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Cognitive and Behavioral Practiexploring mindfulness and acceptance-based approaches.In its most basic form, mindfulness is about focusing ourattention on the present moment and making directcontact with our present experiences, with acceptanceand without defense, and with as little judgment aspossible (Kabat-Zinn, 1994).

This work has led to innovative experimental andapplied applications for a wide range of psychopathology

doing so, we wish to point out that what follows is justone of several ways (not the way) that ACT may beapplied to persons suffering from anxiety disorders.

ACT has two major goals: (a) fostering acceptance ofproblematic unhelpful thoughts and feelings that cannotand perhaps need not be controlled, and (b) commit-ment and action toward living a life according to one'schosen values. This is why ACT is about acceptance and it(Ha(HaHerTea

1077 2Publdevelopment of empirically derived and time-ted behavioral and cognitive-behavioral interventionsssist those suffering from anxiety and fear-relatedlems (Barlow, 2002; Beck, Emery, & Greenberg,). This work continues in earnest, as researchers andtitioners work to improve the potency, durability, andctiveness of such interventions. Gaining knowledge ofhanisms and processes that mediate positive out-es continues to receive research attention as well.r the past decade, part of this effort has focused on

newer line of exploration, and studies have shown tACT can be effective for the treatment of generalianxiety disorder (Roemer, Orsillo, & Salters-Pednea2008), obsessive-compulsive disorder (Twohig, HayesMasuda, 2006), and posttraumatic stress disorder (Ors& Batten, 2005). Our purpose here is to describeintegrated application of ACT that can be adapteduse with any of the major anxiety disorders (EiferForsyth, 2005), including outcome data from thclients with different anxiety disorder diagnoses.Acceptance and Commitment TheraStudies Exemplifying a U

Georg H. Eifert,John P. Forsy

Joanna Arch, Emmanuel Espejo, M

Acceptance and Commitment Therapy (ACT) is an innovativesuccessfully to treat a variety of clinical problems, including the amindfulness processes with commitment and behavior changeexcessive struggle with anxiety and experiential avoidanceattemimages, bodily sensations). The goal is to foster more flexible and mimportant to them. This article describes in some detail a unifiedany of the major anxiety disorders. To exemplify this approach,different anxiety disorders who underwent treatment over a 12-weACT-relevant process measures (e.g., reductions in experiential avquality of life, as well as significant reductions in traditional animproving on their posttreatment level of functioning.

VER the last 40 years, behavior therapy has led theyes, Follette, & Linehan, 2004), including anxietyyes, 1987; Orsillo, Roemer, Block-Lerner, LeJeune, &bert, 2005) and depression (Segal, Williams, &sdale, 2002). Acceptance and Commitment Therapy

-7229/09/368385$1.00/0009 Association for Behavioral and Cognitive Therapies.ished by Elsevier Ltd. All rights reserved.for Anxiety Disorders: Three Casefied Treatment Protocol

pman UniversityUNYAlbanyy Keller, and David Langer, UCLA

ance-based behavior therapy that has been applied broadly anddisorders. Throughout treatment ACT balances acceptance andses. As applied to anxiety disorders, ACT seeks to undermineo down-regulate and control unwanted private events (thoughts,ul ways of relating to anxiety so individuals can pursue life goalsprotocol that can be adapted for use with persons presenting withresent pre- and posttreatment data from three individuals withiod. The results showed positive pre- to posttreatment changes ince, increases in acceptance and mindfulness skills), increases inand distress measures. All three clients reported maintaining or

www.elsevier.com/locate/cabpce 16 (2009) 368385is about change at the same time. Applied to anxietydisorders, clients learn to end the struggle with theiranxiety-related discomfort and take charge by engaging inactions that move them closer to their chosen life goals(values). Instead of teaching more, different, betterstrategies to change or reduce unwanted thoughts andfeelings, ACT teaches clients skills to acknowledge andobserve unpleasant thoughts and feelings just as they are.

369ACT for Anxiety DisordersThis less avoidant and more flexible way of responding toanxiety and other forms of emotional discomfort creates aspace for individuals to act in ways that move them in thedirection of chosen life goals even when unpleasantthoughts, feelings, and bodily sensations are present.

An ACTapproach to anxiety disorders is predicated onthe notion that anxiety disorders are characterized byexperiential and emotional avoidance, defined as atendency to engage in behaviors to alter the frequency,duration, or form of unwanted private events (i.e.,thoughts, feelings, physiological events, and memories)and the situations that occasion them when suchavoidance leads to problems in functioning (Hayeset al., 1999). The function of experiential avoidance isto control or minimize the impact of aversive internalexperiences. Experiential avoidance can produceimmediate, short-term relief from negatively evaluatedanxiety-related thoughts and emotions, which negativelyreinforces such behavior. It becomes problematic when itinterferes with a person's everyday functioning and life-goal attainment. As described in more detail elsewhere(Eifert & Forsyth, 2005; Forsyth, Eifert, & Barrios, 2006),rigid and inflexible down-regulation of emotions andpatterns of emotional and experiential avoidance isthought to function as a core psychological diathesisunderlying the development and maintenance of severalforms of psychopathology (Blackledge & Hayes, 2001;Hayes, Wilson, Gifford, Follette, & Strosahl, 1996;Kashdan, Barrios, Forsyth, & Steger, 2006), including allanxiety disorders and depression (Barlow, Allen, &Choate, 2004). For instance, Karekla, Forsyth, and Kelly(2004) found that emotional avoidance was morepredictive of panic responses than other psychologicalrisk factors for panic such as anxiety sensitivity, even inhealthy individuals. This avoidance of discomfort is linkedwith language processes (e.g., entanglement in one's ownjudgments and evaluations), rule-governed patterns ofaction and inaction (e.g., I might get anxious in thatunfamiliar situation, so I'd better not go), and negativeself-evaluations (e.g., I am worthless or I am incompe-tent). Such avoidance is problematic because it occurs inthe context of competing approach contingencies, that is,actions that clients wish to engage in as part of a goodquality of life, and in that context the avoidance behaviortends to dominate over approach behavior. This is whyexperiential avoidance is one of the most importanttreatment targets in ACT.

Apostureof experiential acceptance, by contrast, qinvolvesexperiencing events fully and without defense . . . andinvolves making contact with the automatic or directstimulus functions of events, without acting to reduce ormanipulate those functions, and without acting on thebasis solely of their derived verbal functionsq (Hayes, 1994,p. 30). Acceptance, unlike experiential avoidance, reflectsan openness to all types of experience (both aversive andpleasant) and a commitment to abandon the changeagenda where it does not work well and thereby has anegative impact on functioning and only serves toincrease distress, namely, in the realm of private events(Marx & Sloan, 2004). Several independent lines ofresearch (for an extensive review, see Hayes, Luoma,Bond, Masuda, & Lillis, 2006) support the notion thatrigid and inflexible (i.e., context insensitive) attempts tosuppress and control unwanted private events are largelyineffective, and can result in more (not less) unwantedthoughts and emotions (Koster, Rassin, Crombez, &Nring, 2003; Purdon, 1999), increase distress and restricteffective life functioning (Marx & Sloan, 2004), andreduce engagement in meaningful and valued lifeactivities with a concomitant poorer overall quality oflife (Dahl, Wilson, & Nilsson, 2004; Hayes et al., 2006).Other related lines of work have shown that avoidantcoping strategies such as denial, mental disengagement,and substance abuse predicted more frequent and intenseCO2-induced physical and cognitive panic symptoms thanacceptance-based coping strategies (Feldner, Zvolensky,Eifert, & Spira, 2003; Spira, Zvolensky, Eifert, & Feldner,2004). Similarly, Eifert and Heffner (2003) found thatwhen highly anxious females were exposed to CO2-enriched air, participants in an acceptance context wereless avoidant behaviorally, reported less intense fear andfewer catastrophic thoughts, and were less likely to dropout of the study than participants in a control context.These results were replicated in a procedurally similarstudy with actual clients suffering from panic disorder(Levitt et al., 2004). Lower experiential avoidance andgreater acceptance also enhance willingness to engage inexposure exercises (Levitt et al., 2004) and may preventdropout (Karekla & Forsyth, 2004) in persons with panicdisorder. Collectively, this work suggests that experientialavoidance is a potentially toxic process linked with formsof distress and life impairment, and that strategiespromoting approach or acceptance of discomfort maybe worthwhile as healthier alternatives.

As in themindfulness-based cognitive therapy programfor depression developed by Segal and colleagues (2002),one of the core skills to be learned in ACT programs ishow to step out of entanglements with self-perpetuatingand self-defeating emotional, cognitive, and behavioralavoidance routines. This is achieved by teaching clientsvarious skills aimed at undermining excessive and rigidthought and emotion regulation (Masuda, Hayes, Sackett,& Twohig, 2004). Based on the bulk of empirical datashowing the negative impact of experiential avoidance,ACT does not attempt to help clients to control ormanage anxiety and instead teaches them how to let go oftheir control struggle. Thus, ACT is different from whatmany clients and therapists typically expect must be done

370 Eifert et al.to solve anxiety problems. It is therefore an essential firststep in treatment that therapists help clients experiencethe costs of remaining trapped in the idea that effectiveanxiety control is a prerequisite for leading a better life,and how anxiety control strategies have negativelyimpacted their life functioning and increased distresswhen they failed to work as intended (see also Eifert &Heffner, 2003; Levitt et al., 2004).

Treatment Overview

The ACT for Anxiety program is a unified treatmentprotocol that guides therapists in the flexible applicationof ACT principles and techniques for clients presentingwith any of the major anxiety disorders (Eifert & Forsyth,2005). An expanded version of the protocol is alsoavailable in the form of a self-help workbook (Forsyth &Eifert, 2008). A formal evaluation and comparison of thisACT protocol with a unified CBT protocol is under wayin the context of a clinical trial at UCLA that specificallyexamines the relation between treatment outcome andprocesses of change in the two treatment approaches.Here, we will provide an overview of the original unifiedACT for Anxiety protocol, followed by outcome datafrom three clients who have completed the ongoingclinical trial.

The delivery of the treatment protocol itself isorganized around three interwoven phases. The goal ofPhase 1 (Sessions 1 through 3) is to create an acceptancecontext for anxiety-related discomfort, and this work setsthe stage for the remaining treatment sessions. With thehelp of metaphors and exercises, clients experience thecosts of past efforts to control and manage anxiety.Rather than avoid their anxiety-related experiences,clients begin to learn some basic skills to stay withanxiety-related discomfort and look at it from a mindfulobserver perspective.

In Phase 2 (Sessions 4 through 7), the focus shifts toidentifying clients' most cherished life goals (values) andteaching skills designed to build more flexible patterns ofbehavior when anxiety and fear arise. During exposureexercises, framed in the context of client values, clientslearn to practice mindfulness skills in the presence ofanxiety-related discomfort. Mindfulness is an importantskill to learn because it counteracts past experientialavoidance strategies aimed at controlling or reducinganxiety-related discomfort that tend to get in the way ofvalue-guided actions. In these sessions, therapists alsohelp clients make commitments to start engaging inactions that are in accord with those values.

In Phase 3 (Sessions 8 through 12) the focus broadensfurther to help clients engage in value-guided actions intheir natural environment and stay committed to movingin those directions in the face of the inevitable anxiety-related barriers. With the help of worksheets adoptedfrom behavioral activation programs (e.g., Addis &Martell, 2004), therapist and client specify concrete andachievable goals that are derived from one or two valuesidentified by clients in Phase 2. As clients engage in suchgoal-directed activities, they invariably encounter anxiety-related difficulties that used to serve as barriers and oftenresulted in avoidance behavior. Therapists devote muchtime to teach clients to move with such barriers by helpingthem to apply mindful observation and other skills whenfaced with anxiety-related discomfort. Increasing a client'swillingness to stay on the course of committed action, andtaking anxiety along for the ride if it shows up, is animportant focus for the remainder of treatment.

An integral part of ACT is the use of metaphors andrelated experiential exercises throughout treatment.These exercises allow clients to make experiential contactwith thoughts, feelings, memories, and physical sensationsthat have been feared and avoided because they were toofrightening to contact directly. Metaphors are verbalstories that consist of analogies and pictures. As such theycannot be taken literally and allow clients to makeexperiential contact with an aspect of their experiencein a new way and from a different point of view (for amore detailed RFT analysis of metaphors, see Stewart,Barnes-Holmes, Hayes, & Lipkens, 2001). In so doing,they help create distance between themselves and howthey are approaching their anxiety, while also opening thedoor for new solutions to emerge (for detailed descrip-tions of all metaphors and exercises used in our study, seeEifert & Forsyth, 2005; Forsyth & Eifert, 2008).

Session-by-Session Treatment Program and CoreProcess Targets

Although we outline the treatment program in theform of session-by-session guidelines, the actual deliveryof ACT is more akin to a fluid dance around several coreprocesses rather than a linear progression. ACT is afunctional approach, not merely a therapy or collection oftreatment technologies. It builds on a model with severalinterrelated treatment targets that are continually re-visited throughout therapy. At a practical level, this meansthat concepts, metaphors, and exercises introduced earlyon, may be revisited again at any time they seem relevant.Therapists are encouraged to sequence and applyexercises andmetaphors in a flexible and creative fashion.This can be accomplished by individualizing and tweakingtechniques based on the specific circumstances andresponses of each client. This individualization shouldbe guided by an understanding of the core processestargeted in ACT.

ACT may be applied to all anxiety disorders, in part,because it targets a set of central processes that feedanxiety-related problems, regardless of the specific formor anxiety subtype: the struggle with unwanted emotions

371ACT for Anxiety Disordersand cognitions and low levels of engagement in meaning-ful life activities (Hayes et al., 2006). The focus is onchanging the function (rather than form or specificcontent) of unwanted thoughts and emotions so that theyno longer get in the way of effective action. In fact, aconsiderable amount of treatment time is spent onincreasing client actions in everyday life that areconsistent with what clients value and wish their lives tostand for. Where appropriate and necessary, the protocoladdresses anxiety subtype-specific considerations andprocedural variations are provided. The protocol alsoprovides therapists with practical guidelines to integrateACT principles and techniques with the most successfuland effective aspects of cognitive behavioral interventionsfor anxiety disordersin particular exposure and beha-vioral activation as well as social skills training to remedydeficits in some persons with social anxiety problems.

Treatment OrientationLearning New Skills

The first session seeks to provide clients with anunderstanding of the nature and purpose of anxiety andwhat can make anxiety become problematic or asignificant life problem. Here, anxiety and fear aredescribed as adaptive emotions that may, however, turninto life shattering problems when clients respond totheir anxious thoughts, feelings, and memories in rigidand inflexible ways with the goal of not experiencingthem. Therapists introduce the notion that struggle andcontrol may actually interfere with the client's everydayfunctioning and life-goal attainment, and then explorethat notion briefly in terms of clients' life experiences.Therapy is framed as an opportunity to learn andpractice new and more flexible ways of respondingwhen experiencing anxiety. The goal is for clients tolearn skills and ways of no longer letting anxiety be anobstacle to doing what they want to do so they can live arich and meaningful life. Therapists also use the firstsession to emphasize the active, experiential, and partici-patory nature of ACT, and focus on developing rapportand dispelling common misconceptions about fear andanxiety (e.g., anxiety is bad and a problem to be solved).

Examining the Effects of Anxiety Control

EffortsCreative Hopelessness

The first step in a new direction is to identify and thenabandon strategies that have neither helped clients improvetheir life goal attainment and quality of life nor actuallyprovided any lasting relief from anxiety distress. For thisreason, Sessions 2 and 3 focus on creating an acceptancecontext for treatment as an alternative to anxiety controland avoidance. This is accomplished by gently exploringthe usefulness (workability) and effects and costs of thevarious strategies clients have used to cope with andmanageanxiety and by encouraging clients to make space for newsolutions. Specifically, clients examine (a) all the variousstrategies they have employed to manage and control theiranxiety and how well those strategies worked, both in theshort and long-term, (b) how experiential avoidance andefforts to control anxiety have constricted or limited thepatient's life, and (c) what letting go of the struggle withanxiety might look like. This is accomplished experientiallywith the help of metaphor-based experiential exercises thatare acted out in session by the therapist and client together.The purpose of these exercises is to (a) let clientsexperience how all their various attempts to down-regulateanxiety-related experiences (e.g., bodily sensations, images,worries) have not worked and constricted their life, and (b)that letting go of their struggle and doing things that goagainst the grain is not only possible but may be moreviable. To illustrate, we provide two examples of metaphorsthat are typically used at some point in Session 2 or 3.

The Chinese Finger Trap ExerciseA Chinese finger trap is a tube of woven straw about fiveinches long and half an inch wide. Therapist and clienteach take a finger trap and do the exercise together. First,they slide both index fingers into the straw tube, one fingerat each end. If one attempts to pull the fingers out, the tubecatches and tightens, causing discomfort. The only way toregain some freedom and space to move is to push thefingers in first and then slide them out. The purpose of thisexercise is to let clients discover through experience thatattempting to pull away from anxiety, while understandableand seemingly logical (like pulling out of the finger trap),only creates more problems: the harder you pull, the morethe trap tightens, resulting in less room to move and evenmore discomfort. In contrast, doing something counter-intuitive, such as pushing the fingers in rather than out andleaning into the discomfort, effectively ends the struggleand creates literally more space (wiggle room). Followingthe exercise, clients take the finger trap home. We adaptedthis exercise from the metaphor described by Hayes andcolleagues (1999), who present the metaphor to clientsonly in verbal form. Based on the results of a study weconducted (Eifert & Heffner, 2003), we suggest that boththerapist and client act out the metaphor with real fingertraps and together explore the experiential effects ofvarious strategies (i.e., pulling out vs. leaning in).

The Tug-of-War With the Anxiety Monster ExerciseSimilar to the finger trap, this metaphorical exercise setsup a struggle, while pointing to solutions that stand inopposition to what people typically do in a struggle.Interestingly, this metaphor was created by a woman withagoraphobia in the context of her work with an ACTtherapist (Hayes, Wilson, Afari, & McCurry, 1990). Whiletherapists explore the clients' efforts to defeat their

372 Eifert et al.anxieties and fears, they gently suggest that this strugglesounds like a tug of war with an anxiety monster. Theclient is asked if they are willing to see how this might playout in the room. For the exercise, therapists play the roleof the anxiety monster. Both therapist and client take oneend of a rope (about 3 to 4 feet long) and start pulling. Asthe tug of war unfolds, clients notice that efforts to pullharder result in the monster pulling harder right back.Acting out this exercise lets clients physically experiencehow much energy and focus it takes to keep the anxietymonster in check. Also, almost all clients will grab therope with both of their hands, and this dramatically showsthem how their efforts fighting anxiety have left theirhands and feet tied up in the fight and no longer free todo other things in life. One key element of this exercise isto let clients experience that they have a choice: continueto fight or drop the rope. Once clients actually drop therope, they experience the difference this action makesand what they gain from it: less strain and more room tomove. Clients also learn that the choice is not whether theanxiety monster is there or not, but whether to pick up therope again and fight. Here clients experience in a veryconcrete fashion what they cannot control (what theanxiety monster does) and what they can controlwhatthey do with their hands and feet. To enhance theexercise, therapists may bring important life areas into theroom, where the anxiety monster tends to show up andgets in the way of what they want to do. Incidentally,therapists need not worry about ending up in a fight withtheir clients. We have found that clients fully recognizeand stay within the playful boundaries of the exercise.

Creative HopelessnessThese metaphors are used during this phase of treatmentto induce creative hopelessness (Hayes et al., 1999) byletting clients experience that former solutions have notworked (hopelessness) and that therapy presents anopportunity to create new outcomes with a radicallydifferent approach (accepting rather than struggling). Toget there, clients must let go of old strategies that have notworked. Many clients have difficulty grasping what lettinggo means in practical terms and what letting-go behaviorlooks like. A practical aspect of letting go is to learn toobserve anxiety-related experiences mindfully rather thanstruggling with, or attempting to eliminate, such experi-ences. This theme is introduced with a formal 12-minuteeyes-closed mindfulness exercise (acceptance ofthoughts and feelings exercise), which was adaptedfrom more generic versions (Davis, Eshelmann, & McKay,2000; Segal et al., 2002) for the purposes of this anxietytreatment program. The goal is for clients to practicepaying attention to a single focus, their breathing, and tolearn to watch and allow other internal events, such asthoughts, feelings, and sensations, to come and go. If theypay attention to their experience, they will see how itchanges frommoment to moment, how it comes and goeson its own, without any effort on their part. Clients areasked to practice this exercises at least once a day at home.

Identifying Values and Goals

ACT is a constructive approach to behavior change with afocus on enhancing quality of life. This is why perhaps themost important goal of our program is to encourage clientsto engage in life-goal directed behavior as an alternativeagenda to managing anxiety. To this end, early on (typicallyin Session 3 at the latest), clients complete severalexperiential exercises to help them explore their corevalues in their lives. Clients are encouraged to think aboutwhat theywant to do with their lives, not what they do not want tohave or feel. This re-orientation is achieved by helping clientsdefine what they want their lives to be about and stand for inkey life domains such as family, friends, romantic relation-ships, leisure, spirituality, health, career, education, andcommunity (see also, Dahl & Lundgren, 2006). At a laterpoint, we use additional experiential exercises and beha-vioral activation worksheets to define more specific goalsthat lead them in the direction of those values.

As clients identify values, they often recognize thatanxiety management behavior has moved them awayfrom their life values. For example, a woman with adaughter in elementary school told us that her mostimportant life goal was to be a good mother. Yet, sherecognized that her agoraphobic avoidance behavior haskept her from attending her daughter's school concerts.In fact, she had not attended a single one. Rather thancontinue to devote more time and energy to keepingpanic away, she made a choice to learn to observe and staywith her discomfort so that she would eventually be ableto approach the previously avoided school auditoriumand watch her daughter perform.

Acceptance: Developing Willingness to Stay

With Discomfort

ACT aims to teach clients acceptance as an alternativebehavior to experiential avoidance. Acceptance involvesthe active and aware embrace of those private eventsoccasioned by one's history without unnecessary attemptsto change their frequency or form, especially when doingso would cause psychological harm (Hayes et al., 2006,p.7). The focus is on teaching clients acceptance andmindfulness skills as ways of learning to observe unwantedanxiety-related responses fully and for what they are (i.e.,thoughts as thoughts, physical sensations as physicalsensations, images as images, feelings as feelings).

Session 4 and 5 introduce clients to acceptance andmindfulness as a skillful way of approaching our variouslife experiences. Clients learn to observe anxiety-related

373ACT for Anxiety Disordersthoughts and feelings without evaluation or judgment,and without holding onto, getting rid of, suppressing, orotherwise changing what they experience. We developedthe acceptance of anxiety exercise as a mindfulness tool toteach clients how to assume an observer perspective inrelation to their anxiety-related feelings and thoughts.This 15-minute closed eyes exercise, to be practiced onceor twice a day, builds upon the acceptance of thoughts andfeelings exercise. Clients again practice paying attention toa single focus, their breathing, and to learn to watch andallow specific anxiety-related thoughts and bodily sensa-tions come and go without trying to change them. Clientsare encouraged to make full contact with the experienceof anxiety, notice all its facets, stay with it, watch it, andmake room for it. The goal is to increase willingness toexperience discomfort and undermine the tendency toreact to anxiety-related thoughts, images, and sensationswith strategies aimed at getting rid of such experiences.The exercise also reinforces the notion of choices:Although experiencing anxiety and fear is not a choice,how clients respond to their discomfort is a choice. Theycan choose to observe and acknowledge their anxiety forwhat it is, or choose to react to it in a way that has limitedtheir options and their lives.

Additional metaphors and exercises in these sessionsare also designed to strengthen the skill of observingrather than responding to anxiety with efforts to controlit. These exercises also provide clients with additionalpractice distinguishing between experiences they have(thoughts, emotions, and physical sensations) and theperson having them. Although these are somewhatabstract notions, the development of an acceptingobserver perspective helps clients experience at a gutlevel that although their anxiety is part of them, they aremore than an anxiety-disordered individual.

Acceptance is closely related to willingness andpurposeful action. Linehan (1993) points out thatwillingness is accepting what is, together with respondingto what is, in an effective and appropriate way. It is doingwhat works and just what is needed in the currentsituation or moment (p. 103). In a similar vein, Orsillo,Roemer, Lerner, and Tull (2004) describe experientialacceptance as a willingness to experience internal eventssuch as thoughts, feelings, memories, and physiologicalreactions, in order to participate in activities that aredeemed important and meaningful. We view acceptanceas the willingness to stay with discomfort while also activelyand intentionally choosing to engage in life-goal directedbehavior (Eifert & Forsyth, 2005). Willingness is a skill tobe learned, not a concept or a feeling. It is not aboutliking, wanting, putting up with, or tolerating, and notabout enduring anxiety with brute force of will. It meansbeing open to the whole experience of anxiety (Luoma,Hayes, & Walser, 2007) and making a choice toexperience anxiety for what it isa collection ofsensations, feelings, thoughts, and images. In this sense,willingness is the opposite of control and avoidance and amajor treatment target in this program.

Cognitive Defusion

The concept of cognitive fusion may help to explainwhy thoughts become so threatening to people that theyare prepared to engage in behavior that is clearlydetrimental to their well-being and quality of life.Cognitive fusion refers to the tendency of human beingsto get caught up in the content of what they are thinkingwith the end result that literal evaluative strategiesdominate in the regulation of human behavior, evenwhen less literal and less judgmental strategies would bemore effective (Hayes, 2004, p. 13). Cognitive fusion is aprocess that involves fusing with or attaching to the literalcontent of our private experiences. The event or stimulus(e.g., I) and one's thinking about it (I am having aheart attack) become one and the samethey are sofused as to be inseparable, which creates the impressionthat verbal construal is not present at all (Hayes, 2004).When fusion occurs, a thought is no longer just a thought,and a word is no longer just a sound; rather, we respond towords about some event as if we were responding to theactual event the words describe. Thus, a fast beating heartexperienced during a panic attack is no longer just a fastbeating heart but a sign of an impending heart attack thatwemust avoid at all costs by engaging in behavior aimed atdown-regulating the physical sensations experienced.

Learning the skill of cognitive defusion is central toACT. At a basic level, cognitive defusion is the processwhereby individuals learn to observe thoughts for whatthey really are (just thoughts), not for what their mindstells them they are (literal truths that must be actedupon). As thoughts are taken less literally, clients arefreed to act on chosen values rather than reacting toanxiety-related, thoughts, worries, and bodily sensations.ACT utilizes a variety of cognitive defusion techniques(e.g., metaphors, mindfulness exercises, paradoxicalstatements, changing language conventions) to teachclients to respond less literally to anxiety-related thoughtsand emotions, and create some distance to their thoughtsand feelings. Instead of responding to the literal contentof a thought, clients learn to respond to and experiencethoughts as just a thought that can simply be observed.Defusion exercises are conducted throughout treatmentwhenever clients appear to be trapped by and entangledin their evaluative mind and when taking their thoughtsliterally (buying their thoughts) interferes with values-consistent behavior. The point of this work is to teach afine discrimination between thoughts that serve the clientwell and those that do not. Clients also learn that athought can simply be observed and need not be

374 Eifert et al.corrected or struggled with, and most importantly, neednot be acted on.

For instance, when a client notices the thought I amhaving a heart attack during a panic attack, defusiontechniques will help that client recognize and experiencethe evaluative thought or image for what it is: a thoughtthat can simply be observed and need not be corrected orstruggled with, and most importantly, need not be actedupon by dropping everything and driving to the next ER.The goal of cognitive defusion is to help the client forge anew relationship with their private experience (Orsillo &Batten, 2002). Hence, defusion techniques do not target,nor do they seek to correct, the content or validity of theclient's evaluation of their physical sensations (whetherthey are really having a heart attack), only the process ofevaluating itself. At the core, defusion techniques helpclients to notice the process of thinking. For this reason,the mindful acceptance exercises described earlier arealso thought of as defusion strategies within ACT. Theyhelp clients make contact with experience as it is, withoutall the evaluative baggage, including verbal rules andreasons, that are usually present when anxiety occurs.Mindfulness exercises allow clients to notice the processof thinking, evaluating, feeling, remembering, and otherforms of relational activity, and not simply the historicalproducts of such activities (Hayes, 2004).

Applying Acceptance, Willingness, and Defusion to Stay

With Anxiety (Exposure)

The goal of Sessions 6 and 7 is learning to stay withanxiety. We describe this part of treatment to clients asgetting ready to face anxiety with mindful acceptanceso you can get on with your life (Forsyth & Eifert, 2008,p. 187). During in-session exposure-like FEEL (i.e.,Feeling Experiences Enriches Living) exercises, clientsemploy mindful observation to let go of the struggle toescape or control anxiety-related thoughts, worries, andbodily sensations by acknowledging their presence andeven embracing and leaning into them. The actualprocedures used to practice are similar to those used inCBT (e.g., hyperventilation, spinning, or worst-caseimagery in the case of chronic worrying). In fact, in theUCLARCTwe use the same exercises in both the ACTandthe CBT condition, albeit framed with very differentrationales and set within different contexts. In ACT, thestated goal of these exercises is not to reduce or eliminateanxiety but to provide clients with opportunities topractice willingness in the presence of anxiety so theycan do what matters to them. The general purpose is toprepare clients for the inevitable times when anxiety andother forms of discomfort show up while engaging in real-life chosen activities that move them in the direction oftheir values. Thus, exposure exercises within ACT arealways done in the context of a client's valued life goals.Exposure practice is a logical extension of the mind-fulness exercises begun earlier. Recall that these exerciseswere designed to promote anobserver perspective, wherebythoughts, feelings, and physical sensations are noticed andexperienced as they are with a nonjudgmental andcompassionate posture. Using similar instructions as in theacceptance of anxiety exercise, clients are encouraged to staywith whatever they are experiencing to help them approachanxiety-related distress from a nonjudgmental, compassio-nate perspective.They are encouraged to choose to be opento their experience and respond nondefensively. Thisposture works to foster cognitive defusion so that evaluativeverbal-cognitive activity does not get in the way of life goal-directed action. Consequently, the choice of the specificinteroceptive and imagery FEEL exercises for a particularclient is largely determined by whether the client's reactionsbrought on by the images or sensations have functioned inthe past as a barrier to life goal-directed action.

Exposure practice provides an important opportunityfor clients to develop willingness to experience anxietyand to see that willingness is a choice. Nobody choosesanxiety. It happens. The choice is whether one is willing toexperience anxiety when it arises and do what matters. So,willingness is about control of choices and actions, notfeelings and thoughts, and as this work unfolds in andoutside of treatment, clients are encouraged to revisit thiscentral question: Am I willing to move with my anxiety todo what I really care about or am I going to run away fromanxiety and the life I truly want to live? In this sense,exposure exercises are willingness exercises, where clientsare encouraged to make the choice to experience anxietyfor what is. In this sense, exposure exercises are will-ingness exercises, where clients are encouraged to makethe choice to experience anxiety for what is. Althoughexposure exercises within ACT are not conducted for thepurpose of fostering extinction processes, such processesare likely to operate regardless of the rationale clientsadopt for facing their anxiety rather than avoiding it. Sowhen anxiety reduction occurs as a consequence, weconsider it a bonus, not a targeted outcome.

Value-Guided Action (Naturalistic Exposure)MovingWith Barriers

Sessions 7 to 12 are devoted to helping clientsimplement meaningful activities that would move themtoward reaching selected goals related to their identifiedvalues. Using worksheets derived from behavioral activa-tion programs (Addis & Martell, 2004), therapists helpclients develop a specific plan of action for each week andidentify sequences of actions that need to be taken toachieve goals. This work includes the following: helpingclients translate their identified values into goal-directedactions, helping clients set realistic goals and criteria,provide ongoing feedback, and monitoring progress. This

375ACT for Anxiety Disorderswill almost invariably involve clients engaging in pre-viously avoided activities or entering previously avoidedsituations. Such activities look similar to naturalisticexposure exercises, except that they are not conductedin a context and with the stated purpose of extinguishinganxiety. Clients choose and engage in activities with thestated purpose of reaching important life goals.

In the process of engaging in life-goal directedactivities, clients inevitably encounter barriers. Most ofthe time, they are related to anxiety-related concerns thatliterally seem to hold clients back. An important recurrenttask for therapists during Sessions 7 though 12 is to helpclients handle barriers to committed action and focus onmaking and keeping action commitments and onrecommitting to action after they have broken a commit-ment. The focus is on teaching clients how to move withpotential barriers rather than try to overcome or pushthrough them. Therapists constantly encourage clients tostay with difficult situations, unpleasant feelings, thoughts,and other anxiety-related barriers to valued living bypracticing mindful acceptance and defusion skills. Themajor goal here is to help clients develop more flexiblepatterns of behavior when relating with the stimuli,events, and situations that elicit fear or anxiety. Therapistscontinue to emphasize that the purpose of FEEL exercisesand value-related activities is to let clients experience thatthey can do things that matter to them and be anxious atthe same time. The crucial point is for clients to learn thatanxiety does not have to go down first in order to do whatis important to them.

Method

Participants

Three individuals who were part of a larger rando-mized clinical outcome trial comparing ACT and CBTserved as participants for this case study. We selected oneclient from each of the three therapists who were seeingclients (typically each saw two clients at a time) at the timewe decided to write up this case report. To illustrate theflexible nature of the treatment program, we selectedthree participants with heterogeneous anxiety disorders,that is, each had a different principal anxiety disorderdiagnosis and also one other secondary diagnosis, whichwas different in each case.

We selected one client from each of the threetherapists who were seeing clients (typically each therapistsaw two clients at a time) at the time we decided to writeup this case report. There were no particular selectioncriteria other than that the three clients should be clearlydifferent. So we made sure they were not all of the samegender, were from different age groups, and to illustratethe flexible nature of the treatment program, each shouldhave a different principal anxiety disorder diagnosis withone other secondary diagnosis, which was different ineach case. These individuals had presented for treatmentat the UCLA Behavioral Anxiety Disorders ResearchProgram in response to ads offering treatment. Clientshad not selected ACT as their preferred treatment buthad been randomly assigned to the ACT treatmentcondition as part of the RCT. We changed the clients'names to protect their anonymity.

All clients were assessed with the Anxiety DisordersInterview Schedule for DSM-IV (ADIS-IV; Di Nardo,Brown, & Barlow, 1994) and their principal and secondarydiagnoses are listed in Table 1. The ADIS-IV is asemistructured interview that assesses for anxiety, mood,and other psychiatric disorders. In addition to assigningdiagnoses, the interviewer makes a clinical severity rating(CSR) for each diagnosis to capture the individual'scurrent level of distress and impairment as a function ofthe particular disorder. CSRs range from 0 (none) to 8(very severe). All diagnostic interviewers had extensivetraining in administering the ADIS-IV and none of themacted as therapists. All diagnoses and CSR ratings werereviewed by a doctoral-level clinical supervisor.

For the 6-month follow-up, therapists contacted theirclients by phone. Therapists talked with clients for about20 minutes, following a standard protocol that includedobtaining ratings of the extent of struggle with anxiety,willingness to experience discomfort, practice of mindfulacceptance, and progress in life-goal directed action. Incase clients had encountered any recurrent barriers tocommitted action, therapists helped clients troubleshootsolutions.

Therapists

The therapists were three advanced graduate studentsenrolled in the doctoral program in clinical psychology atUCLA (EE, JA, DL). All therapists had been trained inACT theory and methods by the first author and attendeda 2-day ACT experiential workshop conducted by StevenHayes. Treatment consisted of 12 weekly sessions, eachlasting 1 hour. All treatments followed the treatmentmanual by Eifert and Forsyth (2005).

Anxiety Mood, and Distress Measures

The Anxiety Sensitivity Index (ASI; Peterson & Reiss,1992) is a 16-item self-report questionnaire that assessesan individual's level of fear of anxiety-related symptoms(e.g., rapid heart beat) based on the belief that suchsensations have negative consequences (e.g., embarrass-ment). Respondents rate the degree to which they agreeor disagree with each item on a 5-point scale, anchoredfrom 0=very little to 4=very much. According to Petersonand Reiss 1992), the ASI has a high degree of internalconsistency (alpha coefficients from .82 to .91) and stabletest-retest reliability over a 3-year period (r= .71).

All Th

Dan

Pre

54

314353

265362135

ty Con(low

orry);onnai

376 Eifert et al.The Penn State Worry Questionnaire (PSWQ; Meyer,Miller, Metzger, & Borkevec, 1990) is a 16-item measureof trait worry with strong psychometric properties (Meyeret al., 1990; Molina & Borkovec, 1994). Participants ratethe extent they agree with each statement on a 5-pointLikert scale. Scores can range from 16 to 80. The PSWQfocuses on the generality, intensity/excessiveness, anduncontrollability of clinical relevant worry (Molina &Borkovec), and reliably distinguishes GAD from otheranxiety disorders (Brown, Antony, & Barlow, 1992). ThePSWQ demonstrates strong psychometric properties(Molina & Borkovec), including good internal consistency( of .86 to .93 across clinical and college samples) andtest-retest reliability (r= .74 to .93 across 2- to 10-weekperiods).

The Mood and Anxiety Symptom Questionnaire(MASQ; Watson & Clark, 1991) is a 90-item self-reportquestionnaire with five subscales: Anxious Arousal (17

Table 1Pre and Post Data for Measures of Anxiety, Mood, and Distress for

Measure James

Pre Post

ADIS SeverityPrincipal 4 (panic) 0Secondary 3 (OCD) 0

ACQ 28 49ASI 27 7PSWQ 54 45MASQ 288 185FQ Total 40 17Social 12 3

Padua 9 7

Note. ADIS=Anxiety Disorders Interview Schedule-IV; ACQ=Anxieover responses to anxiety symptoms); ASI=Anxiety Sensitivity IndexState Worry Questionnaire (lower scores indicate lower levels of windicate fewer depression and anxiety symptoms); FQ=Fear Questiitems), Anhedonic Depression (22 items), GeneralDistress (i.e., General Mixed; 15 items), General Anxiety(11 items), and General Depression (12 items). Thirteenitems do not belong to a subscale. Participants use a 5-point Likert scale (1=not at all to 5= extremely) to rate theextent to which they experienced each symptom duringthe past week, including today. The MASQ anxiety anddepression subscales demonstrates good divergent (r= .02to .09), convergent validity (r= .67 to .76) with otheranxiety and depression scales, and strong incrementalvalidity across student, adult, and patient samples(Watson et al., 1995).

The Anxiety Control Questionnaire (ACQ; Rapee,Craske, Brown, & Barlow, 1996) is a 30-item measuredesigned to assess perceptions of control over potentiallythreatening internal and external events and situationsassociated with anxious responding (alphas from .80 to.89; test-retest, r= .88; Rapee et al., 1996). Recent workevaluating the psychometric properties of the original 30-item ACQ in a clinical (N=1,550) and nonclinical(N=360) sample suggests that the original 30-item ACQis best represented by a 15-item form equivalent (i.e.,patient vs. nonpatient) unifactorial solution, and threelower-order factors reflecting emotion control, threatcontrol, and stress control (Brown, White, Forsyth, &Barlow, 2004). The present study relied on the 15-itemversion of the ACQ, and the unifactorial solutionreflecting perceived control over anxiety-related emo-tional events.

The Fear Questionnaire (Marks & Mathews, 1979) is a15-item scale that assesses fear-related avoidance of avariety of situations. The 9-point scale ranges from noavoidance to total avoidance, and has shown adequatereliability and validity in samples with a variety of anxietydisorders (Cox et al., 1993; Marks & Mathews).

The Padua InventoryWashing State University Revi-

ree Cases

iel Janet

Post Pre Post

(social) 3 6 (OCD) 3(dysth) 0 5 (panic) 0

59 50 417 34 12

30 48 34167 181 16212 39 248 11 77 106 57

trol Questionnaire (higher scores indicate higher perceived controler scores indicate lower levels of anxiety sensitivity); PSWQ=PennMASQ=Mood and Anxiety Symptom Questionnaire (lower scoresre (lower scores indicate lower levels of fear).sion (PI-WSUR; Burns, Keortge, Fromea, & Sternberger,1996) is a self-report questionnaire containing 39 items ofthe original Padua Inventory (Sanavio, 1988), which had60 items. Using a 5-point scale, with responses rangingfrom 1 (not at all) to 5 (very much), the questionnaireassesses obsessions and compulsions related to harm to selfor others, contamination, washing, dressing/grooming,and checking. Burns et al. (1996) found that the internalconsistency values of the PI-WSUR subscales ranged from.77 to .88, the test-retest reliability values ranged from .61to .84, and that the PI-WSUR was a more distinct measureof OCD than the original PI.

ACT Process Measures

The Acceptance and Action Questionnaire (AAQ;Bond & Bunce, 2003; Hayes et al., 2004) assesses twoaspects of psychological flexibility: experiential avoidanceand willingness to engage in action despite unwanted

377ACT for Anxiety Disordersthoughts or bodily sensations. The original AAQ consistsof 9 items loading on a single factor. In this study, we usedthe revised 16-item version by Bond and Bunce (2003)because Hayes et. al. (2004) pointed out that the longerversion may be more useful as a therapy process measure,since the larger number of items may allow smallerchanges throughout therapy to be detected. The Willing-ness Scale consists of seven items assessing willingness toaccept undesirable thoughts and feelings. The ActionScale consists of nine items assessing whether individualsact in ways that are congruent with values and goals.Participants rate the extent to which they agree with eachstatement on a 7-point Likert scale. The 16-item version isscored in such a way that higher scores reflect greateracceptance of experience and willingness in the presenceof discomfort. A study by Bond and Bunce (2003) using ageneral population sample of 412 individuals examinedthe psychometric properties of the 16-item version of theAAQ. Internal consistence was good (= .79) and aconfirmatory factor analysis of the construct validity ofthe measure found that a two-factor (scale) solution was agood fit to the data. Bond and Bunce also report thathigher acceptance scores predicted better mental healthand job performance over and above negative affectivity.

The 15-item Mindfulness Attention Awareness Scale(MAAS; Brown & Ryan, 2003) assesses mindfulness acrosscognitive, emotional, physical, interpersonal, and generaldomains. Respondents indicate how frequently they haveexperienced statements (e.g., provide an item example)using a 6-point Likert scale (anchored from 1=almostalways to 6=almost never) with high scores reflecting moremindfulness. Items are scored by summing all individualresponses. Brown and Ryan have demonstrated that (a)theMAAS has good psychometric properties, (b) the scaledifferentiates individuals who are mindful from those whoare not, (c) higher scores are associated with enhancedself awareness, and (d) following a clinical intervention,cancer patients showed increases in mindfulness overtime that were related to declines in mood disturbanceand stress. Within student and adult samples, psycho-metric properties include good internal consistency(= .82 and .87, respectively), good test-retest reliability(.81, assessed in student sample only), and strongconvergent and divergent validity (see Brown & Ryan,2003). Brown and Ryan reported a mean score of 3.9(SD=0.6) for a nonclinical sample compared to 4.3(SD=0.6) for a group of Zen meditation practitioners.

TheWhite Bear Suppression Inventory (WBSI; Wegner& Zanakos, 1994) is a 15-item measure of the tendency tosuppress (i.e., not accept) and struggle with unwantedthoughts and feelings. This measure has been usedextensively in laboratory and clinical settings to demon-strate the negative effects of experiential avoidance (e.g.,Koster et al., 2003). Clinical studies (e.g., Smari &Holmsteinsson, 2001) involving people with variousanxiety disorders such as obsessive-compulsive disorderand specific phobias have shown that the WBSI is sensitiveto measuring the effects of treatment. Items are scored bysumming all individual responses. Lower scores indicatelower thought suppression. In a large, diverse studentsample for periods ranging from 3 weeks to 3 months, test-retest reliability was reasonable (r= .69), internal reli-ability was strong (= .87 to .89), and the measuredemonstrated good convergent, divergent, and incre-mental validity (Wegner & Zanakos, 1994). Depending onsample characteristics, Wegner and Zanakos found thataverage scores for nonclinical samples vary from 43 to 50.

The Believability of Anxious Feelings and Thoughts(BAFT) is a 30-item self-report measure of defusion thatincludes the content of all 16 ASI items and a set ofrationally derived items reflecting excessive thought andemotion regulation getting in the way of effective action(e.g., When unpleasant thoughts occur, I must push themout of my mind or I need to get a handle on my anxietyand fear for me to have the life I want). Rather thanassessing the presence, intensity, or degree of fear ofsymptoms, the BAFT requires participants to indicate on ascale from 1 (not at all believable) to 7 (completely believable)how much they believe or buy into each statement.Similar believability and defusion measures have beenidiographically developed and used successfully as processmeasures in other ACT outcome studies (e.g., Bach &Hayes, 2002), including mediating outcomes, and haveproven to be the most robust indicator of ACT outcome(see Hayes et al., 2006). The BAFT total score is derived bysumming responses for all items. Initial psychometricevaluation in a nonclinical university sample (N=400)suggests that the BAFT is unifactorial, with strong internalconsistency (coefficient alpha=.95) and convergent validitywith other ACT process variables (e.g., experientialavoidance, mindfulness, self-compassion, and quality oflife; see Herzberg, Sheppard, Forsyth, & Eifert, 2009).

The Quality of Life Inventory (QOLI; Frisch, 1994) is a32-item self-report questionnaire developed to measurelife satisfaction in the areas of health, self-esteem, goalsand values, money, work, play, learning, creativity, helping,love, friends, children, relatives, home, neighborhood,and community. Participants are asked to rate theimportance of each area relative to their overall happinesson a 3-point Likert scale (0=not important to 2=veryimportant) and how satisfied they are with each area on a6-point Likert scale (-3=very dissatisfied to 3=very satisfied).In addition to scores for each life area, the inventory alsoyields an overall quality of life score. Data from over 1,000individuals suggest that the QOLI has good stability (at 2-week intervals), internal consistency (alpha coefficientsrange from .77 to .89), as well as convergent, discriminant,and treatment validity (Frisch et al., 2005).

378 Eifert et al.Case Descriptions and Results

The Case of James: A Man Suffering From

Panic Disorder

James, a single, 31-year-old Caucasian male, is anaspiring actor and screenwriter. Just a few months beforestarting treatment, around the time of his 31st birthday,James experienced his first panic attack. Although hereported experiencing very few panic attacks since his firstattack, he reported a number of changes in his life andsignificant distress beginning around the time of theattack. For example, he had given up drinking caffeine toavoid bodily sensations that simulate panic. In addition,he had given up drinking any alcohol because of concernover doing anything that may harm his health. Alsobeginning around the time of the attack, James beganexperiencing difficulties sleeping. He reported layingawake in bed late into the night distressed that his notbeing able to sleep would disrupt the activities he hadplanned for the next day. His concern over gettingenough sleep appeared to contribute to changes in hisactivities during the day. For example, he began listeningto the radio less because of concern that a song may getcaught in his head, making it difficult for him to fallasleep later at night. In addition, everyday decisions, suchas deciding what time he should exercise, became difficultfor him because they were evaluated in terms of itspotential impact on his sleep. Meanwhile, he struggledwith his decision not to drink alcohol because it was anessential part of his Hollywood nightclub social life.

Although his principal diagnosis was panic disorder(clinician ADIS rating=4) with subclinical symptoms ofOCD (clinician ADIS rating=3), it became clear duringthe initial treatment sessions that it was his dissatisfactionwith the current state of his life that was most distressingfor James. He was frustrated with the lack of progress inhis career and was struggling with thoughts of not havingaccomplished enough to this point in his life and fears ofbeing a failure. What was most upsetting for him abouthis panic symptoms and his difficulty sleeping was thatthey served as further obstacles to progress in his career.He felt as if his life was closing in on him and was leftfeeling increasingly out of control of his life.

Several metaphors, such as the Chinese Finger Trap,presented early on in treatment, helped James connectwith his sense of being stuck within his current situationand to his own experience of how his attempts to gaincontrol over undesirable internal experiences wereactually contributing to further distress and a narrowingof his life space. While he related the metaphors to hisstruggle with panic symptoms and his difficulty sleeping,being able to relate the metaphors to his struggle withfeelings of failure and lack of accomplishment provedmore significant for James. His verbal attributions for thelack of progress in his career, including problems with theindustry and the incompetence of his manager andagent, while functioning to help him feel less like afailure in the short-term, also served as barriers to takingaction and creating his own opportunities for careerprogress. Following the second session, without anyprompting from the therapist, James resumed workingon a script that he had been putting off for several months.

Defusion, especially around the word failure, was amajor focus of James' later sessions. James described along history of self-deprecating thoughts around being afailure. Through a series of direct experiential exercises insession, James gradually became less emotionally reactiveto the word failure. For example, when presented withthe word failure written on a flash card, James reportedwanting to rip up the card and throw it in the trash. Thetherapist then asked James whether he was willing to putthe card in his lap, simply read it, let it be, and have thecard touch him as a thought. James agreed and wassurprised to notice that he could do this without gettingtangled up in what the card says. He was also willing totake the card with him over the next week everywhere hewent. In addition, James and his therapist did an exercisein which they rapidly repeated the word failure forapproximately 30 seconds (Masuda et al., 2004) whileobserving what happens to the quality of the word whendoing so. James reported that after saying the wordrepeatedly failure was reduced to merely a string ofalmost unrecognizable sounds and he could see that it wasultimately just a word. Exercises such as this helped Jamesto become a better observer of his own thinking and helearned that he does not have to take his thoughts, evenhistorically difficult thoughts, so seriously and do whatthey say. Decreases in the degree to which James believedhis anxiety-related thoughts are demonstrated by the dropin his BAFT score from 122 at pretreatment to 51 atposttreatment.

More importantly, James learned to use defusion skillsto help him persist in value-consistent behavior in thepresence of difficult thoughts. This change was alsoreflected in the increase of his AAQ-Action score. Forexample, during the course of treatment James com-pleted his screenplay and put together a team of actors topresent his screenplay to an audience for the very firsttime, despite experiencing occasional thoughts of failingthroughout the process. In addition, by the end oftreatment, James enrolled as a volunteer at a localchildren's hospital, something he had wanted to do foryears and has been putting off due to thoughts of nothaving enough time. His increased participation invalued activities was reflected in changes in his in QOLIscores, which increased from a score in the 1st percentileat pretreatment to a score in the 55th percentile atposttreatment.

379ACT for Anxiety DisordersMeanwhile, his original concerns over panic symptomsand difficulty sleeping faded increasingly into the back-ground over the course of treatment. Toward the end oftreatment, James did note occasional trouble fallingasleep but that his episodes of sleeplessness were lessdistressing than they used to be. During instances ofdifficulty sleeping, James reported that he would watch hismind do the thing it does until, sooner or later, hewould fall asleep. In addition, James reported lessinterference in his daily activities as a result of panicand sleep-related concerns. For example, without anyprompting from the therapist, James reintegratedcaffeine and alcohol into his daily life. Additionally,James no longer reported distress over engaging in dailyactivities that might influence his sleep. The lack ofinterference and distress over panic and problems withsleep are evidenced by increases in his AAQ-Acceptancescore (from 12 pretreatment to 36 posttreatment) and byclinician severity ratings of 0 for both panic disorder andOCD at the end of treatment. Increases in his ACQ scoreand decreases in his ASI score also indicate that heexperienced more control over and was less concernedabout anxiety-related sensations.

At 6-month follow-up, James continued to report littleto no distress or impairment over panic or OCD-relatedsymptoms. Although he experienced a significant set-back with respect to his career since completing thetreatmenthe experienced an injury that put him out ofwork for several monthsJames reported using the skillshe learned in therapy to help him accept the limitationsof his situation without becoming overly frustrated ordiscouraged.

The Case of Daniel: A Man Suffering From

Social Phobia

Daniel, a 51-year-old Caucasian male, presented withgeneralized social phobia and also received a secondarydiagnosis of dysthymia. The social situations he fearedmost were public speaking, being assertive, speaking withunfamiliar people, and attending social gatherings.Daniel could not remember a time when his social phobiahad not been significantly distressing and impairing. Inrecent years, his relationship with his anxiety symptomshad also begun to disrupt his sleep and adversely affect hisphysical well-being. He had maintained a mid-level job ata government agency for over 15 years without apromotion, although he believed he would qualify forone if he applied. He reported that his coworkersfrequently took advantage of him because he would notstand up for himself or express his opinions. He wasunable to approach his long-term girlfriend to discuss hisrelationship concerns because he feared tension andrejection. Understandably, he felt quite hopeless andhelpless. He approached his first session of ACTmotivated to change while simultaneously being highlyskeptical that change would be possible.

Initially, Daniel's social anxiety manifested as reluc-tance to express emotions that he feared would upset histherapist. The creative hopelessness metaphors helpedDaniel recognize that his previousmethods of dealing withpainful emotions (e.g., avoiding, struggling) left himfeeling hopeless and trapped, despite his best, life-longattempts to avoid and fight these emotions. The mindfulacceptance exercises provided Daniel with the opportu-nity to approach painful emotions in a different way. Forthe first time in his life, he took a step back and looked athis emotions and physical sensations with a morecompassionate stance, appreciating emotions and physicalsensations as momentary, ephemeral experiences. Hefound the acceptance of thoughts and feelings and acceptance ofanxiety exercises so helpful that he practiced them morethan once a day (as requested by the protocol) and tookcareful notes about his experiences.

Daniel reported that he experienced these exercises asrelaxing at times and anxiety-inducing at other times. It isimportant for therapists to respond to any such clientcomments, particularly if clients state they like themindfulness exercises because they find them relaxing.The danger here is that clients link acceptance to positivefeeling outcomes and may be attempting to use mind-fulness to achieve the goal of relaxation or anxiety relief,which has little to do with mindful acceptance (Segalet al., 2002). At that point, therapists should emphasizethat the goal of these exercises is not to bring about anyparticular effect, such as relaxation, and that any effect isfine as long as clients focus on watching thoughts andfeelings come and go. As Segal et al. indicate, the goal isnot to relax the mind or body but to learn to relax withoneself. Daniel practiced challenging tasks, such asdeclining inappropriate work requests from coworkers,noticing the anxiety yet focusing on the task at hand. Hisincreased willingness to experience his emotions alsoextended into other parts of his life once the treatmentstarted to focus on life goal-directed action. Instead ofdelaying action until he eliminated his anxiety symptoms,Daniel began to move towards his goals of improvingcommunication with his girlfriend and getting a promo-tion at work with his anxiety symptoms present.

By the end of treatment, Daniel was more willing toaccept undesirable thoughts, as measured by the AAQand the WBSI, and to act in accordance with his values assuggested by increases in his AAQ Action subscale score(see Table 2). Daniel's success at cognitive defusion wasclearly evident in a three-fold decrease from pre- toposttreatment in the believability of thoughts and feelingsas measured by the BAFT. As he began to move forward inhis life, he also reported significant decreases in distressrelated to anxiety and dysthymia. For instance, Daniel

ss, an

Da

Pre

2031173.145

0.79Ve

icatebelieulnesd fee

380 Eifert et al.reported reductions in his anxiety sensitivity (ASI), worry(PSWQ), mood-related distress (MASQ), and a dramaticdecrease in worry and obsessional thinking as measuredby the Padua. In addition, ratings of impairment (i.e.,ADIS Severity) declined from 5 to 3 for social phobia andfrom 4 to 0 for dysthymia. The magnitude of improve-ments was impressive, yet changes occurred graduallythroughout treatment and seemed to occur subsequent toDaniel's increasing abilities with acceptance and defusion.

Daniel occasionally speculated whether he had per-haps succeeded in eliminating his anxiety once and forall. Whenever he brought this issue up, the therapistreminded him that the objective was to move in a valueddirection regardless of his anxiety. If Daniel were to focuson his decreased anxiety-related distress, the next time heexperienced anxiety he would be drawn back into the

Table 2Pre and Post Data for Process Measures of Acceptance, Mindfulne

Measure James

Pre Post

AAQAcceptance 12 36Action 34 40

BAFT 122 51MAAS 3.8 4.7WBSI 66 53QOLIOverall Score 1.2 2.8Percentile (%) 1 55Classification Very low Average

Note. AAQ=Acceptance and Action Questionnaire (higher scores indof Anxious Feelings and Thoughts (lower scores indicate lowerAwareness Scale (higher scores indicate higher levels of daily mindflower levels of suppression and struggle with unwanted thoughts angreater reported quality of life).metaphorical tug-of-war to defeat his anxiety again. Atthe 6-month follow-up, Daniel reported that he wasconsistently using the skills he developed in therapy. Hesaid he had not experienced much anxiety-relateddiscomfort and that experiencing such occasional dis-comfort did not get in the way of [his] life.

The Case of Janet: A Woman Suffering From OCD and

Panic Disorder

Janet, a single, 52-year-old Caucasian female andcorporate accountant, presented with a lifelong historyand principal diagnosis of OCD and a secondary diagnosisof panic disorder. Her obsessions involved severe fear ofcontamination and having to urinate. Her compulsionsinvolved excessive washing behaviors and avoiding placeswithout an easy escape or readily accessible bathroom. Forseveral hours each day, Janet obsessed about hercontamination and urination fears, and engaged incompulsive behaviors. She felt embarrassed and shamefulabout these behaviors, which led her to limit meaningfulsocial contact and relationships. She also experiencedspontaneous panic attacks approximately once per week.Following her first panic attack 5 years earlier, she had feltworried and distressed about panic symptoms on a dailybasis.

Janet had for many years avoided intimate relation-ships with men and close supportive friendships withwomen, and had not completed her undergraduatedegree despite showing much academic promise. Sheplaced a high premium on her current job but hadremained with a disrespectful boss for several years. Shealso felt unable to stand up for her needs or respondeffectively to her negative emotions at work, whichseemed to be linked with her decreased job satisfaction.She feared being an OCD her entire life. Having

d Defusion as Well as Participants' Quality of Life

niel Janet

Post Pre Post

32 33 3540 44 44

4 53 92 874.5 5.1 4.736 65 38

2.9 2.6 3.359 71 49

ry low Average Average Average

higher levels of acceptance and valued action); BAFT=Believabilityvability of thoughts and feelings); MASS=Mindfulness Attentions); WBSI=White Bear Suppression Inventory (lower scores indicatelings); QOLI=Quality of Life Inventory (larger QOLI scores indicaterecently completed 20 years in therapy with little effect onher anxiety symptoms, she was not confident ACT couldhelp her.

When Janet initially began to increase her experientialwillingness, she felt a strong increase in anxiety, sadness,and anger as she allowed herself to feel fully what washappening inside of her for the first time in her life. InSession 3, she vigorously questioned the therapistwhether this treatment would ever help her or just be awaste of her time. This is an important moment in anytreatment whenever this issue arises. The therapistresponded that we could not promise her anxietyreduction but that she could learn new skills that wouldmost likely help her develop a new relation to her anxietyif she persisted with practicing the acceptance, mind-fulness, and other exercises. It is important for therapiststo address this common concern in a way that gets themessage across that ACT is about gaining new skills thatcan be learned over time with sufficient practice. Indeed,

381ACT for Anxiety Disordersonce she honed her mindful observing skills through theacceptance of thoughts and feelings exercise, she learnedthrough her experience that it was possible to simplyexperience intrusive thoughts and uncomfortable emo-tions, without having to do what they seem to be tellingher to do.

Janet showed substantial increases in self-acceptanceand increases in life-goal directed behavior duringtherapy. For the first time, she discovered that she couldlive according to her own needs and values rather thanspending time trying to reduce her anxiety and pleaseothers. This discovery coincided with dramatic increasesin her willingness and acceptance of her OCD symptoms.On a measure of thought suppression (the White BearSuppression Inventory), her score dropped from 65 atpretreatment to 38 at posttreatment, indicating signifi-cantly decreased suppression and increased willingness toexperience her obsessive thoughts. Whenever theyappeared, she literally began saying to herself, Hello,OCD thoughts and feelings! Hello, friends! How are youtoday? You're not my enemy. I can live with you. Shebegan working with panic and anger-related experiencesin the same manner. Janet learned to recognize when sheavoided situations due to anxiety, and chose to respond toanxiety differently. She attended more singles events,resumed dating, socialized more with her women friends,and communicated more honestly and compassionatelywith her family, friends, and colleagues. Instead ofcontinuing to put herself down, she deliberately startedto engage in behaviors that were designed to becompassionate and kind to myself, including takingtime to read, take baths, and watch movies. For the samereason, she also began looking for a new job more to herliking. With these changes, Janet also reported feelinghappier than she had felt in many years.

Janet's pre- to posttreatment PSWQ, FQ, and ACQscores show lower levels of distress and more perceivedcontrol over anxiety. Her OCD severity dropped frommoderately severe at pretreatment (clinician ADISrating=6) to subclinical levels at posttreatment (clinicianADIS rating=3). Whereas her ADIS panic severitypretreatment rating had been 6, her fear of anxiety-related symptoms dropped so dramatically by posttreat-ment (e.g., her ASI scores dropped from 34 to 12 pre topost) that she no longer endorsed any panic disorderdistress in the posttreatment assessment (clinician ADISrating=0). Interestingly, she chose not to eliminate somemild hand-washing compulsions via exposure, becausethey no longer caused her distress or interfered withvalued activities. Although Janet reported more accep-tance of urges informally, she did not report much changeon the formal measures of acceptance and defusionexcept for a dramatic decrease of thought suppression(her WBSI decreased from 65 to 38).At 6-month follow-up, Janet's OCD problems remainedat subclinical levels (clinician ADIS rating=3). She alsoreported a significant change in her life. After remainingin a job in which she endured poor treatment by her bossfor 4 years, she took a brief leave from work to clear hermind, then quit her job and secured another. Althoughseveral OCD problems remain, including mild handwashing and urination compulsions, finding a new jobrealized one of Janet's major goals and reflected movingtoward her personal value of self-respect.

General Discussion

The three case studies illustrate several importantpoints about our ACT program for the treatment ofanxiety disorders. First, the ACT for Anxiety treatmentmanual (Eifert & Forsyth, 2005) flexibly accommodateddifferent clinical presentations of anxiety disorders. In anage of increasingly detailed distinctions among disordersand equally detailed treatments, we take comfort in ourinitial finding that a single treatment manual can beflexibly applied to treat different forms of anxiety-relatedsuffering and presenting concerns.

Second, clients observed shifts in targeted processes ofchange, including reductions in experiential avoidanceand defusion of anxiety-related thoughts and beliefs.James, for example, realized that his fear of failure andexternal attributions of his career difficulties (e.g.,problems with the industry, the incompetence of hismanager and agent) contributed to inaction in thepursuit of his writing and acting aspirations. Defusion ofhis failure-related cognitions and his verbal explanationsfor his lack of career success facilitated the completion ofvalue-oriented goals, including having his screenplayperformed before an audience for the first time. Daniel,after a lifetime of struggling with his anxiety, no longerdefined himself by his symptoms; he saw his anxiety as apart of his overall experience of life.

Third, although ACT does not target anxiety reductionper se, all three clients experienced less distress at the endof treatment, as evidenced by changes in virtually allanxiety and mood distress-related measures. For example,Table 2 shows significant reductions from pre- toposttreatment in anxiety sensitivity (ASI), worry(PSWQ), negative mood and anxiety (MASQ) as well asgeneral fearfulness and fear in social situations (FearQuestionnaire). Moreover, the post-ADIS severity ratingswere much lower at the end of treatment than beforetreatment. As in previous experimental studies (Eifert &Heffner, 2003; Levitt et al., 2004), we observed aparadoxical effect in regard to perceived control overanxiety. As clients developed skills to let go of theirprevious efforts to control unwanted cognitions andemotions, two clients (James and Daniel) were surprisedto find that they actually felt more in control, as reflected

382 Eifert et al.in increased score on the Anxiety Control Questionnaire.Janet, on the other hand, reported becoming more awareof her inability to control the occurrence of obsessions(reflected in increased score on the ACQ) but indicatedshe accepted this inability and that she was not going tofight it anymore.

Fourth, a focal point of ACT is living a life-goal-directedlife and addressing the barriers that are standing in theway of such a life. Although we observed only modestincreases on the ACT Action scale for James and Daniel,and none for Janet, all clients felt empowered by thetreatment's focus on valued living and engaged inbehaviors in accord with their chosen life goals. Theresulting increases in the participant's quality of life wereclearly reflected in the changes on the Quality of LifeInventory. For instance, James completed and beganproducing a screenplay and realized his dream ofvolunteering at a local hospital, Janet began socializingmore broadly and found a new job, and Danielstrengthened his romantic partnership and successfullyrequested a promotion. In terms of barriers, therecontinues to be a debate (e.g., Hayes, 2008; Hofmann &Asmundson, 2008) whether cognitions are causal factorsfor behaviors and feelings. Even if therapists are uncertainas to where they stand in regard to this issue, they canadopt the ACT strategy to change the function ofthoughts: clients can learn that cognitions (and emotionsfor that matter) need not determine what they do even ifcognitions and emotions are intense and seem compel-ling. This was one of the most important lessons for all ourclients to learn because all three clients felt that anxiety-related thoughts and feelings were the main barriers intheir lives. As a result, therapists had to address thosebarriers repeatedly throughout treatment. Following theintroduction of the mindful acceptance and otherdefusion exercises, clients began to struggle less withtheir thoughts and emotions. Janet's increased kindnessand compassion in self-care illustrated this shift. Interest-ingly, her shift occurred after she expressed skepticismabout the treatment's ability to help her, which for her (aswould be the case for most clients) initially meant havingfewer obsessions and feelings of panic. Likewise, havinguntangled his self-identity from his anxiety symptoms,Daniel was able to make space for exploring who hewanted to be and pursuing his values. His progress inobserving and accepting his thoughts and emotions freedhim to start moving, and his values guided his actions.James learned that failure-related cognitions did not haveto be eliminated before he could engage in life goal-directed behavior.

Apart from some new techniques and exercises, theACT for Anxiety program incorporates many establishedbehavior therapy interventions. They include behavioralactivation and exposure exercisesalthough they areconducted in a different way and with a differentrationale than is typical. Behavioral skills training mayalso be employed for individuals with social skills deficits.As Hayes et al. (1999) indicated, during the laterportions . . . ACT takes on the character of traditionalbehavior therapy, and virtually any behavior changetechnique is acceptable (p. 258). On the other hand,there is a crucial difference between ACT and traditionalCBT in how therapists approach difficult cognitive andemotional content (e.g., irrational thoughts). Segal etal. (2004) expressed this difference clearly in regard tomindfulness-based cognitive therapy, and it appliesequally well to ACT: Unlike CBT, there is little emphasisin MBCT on changing the content of thoughts; rather, theemphasis is on changing awareness of and relationship tothoughts, feelings, and bodily sensations (p. 54).

Arguing from an emotion regulation perspective,Hofmann and Asmundson (2008) point out that CBT ismore focused on changing the evaluation of thesituational or internal emotion cues (antecedent-focused emotion regulation), whereas ACT encouragesprimarily emotion-focused problem-solving strategieschanging a person's response to emotions by encoura-ging their acceptance rather than trying to changethem. ACT also recognizes, however, that there aresituations when it is not desirable to accept unpleasantthoughts and feelings and focus on changing theantecedent conditions. Examples might includewomen who feel anxiety and terror because they aretrapped in an abuse relationship. In such cases,treatment may very well focus on changing theantecedent condition, that is, helping the women toleave the relationship and the physical context of abuse.Acceptance does not imply resigning oneself to a badsituation, particularly if the situation is harmful and theperson can leave or change the situation. In suchinstances, acting on what the person's mind andemotion are telling her (get out) is useful and servesto enhance the person's quality of life. Acceptance isonly the better option when acting on one's thoughtsand feelings does not serve to enhance one's quality oflife. Utility (or workability) is the ultimate criterion, andthis would seem apt with any strategy.

Theunified transdiagnostic qone-shoe-fits-allq approachpresented herein has clear advantages in terms of greatersimplicity as well as more efficient training and dissemina-tion. These advantages, however, are predicated on theassumption that the same processes (e.g., experientialavoidance, fusion) operate across all anxiety conditions.Although there is considerable support for this assumption(Hayes et al., 2006; Hayes, 2008), future studies will needto examine what specific adjustments might need to bemade to the program when clients present with particu-larly intense and overwhelming emotions as in PTSD.

ACT for Anxiety treatment program, its implementation

383ACT for Anxiety Disordersin some detail, and point out some differences totraditional CBT protocols. As with any case report suchas this, it is important to be appropriately cautious andnot make sweeping generalizationsthe large clinicaltrial from which we selected completed cases is stillongoing. We must await the outcomes of that workbefore making claims about the efficacy of this programcompared to an established CBT protocol. In thecontext of the large RCT, we will particularly examinethe relation of treatment outcome to changes inprocess variables. We will be able to address issuessuch as client resistance and the impact of clients notwilling to let go of the struggle agenda, therapisttraining and maintaining a consistent ACT or CBTposture throughout treatment, and what variables maytrigger early termination and dropout.

We also noticed from supervision tapes that theremay be a relation between outcome and therapistcompetence in terms of how successfully therapistsmodeled the skills they wish to foster in their clients(e.g., being mindful, open, genuine, and compassio-nate). These are questions that cannot be addressed ina case report and will need to be examined withsufficiently large groups of clients. There is researchevidence that ACT outcomes are mediated by relevantclinical processes such as acceptance, defusion, andengagement in life-goal-directed behavior (for summa-ries, see Hayes et al., 2006, 2008). In an updatedpresentation on this topic, Hayes, Levin, Yadavaia, andVilardaga (2007) were able to show that pre-to-postchanges in ACT processes accounted for nearly 50% ofthe pretreatment to follow-up changes in outcomeproduced by ACT. The comparison conditions in theset included CBT, pharmacotherapy, psychoeducation,supportive treatment, and wait-list controls. Almost all ofthe studies showed significant reductions in the directoutcome path when adjusted for the mediator at least atthe pb .1 level (and the great majority at the pb .05level). This work is now being subjected to furthercareful scrutiny and criticism (Arch & Craske, 2008;Hofmann & Asmundson, 2008), and we remainoptimistic that ACT and related acceptance-basedbehavior therapies will continue to be guided by dataand help move the field forward in reaching our goal ofalleviating a wide range of human suffering.

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