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Re-enchanting behavioral psychology, analysis, and therapy: a review of Eifert & Forsyth's (2005) acceptance & commitment therapy for anxiety disorders.

Abstract

Over the past two decades a new model of behavior change--one derived from a functional contextual philosophy, while up holding to basic principles of learning with an eye on practical utility--has emerged tour de force of the psychotherapy scene. This model is based on a modern behavior analytic account of language and cognition known as relational frame theory (RFT; see Hayes, Barnes-Holmes, & Roche, 2001 or Blackledge, 2003) and the treatment approach is called Acceptance and Commitment Therapy (or ACT as one word). In the latest text to come out of this tradition, Acceptance & Commitment Therapy for Anxiety Disorders by Eifert and Forsyth (2005) thrills the reader with practical solution oriented techniques to working with clients with anxiety problems. It offers a solid case conceptualization and is filled with directions for future research.

Introduction

As the cognitive revolution fades into history a new form of behaviorism has emerged (Hayes, 2004; Kohlenberg, Boiling, Kanter, & Parker, 2002). For nearly two decades, Acceptance and Commitment Therapy (ACT) has evolved from basic learning labs and into clinical practice (Zettle, 2005). In this context, Eifert and Forsyth (2005) offer an inspiring work that brings ACT to the treatment of anxiety disorders including post traumatic stress disorder. Radical changes are underway in the field of mental health care. Many of these changes are challenging the syndrome-based and symptom- focused change agenda that has come to characterize cognitive-behavior therapy and empirically supported psychotherapies. With this book, we have something different--an approach that moves beyond anxiety management and control, to an expanded view of psychological health and functioning. This is the right text coming at the right time for clinicians who work with persons suffering from anxiety-related problems, many of whom spend considerable time stuck in a struggle to control anxiety in order to do what matters most to them in their lives.

Eifert and Forsyth's (2005) Acceptance & Commitment Therapy for Anxiety Disorders emphasizes a theory and process-driven approach to the behavioral treatment of anxious persons. That is, the ACT model of human suffering guides the application of the intervention strategies throughout. This is not a book outlining a hodge-podge collection of intervention techniques. In fact, the treatment flows from a solid conceptual foundation, much of which is fundamental to ACT, namely Relational Frame Theory (or RFT; Hayes, Barnes-Holmes, & Roche, 2001). The central tenet of the ACT approach to anxiety is acceptance of unpleasant private events--be they verbal, imaginable, physical, or behavioral--that accompany anxiety and fear-related emotional states. As the authors point out, non-acceptance of anxiety is suffering, whereas acceptance transforms anxiety into pain that most people experience at one time or another in their lives. Helping clients to move past anxiety as an obstacle to the life they want to lead is fundamental to the treatment outlined in this book. In fact, many clinicians will find the functional and process-oriented feel of the intervention quite refreshing and fitting with what they normally do in clinical practice. With this book, conceptualization is closely tied with assessment and treatment. This welcome bridge is a real step forward in meeting the practical needs of clinicians working with anxious clients. This book takes the reader a long way in reaching that goal.

This is simply a marvelous book, filled with very intriguing ideas. While it has been awhile since I have worked with persons suffering from panic and related anxiety problems, the central message of the book rings true. That message is this--avoidance of anxiety is a diathesis that can turn anxiety into a true disorder. I remember a particular panic client who spent a great number of his days trying to avoid "that feeling" he had "when he panicked." In addition, I remember another client who reported great anger when he became "embarrassed" and that often he would react to these feeling with frustration and violence. Acceptance strategies in such cases could be very helpful in diffusing such situations while helping the client to look forward toward what they wish to spend their time doing. A growing body of research seems to be lending support to the notion that suppression and avoidance are problematic, not the aversive emotions themselves (Eifert & Heffner, 2003; Levitt, Brown, Orsillo, & Barlow, 2004).

An ace for the book is the strong link between conceptualization and treatment. This allows the clinician to gain from the practical wisdom of the book and use it as a flexible guide to treatment cases that on the surface could seem quite disparate

Much of the book can be read as instructions in how to identify and label emotional avoidance, move clients toward greater acceptance of their emotional suffering and toward recognition of the values they hold and ways to live their lives in accord with those values. The importance of balancing acceptance and change in emphasized throughout. The book is nicely divided into three parts: (1) Understanding anxiety disorders (2) How ACT reframes the anxiety dimension and (3) ACT treatment of anxiety. The book does a thorough job of covering the most current and important aspects of ACT interventions for anxiety. I was especially impressed by the second chapter which presents a very strong argument that all anxiety disorders share a common pathway of avoiding negative affect at all costs.

Chapters 7-11 offer a treatment manual for anxiety disorders. The session-by-session breakdown shares much with other ACT treatment manuals but I believe it is the most comprehensive to date. The exercises are easy to use with clients and offer much in generating discussion with students if used as a course text. I particularly liked the "Anxiety News Radio Metaphor." In addition, the treatment manual makes ACT easy to replicate and use to conduct treatment outcome studies. The other ACT books do not include a clear step-by-step outline that shows how ACT is to be done. Along this line, perhaps the most unique feature of the book is that it comes with a CD-ROM that is loaded with practical client surveys, questionnaires, worksheets and inventories. I believe these practical products can be easily printed out and used with clients

In addition the prose and readability for the text is understandable to both clinician and graduate student who have no background or prior understanding of ACT. Finally the book offers much for practical usefulness.

I enjoyed the books final chapters which offer much clinical insight. I found the section on managing resistance to be both practical and interesting. Though the book could be strengthened by reviewing some of the literature on functional models of resistance (Cautilli, Riley-Tillman, Axelrod, & Hineline, 2005), the authors do a fine job of covering this topic in enough depth for their purposes. The chapter outlines clear directions for future research, the need for more flexible process-oriented treatment manuals.

Another area that was of particular interest to me was integrating acceptance with behavioral activation. The authors use behavioral activation as a way to get clients moving forward in valued directions. Much research has supported activation since its first formulation in the 70s as a comprehensive treatment modality. This integration part unique and strengthens ACT as a treatment. This has not previously been done in other ACT books, where the commitment part remains somewhat vague.

The authors have recast behavioral activation within the context of acceptance and value guided action--not simply about feeling better and moving more, but doing what matters in life and living better.

It is hard to find a critical point about the book. The only that I could think of would be that it does not place enough emphasis on controlling variables in the therapeutic relationship. The therapeutic relationship is the source of much growth within therapy (Kohlenberg & Tsai, 1991) and is the source of intensive contingencies (Ryan, & Krumboltz, 1964) whether or not the therapist is aware of using those contingencies (see Cautilli, Riley-Tillman, Axelrod, and Hineline, 2005). Even saying this, I believe that this effect is tempered by the great lengths the Eifert and Forsyth (2005) go to talk about the therapeutic relationship and the importance of compassion and the therapist taking an equal stance/posture with the client throughout treatment. The authors particularly stress such issues in the Core Therapist Competencies Section. I believe that Eifert and Forsyth's (2005) are the first to really pull relational variables and the ACT concepts together in a form that is understandable and useful to practitioners and even students and researchers. Thus maybe this critique boils down to me that ACT is not FAP, but who is to say it should be.

In sum, Acceptance & Commitment Therapy for Anxiety Disorders is a valuable and enormously practical book, especially those who specialize in the field of human anxiety and suffering. It can also be a critical book for non-specialists as well. It offers a unique understanding of a common clinical problem and a model of change that shows great promise as a framework for the promotion of health and the alleviation of human suffering. It gives readers a rare insight into the understanding of a complex behavioral problem. It will be interesting to see what a follow up volume 10 years from now will tell us about the impact of this work

Conclusion

Say "behavior therapy" to a psychologist or counselor in a word association test and you would likely get the response "mechanistic", or "please insurance companies" or possibly "irrelevant to client problems" or "amoral." Eifert and Forsyth's (2005) book goes along way to counter such views. The approaches they describe is solidly clinical, draws strongly from contextualism, and offer clinicians a flexible model and practical intervention strategies to help get their clients unstuck and moving forward with their lives. This book does much toward building bridges to integrate psychology. ACT continues to generate interest and a strong clinical following. In addition, it continues to find clinical utility in many areas of clinical psychology. ACT seeks not to divide psychology but to use well established behavioral principles to unite and strengthen clinical treatment. Thus, as an approach ACT will continue to reenchant interest in behavior therapy. With respect to this book, clinicians, novice and experienced alike, will come away from reading this book understanding ACT but also knowing how to do it. I hope that the authors use this template to address other presenting problems such as depression and issues that get in the way of clients moving forward in their lives. I understand that they have already done so with "ACT on Life, Not on Anger: The New Acceptance and Commitment Therapy Guide to Problem Anger." I eagerly await a read of that book too.

References

Blackledge, J. (2003) An Introduction to Relational Frame Theory: Basics and Applications. The Behavior Analyst Today, 3 (4), 421-431

Bolling, M., Kohlenberg, R.J. & Parker, C. R. (2000). Behavior analysis and depression. In M.J. Dougher (Ed) Clinical Behavior Analysis (pp. 127-152). Context Press: Reno NV

Cautilli, J.D., Riley-Tillman, T.C., Axelrod, S., and Hineline, P.N (2005 a). Behavioral models of resistance. International Journal of Behavioral Consultation and Therapy, 1(2), 126-140.

Cautilli, J.D., Riley-Tillman, T.C., Axelrod, S., and Hineline, P.N (2005 b). The role of verbal conditioning in third generation behavior therapy. The Behavior Analyst Today, 6(2), 138-145.

Eifert, G.H. & Forsyth, J.P. (2005). Acceptance and Commitment Therapy for Anxiety Disorders: A practioner's treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. New Harbinger Publications.

Eifert, G.H. & Heffner, M. (2003). The effects of acceptance versus control contexts on aviodance of panic-related symptoms. Journal of Behavior Therapy and Experimental Psychiatry, 34, 293-312.

Levitt, J.T., Brown, T.A., Orsillo, S.M., & Barlow, D.H. (2004). The effects of acceptance versus suppression of emotion on subjective and psychophysiological responses to carbon dioxide challenge in patients with panic disorder. Behavior Therapy, 35, 747-766.

Hayes, S.C. (2004). Acceptance and commitment therapy, relational frame theory, and third wave of behavior therapy. Behavior Therapy, 35, 639-665.

Hayes, S.C., Barnes-Holmes, D., & Roche, B.(2001). Relational frames theory: A post Skinnerian account of human language and cognition. New York: Kluwer-Plenum.

Kohlenberg, R.J, Boiling, M., Kanter, J.R., & Parker, C. (2002) Clinical Behavior Analysis: Where It Went Wrong, How It Was Made Good Again, and Why Its Future is So Bright. The Behavior Analyst Today, 3 (3), 248-256

Kohlenberg, R.J. & Tsai, M.(1991). Functional analytic psychotherapy: Creating intense and curative therapeutic relationships. New York: Plenum Press.

Ryan, T.A. & Krumboltz, J.D.(1964). Effects of planned reinforcement counseling on client decision-making behavior. Journal of Counseling Psychology, 11, 315-323.

Zettle, R.D. (2005). From comprehensive distancing to ACT. The International Journal of Behavioral Consultation and Therapy, 1(2), 67-75.

Author Contact Information:

Joseph D. Cautilli, Ph.D.

Children Crisis Treatment Center

1823 Callowhill Street

Philadelphia, PA 19130

jcautilli@cctckids.com
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Author:Cautilli, Joseph
Publication:The International Journal of Behavioral Consultation and Therapy
Date:Sep 22, 2005
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