Download Integrating Acceptance-based Behavior Therapy into

Integrating Acceptance-based
Behavior Therapy into
Exposure-based therapy
for PTSD
Acknowledgments
Susan Orsillo, PhD
Suffolk University
Lizabeth Roemer, PhD
University of Massachusetts, Boston
The third wave
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Behavior Therapy
Cognitive Therapy
Acceptance-based models
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Acceptance and Commitment Therapy (ACT)
Mindfulness-based Cognitive Therapy (MBCT)
Acceptance-based Behavior Therapy for GAD
Dialectical Behavior Therapy (DBT)
Integrative Behavioral Couple Therapy (IBCT)
Behavioral Activation (BA)
Functional Analytic Psychotherapy (FAP)
Mindfulness-based Relapse Prevention (MBRP)
An etiological model of PTSD
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Generalized psychological vulnerability
Generalized biological vulnerability
Experience of trauma
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Developed by classical conditioning
Maintained by operant conditioning
Anxious apprehension
Avoidance or numbing of emotional response
Moderated by social support and ability to cope
(Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)
Evidence-based psychological
treatments for PTSD
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General aims
Extinction of conditioned fear and anxiety
responses through repeated, non-reinforced
exposure to CS
 Development of alternative, competing
responses to anxiety and fear
 Emphasis on symptom reduction through
mastery experiences and internal control
strategies
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Evidence-based treatments
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Exposure Therapy
Anxiety Management Training (AMT)
Combination treatments
(Foa, Keane & Friedman, 2000; Keane et al, 2006; Roth & Fonagy,
2005)
Exposure Therapy
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Patient is guided through a vivid remembering of
the trauma until extinction occurs
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Goal is to reduce avoidance of anxiety and
promote control/mastery over trauma-related
cues
(Foa and Rothbaum, 1998)
Anxiety Management Training
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Package of behavioral and cognitive
strategies to reduce and control anxiety
Progressive muscle relaxation
 Diaphragmatic breathing
 Cognitive restructuring
 Communication skills training
 Time management
 Anger management/assertion training
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(Meichenbaum, 1994)
Combination treatments
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Package of CT, exposure and emotion
regulation skills
Essential components of CT
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Self-monitoring
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Cognitive restructuring
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Identification and labeling of thoughts and
associated emotions
Changing the content of a ‘dysfunctional’ cognition
through logical analysis
Hypothesis testing
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Conducting behavioral experiments to evaluate the
validity of dysfunctional thoughts
Combination treatments
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Cognitive Processing Therapy (CPT)
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Written exposure trials
cognitive restructuring of trauma related erroneous
cognitions and schemas, particularly regarding safety,
trust, power, control, self-esteem and intimacy
STAIRS
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Emotion regulation and distress tolerance skills
Prolonged exposure
CSA related PTSD
(Resick et al. 2002; Cloitre et al., 2002)
The good news about EBTs for PTSD
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Treatments are efficacious when compared to
TAU, wait list control and active placebo
treatments
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67% of completers no longer meet criteria for PTSD
56% of intent-to-treat patients no longer meet criteria
for PTSD
Exposure and CBT are generally equally
efficacious
(Bradley, 2005)
Limitations of current treatments
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44% of intent-to-treat patients continue to meet
criteria for PTSD (Bradley, 2005)
Using DSM criteria as treatment outcome may
not be relevant to clinically significant change
Generalization of findings limited by study
exclusion rates averaging 30%
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Co-morbid Axis I disorder
Current substance abuse
Suicidal ideation or behavior
More limitations
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Relative lack of effectiveness research
RCTs generally compare monotherapies and not
multimodal therapies
lack of evidence regarding long-term
maintenance of gains
Vast majority of community sample patients do
not receive EBTs
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Due to lack of dissemination
Due to lack of treatment acceptance by patients
And still more
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Lowest effect sizes for patients with combatrelated PTSD compared to other traumas
Focus on symptom reduction and not functional
improvement
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Interpersonal relationships
Vocational functioning
General quality of life
Limitations specific to CBT
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Relatively difficult to train therapists to
adherence (Kohlenberg, 2004; Dimidjian et al, 2006)
Emphasis on control and mastery strategies can
have paradoxical effect in anxiety disorders
(Roemer & Borkovec, 1994)
Limitations specific to exposure
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Requires memory of a specific trauma event
May have low acceptability to patients and
providers
PTSD patients have more negative attitudes
toward emotional expression
Exposure less effective for patients:
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High levels of anger at pre-treatment
High levels of avoidance at pre-treatment
Perpetrators of harm who experience guilt/shame as
primary symptoms
Potential limitations of standard
therapies for OIF/OEF veterans
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Stigma associated with mental health care
Reluctance to participate in exposure
Presence of co-morbid conditions
Lack of a single traumatic event
Associated feelings of guilt, loss, anger,
sadness, grief
Potential for iatrogenic effects of exposure
The challenge in treating OIF/OEF
veterans
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How do we provide secondary prevention?
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Proper treatment may help prevent the development
or progression of symptoms, or the underlying
mechanisms leading to pathology (Zatzick et al. 2004)
what are these mechanisms?
What is the natural course of resilience, remission
and recovery? (Bonanno 2004)
How can we use current treatments in secondary
prevention?
How can we adapt or elaborate on these treatments
for use with recently returned veterans?
Spectrum of Post-Deployment
Mental Disorders (N = 46,571)
Disorder
PTSD
Drug Abuse
Depression
Neurotic Disorders
Affective Psychosis
Alcohol Dependence
Acute Stress Reaction
N
%
20,638
17,768
14,317
11,481
7,460
3,116
1,327
44%
38%
31%
25%
16%
7%
3%
VHA Office of Public Health and Environmental Hazards, February 14, 2006
The cautionary tale of Critical Incident
Stress Debriefing (CISD)
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Intervention intended as secondary prevention
for occupational trauma exposure (Mitchell 1983;1993)
Proprietary; dramatic claims of effectiveness
Basic assumptions
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Exposure to traumatic stressor is sufficient to cause
symptoms that can escalate to a pathological
condition
Early and proximal intervention involving emotional
catharsis (exposure) is prophylactic
CISD procedures
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Format
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Group administration
Delivered by a mental health provider assisted by
non-professional peers
Conducted in one 2-3 hour session within 24-72
hours of traumatic event
Mandatory attendance customary
Non-attendees or drop-outs typically retrieved by peer
facilitator
CISD treatment protocol
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Introduction of the debriefing
Statement of facts regarding the traumatic event
Disclosure of thoughts regarding the event
Disclosure of emotional reactions, with focus on
strong negative affects
Specification of possible symptoms
Education regarding consequences of trauma
exposure
Planned re-entry to social environment
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(Mitchell & Everly, 1993)
CISD outcome research
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No clinically significant improvement for participants at
long-term follow-up
Slight but statistically significant worsening on outcome
measures for those accepting debriefing
Preference for informal sources of support and
assistance correlated strongly with improved outcome
Those with highest levels of both avoidance and
intrusive recollection deteriorated most after debriefing;
recovery better among those not receiving treatment
(Mayou et al. 2000)
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“CISD is inert at best and iatrogenic at worst” (Lohr et al.
2003)
An etiological model of PTSD



Generalized psychological vulnerability
Generalized biological vulnerability
Experience of trauma





Developed by classical conditioning
Maintained by operant conditioning
Anxious apprehension
Avoidance or numbing of emotional response
Moderated by social support and ability to cope
(Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)
Approaches to providing secondary
prevention
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Watch and wait
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Respect the natural course of recovery among the
resilient
Support naturally occurring restorative factors in
patient’s life
Provide supportive treatments that do not interfere
with natural resilience and are not iatrogenic
Wellness
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Provide treatments that enhance naturally occurring
restorative factors
Example: Behavioral Activation (BA)
Secondary prevention approaches
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Rehabilitation
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Support naturally occurring curative factors in
patient’s life +
Provide treatments that prevent or inhibit pathological
mechanisms implicated in the development and
maintenance of psychological distress
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Experiential avoidance
Co-morbid conditions that serve the function of experiential
avoidance, especially SUDs and rumination
Acceptance-based Behavior Therapy
(ABT)
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Standard therapies
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Based on a conditioning model of PTSD
Aim is to reduce fear and anxiety through extinction
Coupled with strategies to change trauma-related thought
content
An alternative model
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PTSD can be understood as a disorder of experiential avoidance
(Hayes et al. 1999)
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Aim is to improve quality of life
Coupled with strategies to change the process of cognition
rather than the content
(Orsillo & Batten 2005; Batten et al. 2005; Follette et al. 2004)
Experiential avoidance
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Attempts to change the form or frequency of
internal events (thoughts, feelings, memories,
sensations) (Hayes et al. 1996)
EA contributes to the development and
maintenance of various forms of
psychopathology, particularly anxiety disorders
Anxiety disorders develop when individuals are
unwilling to experience anxiety (and associated
thoughts, images, distressing emotions)
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A variety of external and internal control strategies are
utilized to alleviate distress via escape and avoidance
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Behavioral avoidance of situations and cues (CS) that elicit
unwanted internal states (CR)
Cognitive control strategies to avoid unwanted states
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Internal and external control strategies are negatively
reinforced
External control strategies generalize
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lead to disengagement with the naturally rewarding
contingencies in the environment
Internal control strategies generalize
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Thought suppression
Worried rumination
Distraction
Become rigid and inflexible
Lead to narrowing of attention
Control strategies maintain distress / cause rebound
Thought suppression
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Effortful suppression of thoughts
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Initially relieves distress
Has paradoxical long-term effect with rebound of
avoided imagery
Leads to escalating efforts to control and master
thoughts and imagery
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Thought suppression associated with negative tx
outcome (CSA, rape, MVA, Gulf War, urban violence)
Behavioral therapies have been adapted to
specifically target experiential avoidance as a
core feature of pathology
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(Borkovec et al. 2004)
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Acceptance-based Behavior Therapies
(ABT)
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Acceptance and Commitment Therapy (ACT) (Hayes et
al. 1999, 2004; Eifert & Forsyth, 2005)
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Mindfulness-based Cognitive Therapy (MBCT) (Segal et
al. 2002)
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Acceptance-based Behavior Therapy for GAD
(Roemer& Orsillo, 2004, 2005)
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Dialectical Behavior Therapy (DBT) (Linehan, 1993)
Integrative Behavioral Couple Therapy (IBCT)
(Jacobson & Christensen, 1996)
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Behavioral Activation (BA) (Jacobson et al. 1996; Dimidjian et
al. 2006)
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Functional Analytic Psychotherapy (FAP) (Kohlenberg &
Tsai, 1991; Kohlenberg et al. 2004)
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Mindfulness-based Relapse Prevention (MBRP)
(Marlatt et al. 2005)
Acceptance-based Behavior Therapy
(ABT)
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Basic assumptions
Treatment components
Treatment strategies and techniques
ABT assumptions
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Emotions are just emotions; thoughts are just
thoughts; memories are just memories
Emotions are information; not good or bad
Control of internal events is not an option
Control is the problem, not the solution
Similarities to Exposure/CBT
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Both consider avoidance to be a core feature of
pathology
Both advocate approach as an integral
treatment strategy
Differences from Exposure/CBT
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Approach and avoidance
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Approach behaviors are inherently valuable
Approach behaviors are pragmatically valuable in
order to reengage with natural reinforcers and expand
domains of functioning
Emphasis on clinically valued change rather than
symptom reduction
Differences
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Attention
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CBT emphasizes directing attention toward stimuli
associated with disorder (or distract from)
ABT emphasizes directing attention broadly toward
flow of experience
Differences
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Cognition – radically different understanding of
the role of cognition in development and
treatment of disorders
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Cognitions are causal vs. cognitions are responses
Importance of content vs. importance of function
Goal to change content vs. goal to change
relationship to one’s own thoughts and feelings
Differences
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Control within the CBT framework
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Lack of perceived control and unpredictability strongly
associated with distress (Mineka et al. 2006)
Control/predictability can be increased by
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Attending to thoughts and associated emotions
Changing thoughts from irrational to rational
Through process of logical analysis and behavioral
experimentation
Differences
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Control within the ABT framework
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Efforts to exert internal control maintain distress
Thoughts and emotions are transitory experiences of
the mind and body
Treatment provides experiential learning of
acceptance rather than control
Distress naturally wanes as a consequence of not
being escalated by control strategies (e.g., MBCT)
ABT treatment components
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Overarching goals
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Target experiential avoidance and expand experiential
acceptance
Target associated behavioral restrictions and expand
engagement with valued life goals and activities
1. Psychoeducation
2. Assessment
3. Experiential acceptance
4. Valued action
1. Psychoeducation
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Role of emotions as information (Linehan 1993)
Limits and costs of control strategies (Roemer &
Orsilllo 2004)
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Importance of approach and emotional
engagement in therapy sessions (Jaycox et al. 1998)
2. Assessment
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General assessment
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Symptom review and diagnostic assessment
Self-report measures
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PTSD
Anxiety
depression
Self-report functional measures
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Life satisfaction
Valued life domains
(Roemer & Orsillo, 2004; Orsillo & Batten, 2005)
2. Assessment
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Avoidance and suppression
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Self-report measures of experiential avoidance and
thought suppression (Hayes et al. 2006; Eifert & Forsyth, 2005)
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Acceptance and Action Questionnaire (AAQ)
White Bear Suppression Inventory
Thought Control Questionnaire
Values assessment
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Self-report measures to identify idiographic treatment
outcomes (Hayes et al. 1999, Eifert & Forsyth, 2005)
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Generate values
Rate values to establish priorities
Identify intermediate steps, actions and barriers
3. Experiential acceptance
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Mindfulness
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Willingness
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Encourages approach behaviors
Distress tolerance skills
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Targets identification of thoughts/feelings as ‘reality’
Targets avoidance due to inability to tolerate emotion
Emotion regulation skills
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Targets avoidance due to inability to modulate
emotion
Key concepts in Mindfulness
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Decentering
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Early problem recognition
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Intentional awareness allows “turning toward”
difficulties
Anti-ruminative
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Experiencing thoughts and feelings as mental events
and not reality
Experience is of current awareness, not elaborate
thinking about implications, meaning, etc.
Generic skill
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Daily practice competes with development of
avoidance, escape and control strategies
(Segal et al, 2002)
Steps in Mindfulness training
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Practice attention to a single sense
Practice attention to the flow of experience
Practice attention to thoughts, feelings, images
as part of the flow of experience
Practice attention to the flow of experience
during activities
Mechanisms of Mindfulness
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Exposure to previously avoided classes or
categories of emotional experience, leading to
decreased distress via extinction
Self-monitoring associated with improved
appraisal of actual contingencies, leading to
increased flexibility in responding
State of relaxation (response prevention)
Change in attitude toward internal experiences
leads to decreased volatility
(Baer, 2003; Teasdale et al. 2002; Segal et al. 2002)
4. Valued action
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Assessment questions
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What is important to the patient?
To what extent are they living life in accordance with
their values?
How do their symptoms interfere with the pursuit of
their values?
4. Valued action
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Intervention techniques
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Writing exercises to clarify values
Self-monitoring to assess degree to which life is spent
in valued activities (and/or degree to which patient is
emotionally engaged in valued activities)
Goal setting
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Identify concrete steps intermediate to valued activities
Commit to plan
Identify potential barriers
Review previous goals
(Roemer & Orsillo, 2004; Eifert & Forsyth, 2005; Orsillo & Batten, 2005)
Integrating Exposure Therapy
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Exposure sessions for specific events as well as
classes of emotion
Goal is acceptance rather than extinction
Therapist must be practiced in approaching
emotional experience, and mindful of not
colluding with patient in experiential avoidance
Therapist must be capable of achieving the
metacognitive state of ‘engaged observation’
Summary
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Acceptance-based therapies are useful
extensions of exposure-based in secondary
prevention of PTSD and co-morbid disorders
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Empirical support in treatment of anxiety, depression,
SUDs, couples, BPD
Acceptable to patients
Accommodates exposure for emotions other than fear
& anxiety, or in absence of Criterion A
Teaches cognitive and behavioral skills that may
prevent development of avoidant and controlling
strategies associated with the exacerbation of anxiety,
depressive relapse, substance use, conflict, and
intimacy problems
Goal is broad functional improvement