresSelf-report functional measures Life satisfactionLife satisfaction Valued life domainsValued life domains

(Roemer & Orsillo, 2004; Orsillo & Batten, 2005)(Roemer & Orsillo, 2004; Orsillo & Batten, 2005)

2. Assessment2. Assessment

Avoidance and suppressionAvoidance and suppression Self-report measures of experiential avoidance and Self-report measures of experiential avoidance and

thought suppressionthought suppression (Hayes et al. 2006; Eifert & Forsyth, 2005) (Hayes et al. 2006; Eifert & Forsyth, 2005) Acceptance and Action Questionnaire (AAQ)Acceptance and Action Questionnaire (AAQ) White Bear Suppression InventoryWhite Bear Suppression Inventory Thought Control QuestionnaireThought Control Questionnaire

Values assessmentValues assessment Self-report measures to identify idiographic treatment Self-report measures to identify idiographic treatment

outcomes outcomes (Hayes et al. 1999, Eifert & Forsyth, 2005)(Hayes et al. 1999, Eifert & Forsyth, 2005) Generate valuesGenerate values Rate values to establish prioritiesRate values to establish priorities Identify intermediate steps, actions and barriersIdentify intermediate steps, actions and barriers

3. Experiential acceptance3. Experiential acceptance

MindfulnessMindfulness Targets identification of thoughts/feelings as ‘reality’Targets identification of thoughts/feelings as ‘reality’

WillingnessWillingness Encourages approach behaviorsEncourages approach behaviors

Distress tolerance skillsDistress tolerance skills Targets avoidance due to inability to tolerate emotionTargets avoidance due to inability to tolerate emotion

Emotion regulation skillsEmotion regulation skills Targets avoidance due to inability to modulate Targets avoidance due to inability to modulate

emotionemotion

Key concepts in MindfulnessKey concepts in Mindfulness DecenteringDecentering

Experiencing thoughts and feelings as mental events Experiencing thoughts and feelings as mental events and not realityand not reality

Early problem recognitionEarly problem recognition Intentional awareness allows “turning toward” Intentional awareness allows “turning toward”

difficultiesdifficulties Anti-ruminativeAnti-ruminative

Experience is of current awareness, not elaborate Experience is of current awareness, not elaborate thinking about implications, meaning, etc.thinking about implications, meaning, etc.

Generic skillGeneric skill Daily practice competes with development of Daily practice competes with development of

avoidance, escape and control strategies avoidance, escape and control strategies (Segal et al, 2002)(Segal et al, 2002)

Steps in Mindfulness trainingSteps in Mindfulness training

Practice attention to a single sensePractice attention to a single sense Practice attention to the flow of experiencePractice attention to the flow of experience Practice attention to thoughts, feelings, images Practice attention to thoughts, feelings, images

as part of the flow of experienceas part of the flow of experience Practice attention to the flow of experience Practice attention to the flow of experience

during activitiesduring activities

Mechanisms of MindfulnessMechanisms of Mindfulness

Exposure to previously avoided classes or Exposure to previously avoided classes or categories of emotional experience, leading to categories of emotional experience, leading to decreased distress via extinctiondecreased distress via extinction

Self-monitoring associated with improved Self-monitoring associated with improved appraisal of actual contingencies, leading to appraisal of actual contingencies, leading to increased flexibility in respondingincreased flexibility in responding

State of relaxation (response prevention)State of relaxation (response prevention) Change in attitude toward internal experiences Change in attitude toward internal experiences

leads to decreased volatilityleads to decreased volatility(Baer, 2003; Teasdale et al. 2002; Segal et al. 2002)(Baer, 2003; Teasdale et al. 2002; Segal et al. 2002)

4. Valued action4. Valued action

Assessment questionsAssessment questions What is important to the patient?What is important to the patient? To what extent are they living life in accordance with To what extent are they living life in accordance with

their values?their values? How do their symptoms interfere with the pursuit of How do their symptoms interfere with the pursuit of

their values?their values?

4. Valued action4. Valued action

Intervention techniquesIntervention techniques Writing exercises to clarify valuesWriting exercises to clarify values Self-monitoring to assess degree to which life is spent Self-monitoring to assess degree to which life is spent

in valued activities (and/or degree to which patient is in valued activities (and/or degree to which patient is emotionally engaged in valued activities)emotionally engaged in valued activities)

Goal settingGoal setting Identify concrete steps intermediate to valued activitiesIdentify concrete steps intermediate to valued activities Commit to planCommit to plan Identify potential barriersIdentify potential barriers Review previous goalsReview previous goals

(Roemer & Orsillo, 2004; Eifert & Forsyth, 2005; Orsillo & Batten, 2005)(Roemer & Orsillo, 2004; Eifert & Forsyth, 2005; Orsillo & Batten, 2005)

Integrating Exposure TherapyIntegrating Exposure Therapy

Exposure sessions for specific events as well as Exposure sessions for specific events as well as classes of emotionclasses of emotion

Goal is acceptance rather than extinctionGoal is acceptance rather than extinction Therapist must be practiced in approaching Therapist must be practiced in approaching

emotional experience, and mindful of not emotional experience, and mindful of not colluding with patient in experiential avoidancecolluding with patient in experiential avoidance

Therapist must be capable of achieving the Therapist must be capable of achieving the metacognitive state of ‘engaged observation’metacognitive state of ‘engaged observation’

SummarySummary Acceptance-based therapies are useful Acceptance-based therapies are useful

extensions of exposure-based in secondary extensions of exposure-based in secondary prevention of PTSD and co-morbid disordersprevention of PTSD and co-morbid disorders Empirical support in treatment of anxiety, depression, Empirical support in treatment of anxiety, depression,

SUDs, couples, BPDSUDs, couples, BPD Acceptable to patientsAcceptable to patients Accommodates exposure for emotions other than fear Accommodates exposure for emotions other than fear

& anxiety, or in absence of Criterion A& anxiety, or in absence of Criterion A Teaches cognitive and behavioral skills that may Teaches cognitive and behavioral skills that may

prevent development of avoidant and controlling prevent development of avoidant and controlling strategies associated with the exacerbation of anxiety, strategies associated with the exacerbation of anxiety, depressive relapse, substance use, conflict, and depressive relapse, substance use, conflict, and intimacy problemsintimacy problems

Goal is broad functional improvementGoal is broad functional improvement