Open, Aware, and Active: Contextual Approaches as an ...€¦ · CP07CH06-Hayes ARI 24 February...

CP07CH06-Hayes ARI 24 February 2011 15:51

Open, Aware, and Active:Contextual Approaches asan Emerging Trend in theBehavioral and CognitiveTherapiesSteven C. Hayes, Matthieu Villatte, Michael Levin,and Mikaela HildebrandtDepartment of Psychology, University of Nevada, Reno, Nevada 89557;email: [email protected]

Annu. Rev. Clin. Psychol. 2011. 7:141–68

First published online as a Review in Advance onJanuary 6, 2011

The Annual Review of Clinical Psychology is onlineat clinpsy.annualreviews.org

This article’s doi:10.1146/annurev-clinpsy-032210-104449

Copyright c! 2011 by Annual Reviews.All rights reserved

1548-5943/11/0427-0141$20.00

Keywordsacceptance, mindfulness, values, third-wave CBT, mediation

AbstractA wave of new developments has occurred in the behavioral and cogni-tive therapies that focuses on processes such as acceptance, mindfulness,attention, or values. In this review, we describe some of these develop-ments and the data regarding them, focusing on information about com-ponents, moderators, mediators, and processes of change. These “thirdwave” methods all emphasize the context and function of psychologicalevents more so than their validity, frequency, or form, and for thesereasons we use the term “contextual cognitive behavioral therapy” todescribe their characteristics. Both putative processes, and componentand process evidence, indicate that they are focused on establishing amore open, aware, and active approach to living, and that their positiveeffects occur because of changes in these processes.

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ContentsINTRODUCTION. . . . . . . . . . . . . . 142BEHAVIORISM . . . . . . . . . . . . . . . . . 143BEHAVIOR THERAPY . . . . . . . . . 143COGNITIVE BEHAVIOR

THERAPY . . . . . . . . . . . . . . . . . . . 144MINDFULNESS-BASED

THERAPIES . . . . . . . . . . . . . . . . . 145Methods . . . . . . . . . . . . . . . . . . . . . . 145

ATTENTIONAL CONTROL . . 148Metacognitive Therapy . . . . . . . . 148

MOTIVATION ANDBEHAVIORALACTIVATION METHODS . . 149Motivational Interviewing . . . . . 149Behavioral Activation . . . . . . . . . . 150

RELATIONSHIP-ORIENTEDTHERAPIES . . . . . . . . . . . . . . . . . 151Integrative Behavioral Couple

Therapy . . . . . . . . . . . . . . . . . . . 152Functional Analytic

Psychotherapy . . . . . . . . . . . . . 152INTEGRATIVE

APPROACHES. . . . . . . . . . . . . . . 153

Dialectical Behavior Therapy . . 153Acceptance and Commitment

Therapy . . . . . . . . . . . . . . . . . . . 154CONTEXTUAL COGNITIVE

BEHAVIORAL THERAPY . . . 157Contextual Methods and

Principles . . . . . . . . . . . . . . . . . . 157Broad and Flexible Repertoires

Versus an EliminativeApproach to Syndromes . . . . 159

Applied to the Clinician, NotJust the Client . . . . . . . . . . . . . . 159

Builds on Other Strands ofBehavioral and CognitiveTherapy . . . . . . . . . . . . . . . . . . . 159

Deals with More ComplexIssues Characteristic ofOther Traditions . . . . . . . . . . . 159

A CENSUS CONTEXTUALCOGNITIVE BEHAVIORALTHERAPY MODEL. . . . . . . . . . 160

CONCLUSION . . . . . . . . . . . . . . . . . 162

INTRODUCTIONBehavior therapy is nearly 50 years old if theclock is started with the establishment of thefirst journal in the area in 1963, Behavior Re-search and Therapy. The history of the traditionis nearly as complex as that of psychology itself.In the early years, there was no doubt that be-havior therapy was tightly linked to behavioralpsychology—but what that meant varied. Somevariants were based on stimulus-response (S-R)learning theory and others on behavior analyticconceptions. In the latter part of the pastcentury, the tradition embraced an analysis ofcognition, but it also weakened its link to anyparticular basic science or set of principles infavor of well-crafted tests of structured inter-ventions for particular diagnostic categories. Inthe past decade, the behavioral and cognitive

therapies have become more interested in pro-cesses of change, unified models, and transdi-agnostic processes and have explored methodsthat are based more on changing the functionof psychological events such as cognitionand emotion than on their particular form orfrequency.

In the present review, we examine a setof these new behavioral and cognitive therapymethods and their putative key processes. Foreach, we consider the available evidence notjust on outcomes but also on moderators, pro-cesses of change, and components. In the finalsection, we organize this evidence so as to iden-tify certain key empirical and conceptual trendsin these new approaches. We begin, however,with a brief history of behavior therapy up tothese new developments, in order to put theminto context.

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BEHAVIORISMThe father of behavioral psychology, John B.Watson, defined behaviorism in opposition tomind as the subject matter of psychology andto introspection as the method of its investiga-tion (Watson 1913; Watson 1924, pp. 2–5). Inorder to develop what he saw as an objectivescience, he defined “behavior” as muscle move-ments and glandular secretions (Watson 1924,e.g., p. 14). The apparent narrowness of focuswas not due to a disinterest in broader mat-ters. For example, Watson developed methodsfor studying thinking using “think aloud” meth-ods (Watson 1920) that are popular in cognitivescience to the present day (Ericsson 2006), buthe fit this interest into his overall approach byviewing thinking as subvocal muscle movement.Watson also anticipated the eventual develop-ment of behavior therapy with studies demon-strating the applicability of behavioral princi-ples to psychopathology and to intervention(e.g., Watson & Rayner 1920).

Based on his roots in American pragmatism,evolutionary biology, functionalism, and reflex-ology, Watson sought a comprehensive monis-tic account of the situated actions of organisms.Despite the breadth of this vision, as is reflectedin his interest in thinking and application,Watson’s biggest impact was based on the muchnarrower idea that psychology as a science couldnot study mind, even if mind existed, becausethere was no scientifically acceptable method todo so.

In the early to middle part of the past cen-tury, the call for “methodological behaviorism”largely held sway. Psychology was to become anobjective science by eschewing methods (e.g.,introspection) that did not rely on public agree-ment, on the grounds that only publicly avail-able events could be studied scientifically.

There was strong disagreement within thebehavioral tradition about the importance ofpublic agreement or formal properties of be-havior as the defining feature of an objective sci-ence. B. F. Skinner (1945) rejected these ideasoutright, preferring instead to think of objectiv-ity as a matter of the contingencies controlling

observations, whether what was observed waspublic or private. But such philosophical differ-ences were largely unimportant when consid-ering the events that regulated overt behavior,especially in the animal laboratory. Decades ofbasic research proceeded on a wide variety ofbehavioral principles, including those of clas-sical and operant conditioning. It took nearly50 years before these principles were well de-veloped enough to become the core of a clinicalintervention tradition: behavior therapy.

BEHAVIOR THERAPYThe behavioral and cognitive therapies can bereadily organized into different perspectives(Hayes 2004) based on their dominant assump-tions, methods, and goals that helped organizeresearch, theory, and practice. The initial eraof behavior therapy contained two strands.Perhaps the most dominant was based on the as-sociationistic principles of S-R learning theoryand was applied to traditional clinical topics,particularly with outpatient adults. Behavior andResearch Therapy and other early journals suchas Behavior Therapy and the Journal of BehaviorTherapy and Experimental Psychiatry (bothbeginning in 1970) reflected this approach.The other was based in functional operant psy-chology, focused particularly on children andinstitutionalized clients rather than outpatientadults, and emphasized the direct manipulationof environmental contingencies. The Journalof Applied Behavior Analysis (1968) and BehaviorModification (1975) were particularly associatedwith this strand of thinking.

What united these two strands was theapplication of clearly specified and replicabletechniques, tested by well-designed and system-atic experimental research, based on learningprinciples derived from the laboratory (Eysenck1972). Franks & Wilson (1974) defined behav-ior therapy in terms of its adherence to “opera-tionally defined learning theory and conformityto well established experimental paradigms”(p. 7). Of the two traditions, the operant tra-dition had fewer adherents: “Methodologicalbehaviorism is much more characteristic of

www.annualreviews.org • Contextual CBT 143

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CBT: cognitivebehavior therapy

contemporary behavior modifiers than is rad-ical behaviorism” (Mahoney et al. 1974, p. 15).

At the same time, there was a tendency tominimize some of the deeper issues faced byclinical psychology in favor of direct change ef-forts focused on simpler and more overt targets.Stated another way, it was the content of overtbehavior that was typically emphasized aboveother issues.

When behavior therapy arose, psychoana-lytic and humanistic perspectives held sway.The link between interpretation and data inthese approaches was often very weak. Freud’scase of Little Hans (1928/1955) provides an ex-ample. Little Hans was afraid to leave home andfeared horse-drawn carts ever since he had seena cart fall over, injuring riders. Freud saw thehorse as a father figure and fears of being bit-ten as castration anxiety linked to Oedipal feel-ings. He claimed that a horse going througha gate was similar to feces leaving the anus, aloaded cart was like a pregnant woman, and that“the falling horse was not only his dying fatherbut also his mother in childbirth” (Freud 1955,p. 128). The early behavior therapists literallyridiculed this type of fanciful reasoning (Wolpe& Rachman 1960), preferring the far simpleridea that Little Hans had a learned fear of horsesbased on direct conditioning and should havebeen treated with a direct focus on encourag-ing school attendance.

In rejecting fanciful reasoning and vagueconcepts in favor of a direct focus on overt is-sues, behavior therapists tended also to leaveto the side the fundamental human issues thatwere often addressed by less empirical tradi-tions. It is difficult to find early behavior ther-apists researching topics such as what peoplewant out of life or why human suffering is sopervasive.

COGNITIVE BEHAVIORTHERAPYWhile the operant strand of behavior therapycontinued, the S-R learning theory strandchanged within a decade of the beginningof behavior therapy. Part of the reason was

that S-R learning theory itself collapsed, andsimple associationism was replaced by thefar more flexible computer metaphors ofinformation processing. Cognitive psychologystill used “behavioristic” methods rather thanintrospection, but did so in an attempt to assessthe functioning of the mind. Social learningtheory in particular (e.g., Bandura 1969) soonled to the infusion of cognitive mediationalconcepts into behavior therapy (e.g., Mahoney1974, Meichenbaum 1977). Clinicians feltthat a more direct approach to cognition wasneeded, and it was soon being emphasized that“One can study inferred events or processesand remain a behaviorist as long as these eventsor processes have measurable and operationalreferents” (Franks & Wilson 1974, p. 7).

Hard cognitive science was (and is) difficultto apply clinically, in part because these theoriesfocus more on dependent variables consistingof relatively abstract cognitive processes thanon clinically relevant thoughts and the inde-pendent variables that clinicians might directlymanipulate (e.g., variables such as history andcontext) to modify them. This is particularlyclear when the only independent variable of im-portance in the theory is the material causalityof the brain, since brains are not direct targetsof psychosocial manipulation except metaphor-ically. Thus, the cognitive models in cognitivebehavior therapy (CBT) tended to be developedlargely in the clinic. The goal of the behavioraland cognitive therapies shifted from the directmodification of the content of behavior to thedirect modification of the content of cognitionso as to influence emotion and behavior. Mod-els tended to be focused on specific syndromaldisorders. The leading voice in this shift wasthat of Aaron Beck: “Cognitive therapy is bestviewed as the application of the cognitive modelof a particular disorder with the use of a varietyof techniques designed to modify the dysfunc-tional beliefs and faulty information process-ing characteristic of each disorder” (Beck 1993,p. 194). CBT is surprisingly difficult to define,but when it is defined, this core assumption istypically the key focus. For example, Hofmann& Asmundson say that “CBT is based on the

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notion that behavioral and emotional responsesare strongly moderated and influenced by cog-nitions and the perception of events” (2008,p. 3).

Helped by federal funding, CBT enjoyed anenormous expansion in data and influence. Thevast majority of the Division 12 list of empiri-cally supported treatments have emanated fromCBT or behavior therapy. Although clinicalmodels of cognition produced vast literatureson the presence of dysfunctional thoughts inspecific disorders, evidence for the underlyingchange models in traditional CBT was muchweaker, especially in areas such as mediationalanalysis and component analysis (Longmore& Worrell 2007). Work such as that of thelate Neil Jacobson questioned the role oftraditional cognitive methods (e.g., Dimidjianet al. 2006, Gortner et al. 1998, Jacobson et al.1996) and led a major cognitive therapist toconclude, “there was no additive benefit toproviding cognitive interventions in cognitivetherapy” (Dobson & Khatri 2000, p. 913). Incombination with concerns about the progres-sivity of syndromal models (Kupfer et al. 2002),and philosophical changes (Hayes 2004), workbegan to emerge from a variety of laboratoriesthat eschewed direct cognitive change andfocused instead on acceptance, mindfulness,metacognition, the therapeutic relationship,motivation to change, or similar topics.

In the following review, we examine a selec-tion of these clinical approaches. We have se-lected treatment methods that are clearly partof the behavioral and cognitive therapies writlarge and yet that seem to us to go beyondthe content-focused core assumptions of tradi-tional behavior therapy or of traditional CBTas we have described them. In order to gobeyond mere terminological issues, however,it seems important to examine the empiricalevidence regarding how these methods work,not just their putative characteristics. Thus,rather than first attempting to characterize thisset of methods in the abstract, we briefly de-scribe these methods and the outcome datasupporting them, and follow in each case withwhat is known empirically about their compo-

Acceptance:intentionally allowingpainful psychologicalevents to be presentand felt so as to be ableto move in a valueddirection

Mindfulness: thepurposeful awarenessof the present momentin a way that isnonjudgmental andaccepting of one’sinternal and externalexperiences

Attentional control:differentially focusingon particular availableinternal and externalstimulation in afashion that is flexible,fluid, and voluntary

MBSR: Mindfulness-Based StressReduction

MBCT: Mindfulness-Based CognitiveTherapy

MBRP: Mindfulness-Based RelapsePrevention

nents, moderators, mediators, and processes ofchange. In order to save space, descriptions ofoutcome data rely on meta-analyses and a fewexamples rather than on comprehensive refer-encing of areas in which these methods havebeen shown to be useful. Somewhat more spaceis given to studies on processes and componentsbecause they speak most directly to the analyticissues at hand. We then return to the issue ofwhether these methods make sense as a set andwhether they suggest that a new strand of think-ing has emerged in the behavioral and cognitivetherapies.

We organize this review in sections, begin-ning with methods based primarily on mindful-ness practice, followed by methods focused onattentional control, motivation and behavioralactivation, and relationships. Finally, we exam-ine integrative methods that draw from each ofthese other areas.

MINDFULNESS-BASEDTHERAPIESThere is a growing interest in CBT in inter-ventions that focus on teaching contemplativepractices. The most popular methods are basedbroadly on Buddhist practices.

MethodsThe template for this work is Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn1990). MBSR was originally developed in amedical setting and has since been applied toa range of clinical and nonclinical populations.Related approaches such as Mindfulness-BasedCognitive Therapy (MBCT; Segal et al. 2002)and Mindfulness-Based Relapse Prevention(MBRP; Witkiewitz et al. 2005) have beenbased on MBSR but have included other meth-ods for specific problem areas. Recently, a num-ber of meditation practices that are designedto evoke and develop feelings of compassiontoward oneself have also received some at-tention. Examples include loving-kindnessmeditation (e.g., Carson et al. 2005), Lojong


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meditation (Pace et al. 2009), and Compas-sionate Mind Therapy (Gilbert 2009).

Techniques and putative processes. Thenew skills that mindfulness-based therapies at-tempt to establish are fairly broad. They are notlinked to any particular syndrome. MBSR con-sists of an eight-week group program involv-ing practices such as sitting meditation, yoga,body scans, and mindfulness during everydayactivities as well as group discussions, psychoe-ducation, and intensive out-of-session practice.Programs such as MBCT and MBRP integratethe more general MBSR approach with re-fined technologies such as dealing with depres-sion or relapse prevention with substance useproblems.

These mindfulness-based therapy ap-proaches attempt to increase a focused,purposeful awareness of the present momentand relating to one’s experiences in an open,nonjudgmental, and accepting manner (Baeret al. 2006, Kabat-Zinn 1994). These featuresof mindfulness are theorized to account forthe impact of mindfulness-based therapies onclinical outcomes.

Awareness of the present moment is thoughtto increase one’s sensitivity to important fea-tures of the environment and one’s own re-actions, and thus to enhance self-managementand successful coping. Present-moment aware-ness can also serve as an alternative behavior toruminating about the past or worrying aboutthe future and can help to reduce engagementin these maladaptive cognitive processes. Indi-viduals are taught to relate to one’s thoughtsas just passing events rather than identifyingwith them or seeing them as literally true—a process that is sometimes termed decenter-ing. Decentering is particularly emphasized inMBCT, which focuses on targeting the nega-tive thinking patterns that are reactivated withthe occurrence of dysphoric moods. Decenter-ing is thought to help clients to identify anddisengage from maladaptive cognitive pro-cesses, such as self-criticism and rumination.The capacity to notice difficult thoughts, feel-ings, and sensations in a nonjudgmental and

open manner without avoiding, suppressing, orotherwise trying to change their occurrence isargued to reduce distress and reactivity as wellas reduce problematic avoidance/escape be-haviors and increase engagement in importantactions.

Compassion-focused methods are thoughtto generate feelings of connectedness with oth-ers. This may enhance interpersonal function-ing or produce an increase in positive emotionsmore generally, which may broaden attentionand expand behavioral and cognitive repertoiresin the moment, producing more options andgreater flexibility (Frederickson 1998). This en-hanced flexibility and sensitivity can lead to be-haviors that alter people’s growth over time andincrease their personal resources.

Clinicians are generally asked to adopt ameditation practice in addition to using thesemethods with clients.

Outcome evidence. These evidence inter-ventions have been tested across a broad rangeof problem areas including anxiety disorders,mood disorders, substance use disorders, eatingdisorders, chronic pain, ADHD, insomnia, andcoping with a variety of medical conditions(Grossman et al. 2004, Zgierska et al. 2009),as well as with special populations includingchildren and adolescents, parents, teachers,therapists, and physicians. A meta-analysis byHofmann and colleagues (2010) summarized39 studies that tested the impact of MBSRand similarly structured programs with adultclinical populations on symptoms of anxietyand depression. The meta-analysis foundmedium within-group effect sizes on pre topost changes in anxiety and depression andlarge effect sizes in the subset of studies target-ing clinical anxiety/mood disorder populationsspecifically. These effects appear to persist overtime, with significant medium within-groupeffect sizes observed on anxiety and depressionat follow-up (mean follow-up time of 27 weekspost treatment). Significant small to mediumbetween-group effect sizes were observedfor depression and anxiety in relation towaitlist, treatment as usual (TAU), and active

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treatment comparisons. Similar effect sizeswere observed in a broader meta-analysis byGrossman and colleagues (2004) of 20 studiestesting MBSR or similarly structured programswith clinical and nonclinical populations onphysical/mental health outcomes. The researchevidence for MBRP per se is more limited, buta randomized controlled trial (RCT) showedsignificantly lower substance use compared toTAU (Bowen et al. 2009).

Components. Several studies have tested theimpact of brief mindfulness interventions inmore controlled laboratory settings. Thesestudies have found that single-session mind-fulness meditation interventions reduce par-ticipants’ psychological distress in reaction tomood inductions and difficult tasks relative tocontrol conditions (e.g., Huffziger & Kuehner2009). A recent study also found that a brief,single-session mindfulness meditation can im-pact cigarette smoking over the following week(Bowen & Marlatt 2009). These are not reallycomponent studies, though, since what is beingmanipulated is the length of the putative keyfeatures, not their elements.

Moderation. MBCT is effective with par-ticipants who have had three or more pastepisodes of depression, but not with thosewho have had only one or two (Ma &Teasdale 2004, Teasdale et al. 2000). Amongthose with three or more episodes, MBCT ismore effective with individuals whose depres-sive episode was not due to life events (Ma& Teasdale 2004). A potential explanation forthese results is that MBCT targets automaticdepressogenic cognitive processes that are morelikely to occur in chronically depressed patients,but the reason is not yet fully understood.

Process of change. There appears to be no re-lationship between time in mindfulness trainingand effect sizes (Carmody & Baer 2009). Abouthalf of the studies have failed to find a signifi-cant relationship between at-home meditationhomework compliance and clinical outcomes(Vettese et al. 2009).

Self-reported mindfulness measures docorrelate consistently with outcome. Thesemeasures capture a range of core featuresof mindfulness, including present-momentawareness, being nonjudgmental and nonre-active, decentering/distancing, and acceptance(Baer et al. 2006). Mindfulness meditationincreases self-reported mindfulness, and thesechanges relate to (e.g., Carmody et al. 2009)or mediate changes in relevant outcomes (e.g.,Shapiro et al. 2007, 2008). Studies have foundthat outcomes are mediated by reductionsin maladaptive cognitive processes such asrumination ( Jain et al. 2007) or thoughtsuppression (Bowen et al. 2007).

Mindfulness-based therapies may also im-pact clinical outcomes by disrupting maladap-tive links between what people think, feel, anddo (i.e., a desynchrony effect). For example,MBCT reduces the tendency for depressivethoughts to be activated by depressed mood(Raes et al. 2009) and reduces the relationshipbetween the frequency of repetitive thoughtsand negative reactions to these thoughts(Feldman et al. 2010). These findings com-port with studies showing that depressed af-fect relates to negative cognitions only in thoselow in trait mindfulness (Gilbert & Christopher2009).

In a recent study (Witkiewitz & Bowen2010), craving mediated the relationship be-tween depression and substance use in a controlgroup but not in one receiving MBRP. Mind-fulness interventions have also been shown toreduce the relationship between negative af-fect and urges to smoke cigarettes (Bowen &Marlatt 2009).

Mindfulness can also affect the relationshipbetween behavior and implicit processes. Forexample, Ostafin & Marlatt (2008) found thatthose higher in mindfulness demonstrated lessof a relationship between implicit approach biastoward alcohol and hazardous drinking. Simi-larly, other studies have found that the impactof priming on behavior is reduced in individ-uals who received a mindfulness intervention(e.g., Djikic et al. 2008) or who had high traitmindfulness (e.g., Radel et al. 2009).


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MCT: MetacognitiveTherapy

Compassion-focused methods seem to pro-duce higher feelings of social connectedness(Hutcherson et al. 2008), and more positiveemotions (Frederickson et al. 2008, Hutcher-son et al. 2008). Outcomes appear to be medi-ated in part by positive mood changes leadingto more personal resources (Frederickson et al.2008) and positivity toward strangers (Hutch-erson et al. 2008).

Overall, these studies lend preliminary sup-port to many of the hypothesized processesof change described by mindfulness-basedtherapies.

ATTENTIONAL CONTROLMindfulness-based methods teach attentionalcontrol and detachment (for example, by learn-ing to follow the breath) but new methods focuson these two processes directly.

Metacognitive TherapyMetacognitive Therapy (MCT; Wells 2000)emphasizes changing attentional processes toalter the relation to thoughts instead of at-tempting to change thoughts themselves. Thisoverlaps significantly with the mindfulness-based approaches but has certain distinctfeatures.

Techniques and putative processes. At thetheoretical level, MCT is grounded in theSelf-Regulatory Executive Function model(S-REF; Wells & Matthews 1994). Accordingto this model, a specific way of thinking, termedthe cognitive attentional syndrome (CAS), isat the core of most psychological disordersand is responsible for the intensification andmaintenance of distressing emotions. Thisthinking style is composed of three maintendencies: worrying and ruminating (i.e.,repetitive and unsuccessful attempts to solveproblems), threat monitoring (i.e., attentionfocus on internal and external potential threatsresulting in an increase of anxiety and negativethoughts), and coping strategies that interferewith contacting corrective experiences (e.g.,avoidant behaviors). Wells (2008) argues that

this thinking style is the product of metacog-nitions, particularly the belief that worrying,ruminating, and threat monitoring will avoiddanger and/or solve past and future problemsand the belief that it is necessary to behaveaccording to thoughts.

The Attention Training Technique (ATT;Wells 1990) is used to reduce self-focusedattention and to develop detachment fromcontent of thoughts and flexible control overthinking. It consists of short daily auditory exer-cises requiring selective switching and dividingattention on sources of stimulation comingfrom various spatial locations. The point is notto distract from difficult thoughts but ratherto increase flexibility by opening attention tosources of information other than threats.

The MCT package also comprises the use ofa specific form of mindfulness called DetachedMindfulness (DM), presented by Wells (2005)as the antithesis of the CAS and correspond-ing to a state of mind in which thoughts areapprehended as objects separated from reality.The goal of developing such a state of aware-ness is to prevent automatic responses to psy-chological events. Clients trained in this typeof mindfulness practice learn notably to stopworrying or ruminating in presence of mentaltriggers. DM exercises consist of different tech-niques such as free association tasks in whichthe therapist reads a series of words to a client,who is asked to let his mind go without tryingto control his thoughts or emotions. Exercisesare used to demonstrate that the problem comesfrom needless attempts to control thoughts. Topromote the distinction between the self andpsychological events, clients are also proposedto mentally observe their thoughts printed onclouds in the sky and to let them pass.

A third element of MCT, metacognitivelydelivered exposure, aims at changing the client’sthinking style while conducting traditional ex-posure and challenging metacognitions. Thus,all of the new skills MCT targets are fairlybroad, and none are syndrome specific.

Outcome evidence. Evaluated as a pack-age, MCT was shown to be effective for the

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treatment of generalized anxiety disorder(GAD) in an RCT comparing MCT to appliedrelaxation (Wells et al. 2010) with large effectsizes. Simons and colleagues (2006), in an RCTcomparing MCT to Exposure with ResponsePrevention, observed improvements in partici-pants’ symptoms, but no difference was shownbetween the two interventions in the secondstudy. A variety of other open trials and sys-tematic case studies on MCT are available.

Processes and components. We are notaware of mediational studies of MCT, butcomponents have received attention. ATT hasbeen shown to be helpful in isolation in sev-eral single cases in areas of anxiety, depres-sion, or psychosis (e.g., Siegle et al. 2007).Varieties of metacognitively delivered expo-sure, a component of MCT, have also beenevaluated (e.g., Fisher & Wells 2005), and bet-ter effects have been found in comparison withtraditional exposure.

MOTIVATION AND BEHAVIORALACTIVATION METHODSBehavior therapy has always focused on behav-ior, but this emphasis has re-emerged in thecontext of motivation and acceptance methods.

Motivational InterviewingMotivational interviewing (MI) is a broad,client-centered, directive clinical method thatenhances readiness for change by reducingresistance and ambivalence within the contextof a supportive and empathic therapeuticrelationship (Miller 1983). In contrast to con-frontational techniques commonly employedin substance abuse treatment, MI supports theclients’ autonomy and assumes their ability tomake sufficient and necessary behavior changes.

Techniques and putative processes. Thesix components of MI are summarized by theacronym FRAMES: Feedback, an emphasison personal Responsibility, Advice, a Menuof options, an Empathic counseling style, and

MI: motivationalinterviewing

support for Self-efficacy (Bien et al. 1993). Thegoal is for the interviewer to occasion client“change talk,” the client’s own verbalizedmotivations for change (Miller & Rose 2009).Counterchange arguments (or “sustain talk”)represent the flip side of the client’s ambiva-lence, to which the MI counselor respondsempathically. Once sufficient motivation ap-pears to be established, the counselor then aimsto strengthen the client’s verbal commitmentto change by occasioning specific change goalsand plans (Miller & Rollnick 2002).

Outcome evidence. Numerous clinical tri-als have shown MI to be an effective clini-cal method for promoting adaptive behaviorchanges (i.e., exercise and diet), reducing poten-tially harmful behaviors (i.e., problem drinking,gambling, and HIV risk behaviors), and increas-ing medical adherence (diabetes managementand cardiovascular rehabilitation; see Hettemaet al. 2005 for a review and meta-analysis). Thisrecent meta-analysis of 72 clinical trials, span-ning a range of target problems, suggests thatMI has an average short-term between-groupeffect size of 0.77, decreasing to 0.30 at one-year follow-up (Hettema et al. 2005). MI hasalso been successfully added as a precursor toother active treatments, yielding unexpectedlylarger (Burke et al. 2003) and more enduring(Hettema et al. 2005) treatment effects thanwhen delivered alone. These findings may beattributable to the impact of MI upon treat-ment retention and adherence (Brown & Miller1993).

Moderation. MI treatment developers havereported that the observed effect sizes of MIwere larger with ethnic minority populations(Hettema et al. 2005). MI also appears to bemore effective with clients who are less mo-tivated for and/or more resistant to change(e.g., Heather et al. 1996). This finding isconsistent with MI’s theoretical rationale anddevelopment.

Processes of change. Client change talk,client commitment language, and counselor


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BA: behavioralactivation

empathic understanding have been empha-sized as key change processes (Miller & Rose2009). Researchers have utilized a taxonomycoding system in order to define change talk(e.g., Amrhein 1992). Results of coded MIsessions indicate that clients’ stated desire,ability, reasons, and need for change all con-tribute to subsequent strength of commitmentlanguage, but only commitment directlypredicts behavior change (Amrhein et al.2003). Studies employing behavioral codingfor in-session verbal exchanges have concludedthat MI-consistent therapist statements weresignificantly more likely to be followed byclient change talk, whereas MI-inconsistenttherapist statements were significantly morelikely to be followed by client counterchangetalk (Moyers et al. 2007). When compared withconfrontational clinical methods, clients in theMI condition also voice about twice as muchchange talk and half as much resistance (Milleret al. 1993). This between-groups effect is alsoseen within session as the client’s resistance tochange varied as a step-wise function to thetherapist’s directive versus reflective statements(Patterson & Forgatch 1985). Furthermore,the strength of the client’s commitment lan-guage predicts drinking outcomes (Amrhein1992), whereas resistance predicts relapse at 6,12, and 24 months (Miller et al. 1993).

Behavioral ActivationBehavioral activation (BA) is a structuredtreatment approach rooted in the behavioraltradition established by Ferster (1973) andLewinsohn (1974), which primarily incorpo-rated strategies aiming to alter the environingcontingencies influencing the client’s depressedmood and behavior (see Dimidjian et al. 2011for a more complete description). In its originalform it is part of the first wave of behavior ther-apy, but in its modern form it includes issuesaddressed by the other approaches discussed inthis review.

Techniques and putative processes. Pleas-ant activity scheduling and mood-monitoring

techniques were originally employed in BA toaid clients in enriching their behavioral reper-toires to include adaptive behaviors with suf-ficient frequency, intensity, and quality suchthat they may be reinforced by the environment(Lewinsohn et al. 1980). Other variants of BApromoted clients’ learning self-control or man-agement skills in order to accomplish personalgoals (e.g., Kanfer 1970) and self-evaluate andself-administer rewards (e.g., Fuchs & Rehm1977).

In the latter part of the twentieth century,BA was criticized for not including componentsthat facilitated cognitive change. Thus, cog-nitive strategies, such as mental rehearsal andcognitive restructuring, were combined withthe behavioral components of BA, producingdifferent variants of cognitive-behavioral treat-ment packages (e.g., Beck et al. 1979). Morerecently, BA treatment researchers have ques-tioned the wisdom of abandoning “pure” BAapproaches and have begun to reconsider itscontextual roots in evaluating processes ofchange (e.g., Hopko et al. 2003). Such effortshave led to recent adaptations in BA, whichincluded idiographic functional assessmentsof depressed behavior, as well as the inclusionof acceptance and mindfulness components(e.g., Dimidjian et al. 2006). Similar to theearlier conceptualizations of BA, these newerapproaches have conceptualized the importantchange processes as moving patients from anavoidance to an approach (or action)-basedlifestyle, without directly targeting the contentof the individual’s private experience (i.e.,catastrophic thinking or depressed mood),but they add techniques that attempt toundermine avoidance of private experience.BA interventions also commonly introducepatients to a functional analytic style of un-derstanding behavior so that they may betteridentify harmful patterns of avoidance (oraversive control) and implement secondarystrategies to foster desired changes in overtbehavior. It is therefore assumed that theincreases in overall activity (e.g., via pleasantevents scheduling) will increase contact withresponse-contingent reinforcement, which will

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then reduce depressive mood and behaviors(i.e., social withdrawal; Manos et al. 2010).

Outcome evidence. Several variants of BAhave been tested and have demonstratedefficacy as compared with nontreatment andactive treatment. The most recent comprehen-sive meta-analysis of BA concluded that thecollective evidence for it satisfies the criteriafor a “well-established empirically validatedtreatment” (Mazzucchelli et al. 2009). Whencompared with control treatment conditions,the reported pooled effect size for all variantsof BA was large and significant at 0.78. BAinterventions also significantly increased par-ticipants’ level of activity at posttest, yieldinga moderately large and significant mean effectsize of 0.54. Recent variants of BA have beenfound to be comparable to antidepressant medi-cation in outcome, even after considering initiallevels of depression severity, and superior totraditional CBT among severely depressed pa-tients (Dimidjian et al. 2006). Furthermore, BAhas demonstrated lower attrition than antide-pressant medications (Dimidjian et al. 2006).

Components. So far it does not appear thatthe variants of BA are significantly differentfrom each other (Mazzucchelli et al. 2009).There is no reliable difference between BA andCBT (pooled effect size = 0.01), which com-ports with studies showing that the behavioralcomponent of CBT was equally effective aloneor in combination with cognitive components(e.g., Gortner et al. 1998).

Moderation. Researchers (e.g., Sturmey2009) have argued that BA may be moreappropriate for depressed individuals who aremore difficult to treat or are less responsiveto cognitive or cognitive-behavioral therapies,such as those with cognitive impairments(Teri et al. 1997) and comorbid substanceabuse problems (Daughters et al. 2008), aswell as psychiatric in-patients (Hopko et al.2003). There is evidence that it is more helpfulthan alternatives with more severe patients(Dimidjian et al. 2006), which comports withthis analysis.

Processes of change. Several measures havebeen developed to assess BA’s hypothesizedprocesses of change (see Manos et al. 2010 fora review). Decreased depression is correlatedwith increased positive events and behavioralactivation as assessed by the EnvironmentalReward Observation Scale (Armento & Hopko2007) and the Behavioral Activation forDepression Scale (Kanter et al. 2007). Further-more, the proposed relationship between aver-sive events, behavioral avoidance, and increaseddepression has been substantiated (Manos et al.2010).

Difficulties with measurement continue tocontribute to problems in assessing the pro-cesses of change for BA models, primarily dueto the fact that important components often co-occur temporally. This commonly occurringphenomenon contributes to the entanglementof these components within putative processmeasures, especially with regard to positivereinforcement and mood (Manos et al. 2010).Technically, changes in mood are conceptu-alized as a reaction, or respondent by-product,to changes in contingencies (Kanter et al.2008a). However, the measurement of contactwith reinforcing events is confounded withthe measurement of the behavior hypothesizedto produce such contact. Researchers havepreviously circumvented this issue by measur-ing mood as a proxy for reinforcement (e.g.,Lewinsohn et al. 1980). Although such mea-surement strategies aided in building evidencefor BA efficacy in treatment outcome trials,this approach needs to be readdressed to betterunderstand its mechanisms of change. Newmeasurement strategies appear to be needed,especially those that assess key behaviors anddepressed mood at multiple points over time(Sturmey 2009).

RELATIONSHIP-ORIENTEDTHERAPIESThe focus on acceptance has entered into be-havioral approaches to relationships, includingthe therapeutic relationship.


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IBCT: IntegrativeBehavioral CoupleTherapy

FAP: functionalanalytic psychotherapy

Integrative BehavioralCouple TherapyIntegrative Behavioral Couple Therapy (IBCT)grew out of Traditional Behavioral CoupleTherapy (TBCT; Jacobson & Margolin 1979),which focused on helping couples make posi-tive changes in their relationship, such that theyhave more reinforcing interactions. IBCT waslater developed to address some of the limi-tations in TBCT, namely the strong focus onchange, by including an emphasis on emotionalacceptance (Christensen et al. 1995).

Techniques and putative processes. IBCTassumes that there are genuine incompatibil-ities in all couples that are not amenable tochange and that the partners’ ability to foster ac-ceptance of emotional difficulties may enhancerelationship satisfaction as well as reduce resis-tance to change. IBCT uses both didactic andexperiential treatment procedures to help cou-ples balance acceptance and change strategies,not merely in being more accepting of partnersbut also more accepting of their own psycho-logical processes. In order to further build inti-macy between couples, the IBCT therapist alsoattempts to move partners from an adversar-ial confrontation to collaborative engagement.Training in emotional acceptance was proposedto increase long-term maintenance of treat-ment gains by shifting the attention away fromthe “right way” to communicate (and otherrule-governed behaviors) to the natural con-tingencies within the relationship ( Jacobson &Christensen 1998).

Outcome evidence. In the largest clinical trialof couple therapy to date, Christensen et al.(2004) compared the effectiveness of TBCTand IBCT, concluding that both conditionsled to clinically and statistically significant im-provements at the end of treatment, with IBCTshowing more consistency in gains through-out treatment. Prospective longitudinal follow-ups were conducted with the same sampleand found that approximately two-thirds ofcouples demonstrated clinically significant im-

provements relative to pretreatment relation-ship satisfaction ratings at two years (d = 0.90and d = 0.71 for IBCT and TBCT, respec-tively) and five years (d = 1.03 and d = 0.92for IBCT and TBCT, respectively) for coupleswho stayed together (Christensen et al. 2006,2010). There were few significant differencesbetween treatments, but the differences that didemerge tended to favor IBCT. Additional stud-ies of IBCT also indicate that it is effective whendelivered in group formats as compared to wait-list controls and is comparable to CT in reduc-ing depression in maritally distressed women.

Processes of change. There is evidence forthe mediating role of both behavior changeand acceptance in predicting relationship sat-isfaction in IBCT (Doss et al. 2005). Increas-ing couples’ experiential acceptance of difficultemotions also appears to reduce the intensityof emotional arousal, which may improve part-ners’ ability to engage in the more directivestrategies, such as communication techniquesdelivered in TBCT (Christensen et al. 2010).

Functional Analytic PsychotherapyFunctional analytic psychotherapy (FAP) isa contextual behavioral approach that aimsto shape the client’s in-session behaviors bythe therapist contingently responding to theclient’s behavioral excesses or deficits withinmoment-to-moment client-therapist interac-tions (Kohlenberg & Tsai 1991, Tsai et al.2009). Its present-moment focus overlaps withthe methods discussed above, and in recentvariants, FAP (Tsai et al. 2009) has beenclearer about the importance of acceptance andmindfulness.

Techniques and putative processes. FAPtherapists conceptualize the client’s clinicallyrelevant behaviors (CRBs), according to theclient’s specified problems and goals fortherapy, as behaviors that either need to bereduced (CRB1s) or strengthened (CRB2s)within the client’s repertoire. The therapistthen aims to (a) punish or extinguish CRB1s

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and (b) occasion and reinforce CRB2s. For thetherapist’s responses to achieve their intendedfunction, it is important that the therapist firstestablish him/herself as a salient source ofsocial reinforcement (Follette & Bonow 2009).FAP treatment developers have providedbehavioral accounts of interpersonal intimacyand how to produce a therapeutic relationshipcharacterized as genuine, open, and curative.Throughout its development, FAP has alsotheoretically addressed issues regarding thedevelopment and experience of “self ” aswell as what constitutes adaptive emotionalexperiencing and expression (Tsai et al. 2009).Because most clients appropriate for a FAPintervention are dealing with difficulties thatemerge socially, improvements that are madein the client’s repertoire in session with thetherapist are expected to be relevant andgeneralize to the natural environment.

Outcome evidence. Multiple case studiessupport FAP applications to a wide varietyof problems, including depression, obsessive-compulsive disorder, anxiety with agoraphobia,chronic pain, and post-traumatic stress disorder(see Baruch et al. 2009 for a review), but FAP asa stand-alone treatment has yet to be evaluatedin a randomized controlled trial. Single-subjectand group designs suggest that when used inconjunction with other empirically evaluatedtreatments such as CBT (Kohlenberg et al.2002), FAP may produce good outcomes.

Processes of change. The FAP tenet of uti-lizing the therapeutic relationship to impactchanges in client outcomes has been inves-tigated and supported in the literature (e.g.,Wolfe & Goldfried 1988). Unlike the majorityof research regarding the “nonspecific” com-mon factors of the working therapy alliance,FAP aims to specify the therapeutic mecha-nism of change as contingent reinforcement ofCRB2s (Follette et al. 1996). Successful FAPcases (e.g., Busch et al. 2010) support the hy-pothesis that CRB1s decrease and CRB2s in-crease in frequency over the course of FAPtreatment, which is a key process hypothesis

DBT: dialecticalbehavior therapy

(Kanter et al. 2008b). Micro-process analysesof moment-to-moment client-therapist inter-actions have concluded that client’s in-sessiontarget behavior improved as a function of thetherapist’s contingent responses (Busch et al.2009) and led to significant improvements inout-of-session target variables (Kanter et al.2006).

INTEGRATIVE APPROACHESMore general models have also emerged thatmix together the central themes of issues of ac-ceptance, present-moment focus, mindfulness,the therapeutic relationship, and motivation tochange.

Dialectical Behavior TherapyAn example of an integrated approach is dialec-tical behavior therapy (DBT; Linehan 1993).Originally developed for borderline personal-ity disorder (BPD), it has been expanded as atreatment approach for emotion dysregulationdisorders more broadly.

Techniques and putative processes. DBTis based on a dialectical philosophy, focusingon the inherent tensions and synthesis of op-posing forces. One of the main dialectics inDBT is between acceptance and change, whichis reflected in the combination of mindful-ness, acceptance, and validation strategies withbehavior change strategies. DBT embraces abiosocial or transactional model, which de-scribes how individual characteristics and an in-validating environment affect each other andserve to evoke and strengthen emotional dys-regulation (Linehan 1993).

Treatment is divided into stages, with thefirst stage focusing more on safety and stabilityand later stages working toward well-being andlife satisfaction. DBT consists of four primarymodes of delivery: group skills training, individ-ual psychotherapy, phone coaching, and groupconsultation for the therapist. A core target isthe acquisition, strengthening, and generaliza-tion of a broad set of DBT skills. In particular,


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DBT seeks to strengthen effective use of foursets of skills: mindfulness, distress tolerance,emotion regulation, and interpersonal effec-tiveness. Skills are generally acquired in grouptherapy, with phone coaching and individualtherapy further supporting their strengtheningand generalization.

Outcome evidence. There is a significantevidence-base supporting the efficacy of DBT.A recent review by Lynch and colleagues (2007)identified seven well-controlled RCTs demon-strating the efficacy of DBT for BPD. Thesestudies found significant effects on outcomes,including reduced suicidality, hospitalizations,depression, and anger, as well as higher socialadjustment and retention in treatment. Theseoutcomes were demonstrated in comparisonto TAU, client-centered therapy, combined12-step/comprehensive validation therapy, andtreatment by community experts. Some RCTshave failed to find differences between DBTand other well-structured treatments, however(e.g., Clarkin et al. 2007). DBT has also beenfound to be effective for other mental healthproblems and in specific populations in RCTsand open trials, including substance use disor-ders, binge eating and bulimia, depression inolder adults, bipolar disorder, clients in forensicsettings, violence and aggression, oppositionaldefiant disorder, female victims of domestic vio-lence, family members of individuals with BPD,and couples (see Lynch et al. 2007).

Components. As an integrative approach,some of the components of DBT have beenadopted from empirically validated treatmenttechnologies. For example, we have reviewedthe efficacy of mindfulness technologies in theprevious section (e.g., Grossman et al. 2004,Hofmann et al. 2010). Similarly, the commit-ment strategies used in DBT to improve treat-ment retention have been validated in studiesacross a range of approaches and disciplines inpsychology (Bornalova & Daughters 2007).

Studies have found that the DBT skills train-ing group alone, without the other treatmentcomponents, is psychologically active and im-

pacts relevant outcomes. For example, an RCTwith BPD clients by Soler and colleagues (2009)found that a DBT skills training group hadsignificantly lower dropout rates and greatersymptom reduction at post and three-monthfollow up compared to a standard group ther-apy. Similar results have been found in RCTscomparing the efficacy of DBT skills traininggroups to wait list for binge eating (Telch et al.2001) and medications for depression (Lynchet al. 2003) and in open trials with specificpopulations, including those with parasuicidalbehaviors (Sambrook et al. 2006), depression(Harley et al. 2008), and oppositional defiantdisorder (Nelson-Gray et al. 2006).

Moderation. Patients with high levels of expe-riential avoidance and anxiety tend to drop outof DBT (Rusch et al. 2008), but little is knownabout patterns of moderation of DBT effects

Process of change. Processes of change havenot been regularly studied in DBT outcomestudies, though they are beginning to gain at-tention (Lynch et al. 2006), and DBT-specificmeasures are being developed (e.g., Neacsiuet al. 2010). A recent study found that DBT re-duced experiential avoidance as assessed by theAcceptance and Action Questionnaire (Hayeset al. 2004) and that this change predictedlater changes in depression, but not vice versa(Berking et al. 2009). Although the reductionin experiential avoidance does not rise to thelevel of mediation, it does suggest strongly thatexperiential avoidance is a functionally impor-tant process of change in DBT.

It has also been found that use of DBT skillsincreases over time and that these increases re-late to improvements in BPD symptoms (e.g.,Stepp et al. 2008). Other processes identifiedas possibly important are emotional processing(Feldman et al. 2009) and balancing acceptanceand change (Shearin & Linehan 1992).

Acceptance and Commitment TherapyAcceptance and Commitment Therapy (ACT;Hayes et al. 1999) uses acceptance and

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mindfulness techniques, and commitment andbehavioral activation techniques, to producepsychological flexibility. It is one of the morebroadly focused of the methods in CBT that isnot based on traditional CBT assumptions, inpart because ACT emphasizes basic principlesover specific syndromal issues.

Techniques and putative processes. Psy-chological flexibility is the applied model thatunderlies an ACT approach to psychopathol-ogy and psychological health. Psychologicalflexibility refers to the ability to contact con-sciously the present moment and the thoughtsand feelings it contains more fully and withoutneedless defense, and based on what the situa-tion affords, to persist or change in behavior inthe service of chosen values. It in turn is basedon Relational Frame Theory (RFT; Hayes et al.2001), which is a modern behavioral researchprogram in language and cognition.

At the core of RFT lies the idea that lan-guage is based on the learned derivation of re-lations among events based on cues that canbe arbitrary. For example, although a nickelis larger than a dime (according to the size),young children learn that “is larger than” canalso be applied arbitrarily, and thus a dime canbe larger than a nickel (according to the value).RFT studies have shown that any event can ac-quire an aversive function even without hav-ing been directly associated with another eventand without sharing formal properties based onthis process of arbitrarily applicable responding(Dymond & Roche 2009). In other terms, lan-guage can turn any event into a source of pain.For example, a successful career can be experi-enced as a failure just because it is “less than” ahoped-for ideal. As a consequence of this lan-guage process, any object of thought can be-come a source of pain (e.g., feeling sad whenremembering the death of a parent).

In addition, any event can relate to any otherevent cognitively so that one is never able todurably isolate a source of pain from all otherevents (Hooper et al. 2010) (e.g., a happy mem-ory is a reminder that the present is not thesame as when the loved parent was still alive).

ACT: Acceptance andCommitment Therapy

Psychologicalflexibility:consciously contactingthe present momentwithout needlessdefense whilepersisting or changingbehavior in the serviceof chosen values

Values: freely chosen,verbally constructedconsequences ofongoing patterns ofactivity, whichestablish immediaterewards intrinsic to thebehavioral patternitself

Defusion: the processof relating to thoughtsas just thoughts so asto reduce theirautomatic impact

Unable fully to avoid the situations that canoccasion distress, language-able humans beginto avoid the psychological experience of dis-tress itself even when doing so causes behav-ioral difficulties—verbal relations lead readilyto experiential avoidance (Hayes et al. 1996).

The evolutionary advantage of derived re-lational responding is verbal problem-solving,but there are times that this mode of mindincreases entanglement with verbal rules andproduces a decreased sensitivity to direct conse-quences of responding (see Hayes et al. 1989 foran experimental demonstration). This seemsto operate in particular when an individualpersists in counterproductive attempts to avoidpainful thoughts and emotions. Together,experiential avoidance and cognitive fusion re-duce flexible contact with the present momentand forestall individuals from contacting whatthey value (in part because knowing what theycare about connects them with sources of pain).

ACT targets the language and cognitiveprocesses maintaining cognitive entanglement,experiential avoidance, rigid attentional pro-cesses, lack of values clarity, and other sourcesof psychological inflexibility (Boulanger et al.2010). Since these appear to be common pro-cesses for most psychological disorders (Hayeset al. 2006), at a functional level the clini-cal perspective of ACT is largely the sameacross the variety of syndromes included in theDiagnostic and Statistical Manual of Mental Disor-ders. The approach is organized around six mainprocesses: acceptance, defusion, self, the now,values, and commitment. Most ACT principlesare taught to clients by means of experiential ex-ercises, mindfulness methods, and a specific useof language (e.g., metaphors and paradoxes). Allof this is to bypass the deleterious effects of ex-cessively literal language in contexts requiringmore psychological flexibility. Thus, instead ofapprehending their external and internal envi-ronment through what they think, clients learnto contact directly what is happening here andnow.

To encourage acceptance, the therapistuses metaphors, such as “struggling in quick-sand,” in which the client observes the similar


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counterproductive effects of attempting to es-cape sinking in the sand and of attemptingto avoid thoughts and emotions (Hayes et al.1999). The metaphor is presented in an expe-riential rather than a didactic way so as to leadclients to observe the concrete consequences oftheir actions.

Defusion techniques create a context inwhich the dominance of linear thought isdiminished so that clients learn that thoughtscan be apprehended as just thoughts insteadof being literally followed or resisted, believedor disbelieved. Thus, instead of analyzingthe veracity of their thoughts, clients are ledto consider the utility of acting according tothoughts for moving in a valued direction. Totrain defusion, the therapist, for example, playsthe role of the client’s mind by formulating aseries of statements, evaluations, and injunc-tions that the client notices without actingunder their control.

Exercises to improve contact with thepresent moment are used to train flexible at-tention to what is present. For example, mind-fulness exercises may be used (e.g., follow thebreath, scan the body).

Perspective-taking exercises are used to en-courage contact with a transcendent sense ofself. For example, clients might look back atthemselves from a wiser future and write them-selves a letter of encouragement. Such exer-cise helps the client distinguish between thecontent of consciousness and the person as aperspective-taking context for that content, inthe hopes that this will reduce attachment tothe conceptualized self.

Values are apprehended in ACT as chosenlife directions that establish reinforcers in thepresent that are intrinsic to patterns of action.The therapist helps clients elaborate what isheld dear in domains such as family, work,or education and reinforces even the smallestactions if they are actually values oriented.

Committed action consists of behavioralactivation techniques such as goal setting,homework, skills development, exposure, andshaping. These are technologically similar to

behavior therapy or traditional CBT, but thegoals may differ. For example, exposure is notbeing done to reduce arousal but rather to in-crease behavioral flexibility in the presence ofpreviously repertoire-narrowing stimuli (e.g.,anxiety).

Outcome evidence. More than 50 trials andcase series have been carried out with ACT.About 30 of these are RCTs. Reviews andmeta-analyses have revealed medium to largegroup effect sizes (see Hayes et al. 2006, Powerset al. 2009, Ruiz 2010). What is perhaps mostnotable is the range of disorders and problemsaddressed with the same model and in manycases with highly similar technology. With afocus only on areas with published RCTs (seethe meta-analyses above for citations), suc-cessful studies have been done on depression,coping with psychosis, substance use, chronicpain, epilepsy, obsessive-compulsive disorder,diabetes management, reduction of prejudicetoward people with psychological problems,helping drug and alcohol counselors learnand apply evidence-based pharmacotherapy,worksite stress, smoking cessation, obesity,adjusting to college, eating pathology, andother problems. ACT has been successfullycompared to other empirically supportedtreatments as well, including cognitive therapy(e.g., Zettle et al. 2011) and pharmacotherapy(e.g., Gifford et al. 2004).

Components. ACT components have beentested in more than 40 studies, most done witha single technique or a small set of techniques(Levin et al. 2011, Ruiz 2010). Significanteffect sizes were found for defusion, values,contact with the present moment, mindfulnesscomponents (combinations of acceptance,present moment, defusion, or self as context),and values plus mindfulness in comparisonwith techniques such as thought suppressionor distraction. Effects sizes in levels of anxiety,pain tolerance, or discomfort were signifi-cant not merely for rationales but also grew asmetaphors and exercises were added to the mix.

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Moderators. There is some evidence thatACT is relatively more effective for highly ex-perientially avoidant participants (e.g., Masudaet al. 2007) or for those with more severe prob-lems (e.g., Muto et al. 2011).

Processes of change. ACT alters psycholog-ical flexibility and its components, such as ex-periential avoidance, fusion, and values (Hayeset al. 2006). Most of the existing ACT RCTshave included process measures, and about two-thirds have published mediational analyses.Across all studies, about 50% of the between-group differences in follow-up outcomes can beaccounted for by the mediating role of differ-ential post levels in psychological flexibility andits components. A few examples show the pat-tern. Wiscksell and colleagues (2011) showedthat follow-up improvement in ACT for per-sons with chronic pain was mediated by dif-ferential post levels of psychological flexibility.Gaudiano et al. (2011) found that the follow-upimpact of ACT on distress caused by hallucina-tions was mediated by differential post levels ofthe believability of these hallucinations (oftenused as a metric for defusion in ACT studies)but not by their frequency. Zettle et al. (2011)found that the differential follow-up impact ofgroup ACT versus group CBT on depressionwas mediated by differential post levels of thebelievability but not the intensity of depresso-genic thoughts. Gifford et al. (2004) found thatthe follow-up impact of ACT on smoking ces-sation was caused by differential post levels ofpsychological flexibility focused on smoking-related thoughts and feelings. Behavioral mea-sures of psychological flexibility as early as ses-sion two have been successful in predicting pos-itive outcomes in ACT (Hesser et al. 2009).In some cases, more traditional cognitive mea-sures have also been tested for mediation (e.g.,Wicksell et al. 2011, Zettle et al. 2011), andin all of these cases, psychological flexibility hasproven more powerful as a mediator. As a resultof greater flexibility, ACT often leads to desyn-chrony between emotion or thought and behav-ior. For example, admission of hallucinations isa predictor of staying out of the hospital in ACT

Contextual CBT:approaches focused onaltering the person’srelationship to thoughtand emotion ratherthan the form of theseexperiences

for psychosis (Bach & Hayes, 2002), and painintensity no longer relates reliably to psychoso-cial disability or work absence (Dahl et al. 2004).

CONTEXTUAL COGNITIVEBEHAVIORAL THERAPYSeveral years ago, five features were suggestedas characteristics of the “third wave” of be-havioral and cognitive therapy (Hayes 2004,p. 658). The methods discussed in the presentreview were called the third wave of CBT be-cause they seemed to represent the emergenceof a coherent set of new assumptions arisingin many corners that differed both from tra-ditional behavior therapy and from traditionalCBT assumptions. The term “third wave” (orsometimes “third generation”) CBT has beenused frequently since, with more than 1,000Web site citations and 70 publications using it,according to Google. It has invited resistance,however (e.g., Hofmann & Asmundsun 2008),due in part to the unwanted connotation thatbehavior therapy or traditional CBT is old hator is being left behind, when the point was moreto orient readers to a strand of thinking thatwas emerging in the behavioral and cognitivetherapies. The term is also too vague and timebased for long-term use, especially as existingapproaches begin to include these new methodsor even their core assumptions. In this review,we propose the more descriptive term “con-textual CBT” to denote methods such as thosewe have been discussing and any other method(including the evolution of more traditionalmethods) that has similar assumptions.

The list of features described in 2004 seemseven more clearly true today, after several addi-tional years of development. Below, we describethese features and briefly discuss the evidencefor each.

Contextual Methods and PrinciplesThe first attribute of this set of methods isperhaps the most important, and it is the onethat justifies the use of the term “contextualCBT.” These new methods target the context


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and function of psychological events suchas thoughts, sensations, or emotions, ratherthan primarily targeting the content, validity,intensity, or frequency of such events, and theydo so in a way that is focused on principles ofchange and not merely on new techniques. Thecontent-versus-context distinction has beenexplicitly stated as an important one by the de-velopers of virtually all of the methods discussedin this review. For example, Segal, Teasdale,and Williams have stated, “Unlike CBT, thereis little emphasis in MBCT on changing thecontent of thoughts; rather, the emphasis ison changing awareness of and relationship tothoughts” (2004, p. 54). In another example,the developers of BA stated, “Interventionsaddress the function of negative or ruminativethinking, in contrast to CT’s emphasis onthought content. . . . BA specifies attention-to-experience interventions to counter ruminativethinking by attending to direct sensations.Similar to recent mindfulness-based treatments(e.g., Segal, Williams & Teasdale 2002), theseinterventions provide a method for addressingrumination that does not engage the contentof thoughts” (Dimidjian et al. 2006, p. 668). Inanother, the developer of MCT emphasized,“MCT does not advocate challenging of nega-tive automatic thoughts or traditional schemas”(Wells, 2008, p. 651), adding that although“CBT is concerned with testing the validityof thoughts (. . .) MCT is primarily concernedwith modifying the way in which thoughtsare experienced and regulated” (p. 652). Inyet another example, the developers of ACTstate, “The ACT model points to the contextof verbal activity as the key element, ratherthan the verbal content. It is not that peopleare thinking the wrong thing—the problemis . . . how the verbal community supportsits excessive use as a mode of behavioralregulation” (Hayes et al. 1999, p. 49). Similarstatements have been made by most if notall of the developers of the other methodsdiscussed in this review. These methods focuson changes in the psychological and socialcontext of difficult psychological events, moreso than changes in their content, and the focus

is more on changes in their function than onchanges in their form and frequency. Thecontextual targets of these methods includeawareness, mindfulness, decentering, accep-tance, defusion, values, cognitive flexibility,motivation, metacognition, function, attention,curiosity, a supportive relationship, spirituality,detachment, psychological flexibility, waysof experiencing, readiness to change, andcommitment, among many others.

The emphasis on function and context overform and content is not merely rhetorical,philosophical, or technological. It is revealed inthe empirical review we have conducted in thecurrent article on what is known about the com-ponents, moderators, mediators, and processesof change produced by these various thera-pies. For example, mindfulness-based thera-pies, ACT, and other methods are known toproduce an unexpected desynchrony betweenthought or emotion and behavior. In otherwords, as a result of these methods, the sameemotional or cognitive content now functionsin a different way. That is empirical evidence ofa contextual effect. For example, Varra and col-leagues (2008) found that clinicians exposed toACT and then trained in pharmacotherapy ad-mitted to more barriers to using evidence-basedpharmacotherapy but were also now more will-ing to use these methods and at follow-up hadin fact done so. That is, worries about what col-leagues would think and the like were more psy-chologically accessible but less behaviorally im-pactful. That kind of effect is precisely on pointwith the key content-versus-context distinctionbeing made by these new methods, and it is notin line with the traditional assumptions of be-havioral and cognitive therapies.

The present review shows (see referencesabove) that acceptance, mindfulness, anddecentering or defusion mediate or at leastcorrelate with outcomes in mindfulness-basedmethods, DBT, ACT, and IBCT. Valuesand commitment (e.g., as assessed by valuesassessment, change talk, and similar means)are known to be important in ACT, BA, andMI. Component analyses have shown thatflexible attention to the present is important

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in mindfulness-based methods, MCT, andACT. These are all contextual variables thatcan have an impact even without any changein cognitive or emotional content.

Broad and Flexible Repertoires Versusan Eliminative Approach to SyndromesA second characteristic of contextual CBTmethods is that they are all relatively broad andfit with a transdiagnostic approach to mentalhealth. Indeed, in most approaches, very simi-lar procedures have been applied with positiveoutcomes to a variety of pathologies and syn-dromes. The transdiagnostic qualities of thesemethods are demonstrated in their broad andgrowing range of application. The focus onbroad and flexible repertoires is evident in thescope of their putative and empirical processes,as we have described. Good emotion-regulationabilities, or more functional attentional pro-cesses, and so on, are skills that can apply tovirtually any life situation. As a result, contex-tual CBT methods already have vigorous em-pirical programs in areas that were rarely if everaddressed by more traditional clinical methods,including traditional CBT, such as prejudice(e.g., Masuda et al. 2007).

Applied to the Clinician, Not Justthe ClientAs a third characteristic, it is notable that manycontextual CBT methods require or encouragetherapists to explore these same processes suchas by having their own mindfulness practice orby working on acceptance of their own emo-tions. For example, it has been said that “Per-haps the most important guiding principle ofMBCT is the instructor’s own personal mind-fulness practice” (Dimidjian et al. 2009, p. 316).FAP therapists are told, “In order to best attendto the client’s experience, therapists first needto be in touch with their own” (Kohlenberget al. 2008, p. 16). DBT therapists are told tomaintain consultation groups, and “The taskof the consultation group members is to applyDBT to one another, in order to help each ther-

apist stay within the DBT protocol” (Linehan1993, p. 118). In ACT, it is said, “To the ex-tent that the model is correct there is no fun-damental distinction between the therapist andthe client at the level of the processes that needto be learned” (Pierson & Hayes 2007, p. 225).The assumption that therapists should them-selves be mindful, accepting, defused, and con-nected to values is just beginning to be testedexperimentally, but it appears that the idea hassome merit, at least is some contexts. For ex-ample, applying ACT to therapists makes themmore open and able to learn (Varra et al. 2008).

Builds on Other Strands of Behavioraland Cognitive TherapyAnother characteristic of contextual CBT isthat it has emerged without an interest is tear-ing down previous CBT approaches so muchas carrying them forward. As a body of meth-ods, contextual CBT protocols include virtu-ally all of the components of more content-focused forms of behavior therapy and CBTthat are well-supported empirically, includingexposure, skills training, and self-monitoring(e.g., thought recording). Two things are dif-ferent. First, there are different purposes andassumptions about processes of change forthese methods. For example, thought record-ing might be used to decenter or defuse fromthoughts rather than to test or challenge them;exposure might be used to increase behavioralflexibility in the presence of difficult emotionsor thoughts rather than to decrease emotionalresponding per se. Second, contextual CBTseems more willing to abandon elements andprocesses that have not received good empiri-cal support in component and process studies,such as cognitive restructuring.

Deals with More Complex IssuesCharacteristic of Other TraditionsThe final characteristic is admittedly moreof a judgment call, but the density of writingand research on such topics as spirituality,meaning, sense of self, relationships, and values


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suggests that contextual CBT methods aredealing more with the kinds of deep issues thathave historically been more the purview ofother traditions than was the case historicallyin CBT. One impact of this characteristic isthat many practicing clinicians who are drawnto contextual CBT do not have an empirical orbehavioral background. You can see this in therapid growth of organizations that promotecontextual CBT (e.g., the ACT-focused group,the Association for Contextual BehavioralScience, has grown by nearly 3,000 membersin the past five years) and in the penetrationof mindfulness and acceptance into moretraditional clinical training or commercialworkshops. On the one hand, the results seemsto be that contextual CBT is expanding theinterest in empirically supported treatmentsamong clinicians from nonempirical back-grounds. On the other, it raises a challenge ofhow to socialize clinicians from less-empiricalbackgrounds into the scientific culture of CBT.

The five characteristics described abovewere listed several years ago when the trendswere much harder to discern (Hayes 2004).They seem far more established today.

A CENSUS CONTEXTUALCOGNITIVE BEHAVIORALTHERAPY MODELIt is still early, but it appears that an empiri-cal if not yet intellectual consensus is emergingabout the key processes in psychopathology andpsychotherapeutic change from the point ofview of contextual CBT approaches. We canorganize these components, moderators, andprocesses of change into three basic categories.One cluster addresses issues of acceptance, de-tachment, metacognition, defusion, emotionalregulation, and the like. Contextual CBT meth-ods contain techniques designed to reducethe automatic behavioral regulatory power ofthoughts, feelings, memories, and bodily sensa-tions, but without necessarily first changing theform or frequency of these experiences. Saidin another say, they are designed to producegreater psychological openness. In Table 1 we

give a single example of a particular techniquefrom each therapy approach that putatively tar-gets psychological openness (although often itis addressed in several ways). In the columns,we indicate further whether there is any ac-tual process or component evidence showingthe importance of openness to the outcomesproduced by the specific approach.

A second cluster deals with flexible atten-tion, attention to the now, pure awareness, per-spective taking, theory of mind, and the like.These methods all deal with awareness andmindfulness, from a conscious person and to-ward the present moment both externally andinternally. Again, most of the approaches ad-dress this area, and we provide examples of thetechniques used in Table 1.

A third cluster deals with motivation tochange, values, commitment, and behavior ac-tivation. These all deal with meaningful ac-tion. Most of the contextual CBT methods wehave summarized address this area as well, as isshown in Table 1.

As we have shown, the component and pro-cess evidence for these processes is growing veryrapidly. This is important because as processesof change are identified, they provide a moreproximal target for intervention and allow dif-ferent perspectives to compete in changing pro-cesses of known importance.

Like the legs of a stool, when a person isopen, aware, and active, a steady foundationis created for more flexible thinking, feeling,and behaving. Metaphorically, it is as if thereis greater life space in which the person canexperiment and grow and can be moved byexperiences. Although not all of the approachestarget all of the processes, it seems as thoughcontextual forms of CBT are designed toincrease the psychological flexibility of partic-ipants by fostering a more open, aware, andactive approach to living. In some sense, thisidea is an extension of evolutionary sciencethinking into the ontogenesis of behaviorchange since it depends on the key issues ofvariation, selection, and retention of behavior.It seems possible that this emerging consensusmay have an extended life, in part because of

160 Hayes et al.

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Tab

le1

Put

ativ

epr

oces

sex

ampl

esan

dco

mpo

nent

and

proc

ess

evid

ence

for

cont

extu

alfo

rms

ofco

gnit

ive

beha

vior

alth

erap

y

Pro

cess

esO

pen

Aw

are

Act

ive

Met

hods

Put

ativ

epr

oces

sex

ampl

eC

ompo

nent

sP

roce

sses

Put

ativ

epr

oces

sex

ampl

eC

ompo

nent

sP

roce

sses

Put

ativ

epr

oces

sex

ampl

eC

ompo

nent

sP

roce

sses

Min

dful

ness

base

dO

pen,

acce

ptin

gfo

cus

–!

Att

entio

nal

trai

ning

byfo

llow

ing

the

brea

th

–!

––

–

MC

TD

etac

hed

min

dful

ness

––

Att

entio

nal

trai

ning

tech

niqu

e

!E

xpos

ure

!

MI

Ope

nqu

estio

ns–

––

––

Exp

lora

tion

ofm

otiv

es–

!

BA

Und

erm

inin

gav

oida

nce

––

––

–Sc

hedu

ling

even

ts–

!

IBC

TA

ccep

tanc

em

etho

ds–

!–

––

Beha

vior

alho

mew

ork

–!

FAP

Acc

epta

nce

mod

eled

inth

ere

latio

nshi

p

–!

Focu

son

pres

ent-

mom

ent

awar

enes

s

–!

Beha

vior

alho

mew

ork

––

DB

TR

adic

alac

cept

ance

–!

Att

entio

nal

flexi

bilit

yan

dco

ntro

l

––

Skill

stra

inin

g!

!

AC

TA

ccep

tanc

ean

dde

fusio

nex

erci

ses

!!

Obs

erve

rsel

fan

dpe

rspe

ctiv

eta

king

!!

Val

uesw

ork

!

AC

T,A

ccep

tanc

ean

dC

omm

itmen

tThe

rapy

;BA

,beh

avio

rala

ctiv

atio

n;D

BT,d

iale

ctic

albe

havi

orth

erap

y;FA

P,fu

nctio

nala

naly

ticps

ycho

ther

apy;

IBC

T,i

nteg

rativ

ebe

havi

oral

coup

leth

erap

y;M

CT

,met

acog

nitiv

eth

erap

y;M

I,m

otiv

atio

nali

nter

view

ing.


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its simplicity and coherent link to evolutionaryscience.

CONCLUSIONContextual CBT is a distinguishable andemerging strand of thinking within CBT thathas produced an emerging consensus regardingthe key variables in psychopathology and psy-chotherapeutic change. This provides a target

for treatment development that is both theoryrich and clinically deep. A growing body of evi-dence suggests that it is possible to move clientstoward a more open, aware, and active approachto dealing with the psychological barriers to ef-fective living and that a broad set of positivelife benefits results. This work seems likely toimpact not just contextual CBT but also othertherapy approaches both inside and outside ofthe behavioral and cognitive therapy tradition.

DISCLOSURE STATEMENTWith the possible exception of being authors of books in the area and involvement in scientificsocieties focused on the content of this work, the authors are not aware of any affiliations, mem-berships, funding, or financial holdings that might be perceived as affecting the objectivity of thisreview.

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Hayes SC. 2004. Acceptance and Commitment Therapy, Relational Frame Theory, and the thirdwave of behavior therapy. Behav. Ther. 35:639–65

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Hayes SC, Barnes-Holmes D, Roche B. 2001. Relational Frame Theory: A Post-Skinnerian Account ofHuman Language and Cognition. New York: Plenum

Describes thepsychological flexibilitymodel on which ACT isbased and a meta-analysis of ACToutcomes and processevidence.

Hayes SC, Luoma JB, Bond F, Masuda A, Lillis J. 2006. Acceptance and Commitment Therapy:model, processes and outcomes. Behav. Res. Ther. 44:1–25

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Hayes SC, Strosahl KD, Wilson KG. 1999. Acceptance and Commitment Therapy: An ExperientialApproach to Behavior Change. New York: Guilford

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A book-lengthdescription of IBCT.

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The original, book-length description ofDBT.

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Manos RC, Kanter JW, Busch AM. 2010. A critical review of assessment strategies to measure the behavioralactivation model of depression. Clin. Psychol. Rev. 30:547–61

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controlled comparison of two therapist styles. J. Consult. Clin. Psychol. 61:455–61A book-lengthdescription of MI.

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Miller WR, Rose GS. 2009. Toward a theory of motivational interviewing. Am. Psychol. 64:527–37Moyers TB, Martin T, Christopher PJ, Houck JM, Tonigan JS, Amrhein PC. 2007. Client language as a

mediator of motivational interviewing efficacy: Where is the evidence? Alcohol Clin. Exp. Res. 31:40–47Muto Y, Hayes SC, Jeffcoat J. 2011. The effectiveness of acceptance and commitment therapy bibliotherapy

for enhancing the psychological health of Japanese college students living abroad. Behav. Ther. In pressNeacsiu AD, Rizvi SL, Vitaliano PP, Lynch TR, Linehan MM. 2010. The dialectical behavior therapy Ways

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training program for oppositional defiant adolescents: promising preliminary findings. Behav. Res. Ther.44:1811–20

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Ost LG. 2008. Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis.Behav. Res. Ther. 46:296–321

Ostafin BD, Marlatt GA. 2008. Surfing the urge: Experiential acceptance moderates the relation betweenautomatic alcohol motivation and hazardous drinking. J. Soc. Clin. Psychol. 27:404–18

Pace TWW, Negi LT, Adame DD, Cole SP, Sivilli TI, et al. 2009. Effect of compassion meditation onneuroendocrine, innage immune and behavioral responses to psychosocial stress. Psychoneuroendocrinology34:87–98

Patterson GR, Forgatch MS. 1985. Therapist behavior as a determinant for client noncompliance: a paradoxfor the behavior modifier. J. Consult. Clin. Psychol. 53:846–51

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Rusch N, Schiel S, Corrigan PW, Leihener F, Jacob GA, et al. 2008. Predictors of dropout from inpatientdialectical behavior therapy among women with borderline personality disorder. J. Behav. Ther. Exp.Psychiatry 39:497–503

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Sambrook S, Abba N, Chadwick P. 2006. Evaluation of DBT emotional coping skills groups for people withparasuicidal behaviours. Behav. Cogn. Psychother. 35:241–44

A book-lengthdescription of MBCT.

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Segal ZV, Teasdale JD, Williams JMG. 2004. Mindfulness-based cognitive therapy: theoretical rationale andempirical status. In Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition, ed. SC Hayes,VM Follette, MM Linehan, pp. 45–65. New York: Guilford

Shapiro SL, Brown K, Biegel G. 2007. Teaching self-care to caregivers: effects of mindfulness-based stressreduction on the mental health of therapists in training. Train. Educ. Profess. Psychol. 1:105–15

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Siegle GJ, Ghinassi F, Thase ME. 2007. Neurobehavioral therapies in the 21st century: summary of anemerging field and an extended example of cognitive control training for depression. Cogn. Ther. Res.31:235–62

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CP07-FrontMatter ARI 8 March 2011 4:13

Annual Review ofClinical Psychology

Volume 7, 2011 Contents

The Origins and Current Status of Behavioral Activation Treatmentsfor DepressionSona Dimidjian, Manuel Barrera Jr., Christopher Martell, Ricardo F. Munoz,

and Peter M. Lewinsohn ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 1Animal Models of Neuropsychiatric Disorders

A.B.P. Fernando and T.W. Robbins ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !39

Diffusion Imaging, White Matter, and PsychopathologyMoriah E. Thomason and Paul M. Thompson ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !63

Outcome Measures for PracticeJason L. Whipple and Michael J. Lambert ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !87

Brain Graphs: Graphical Models of the Human Brain ConnectomeEdward T. Bullmore and Danielle S. Bassett ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 113

Open, Aware, and Active: Contextual Approaches as an EmergingTrend in the Behavioral and Cognitive TherapiesSteven C. Hayes, Matthieu Villatte, Michael Levin, and Mikaela Hildebrandt ! ! ! ! ! ! ! ! 141

The Economic Analysis of Prevention in Mental Health ProgramsCathrine Mihalopoulos, Theo Vos, Jane Pirkis, and Rob Carter ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 169

The Nature and Significance of Memory Disturbance in PosttraumaticStress DisorderChris R. Brewin ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 203

Treatment of Obsessive Compulsive DisorderMartin E. Franklin and Edna B. Foa ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 229

Acute Stress Disorder RevisitedEtzel Cardena and Eve Carlson ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 245

Personality and Depression: Explanatory Models and Reviewof the EvidenceDaniel N. Klein, Roman Kotov, and Sara J. Bufferd ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 269

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CP07-FrontMatter ARI 8 March 2011 4:13

Sleep and Circadian Functioning: Critical Mechanismsin the Mood Disorders?Allison G. Harvey ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 297

Personality Disorders in Later Life: Questions About theMeasurement, Course, and Impact of DisordersThomas F. Oltmanns and Steve Balsis ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 321

Efficacy Studies to Large-Scale Transport: The Development andValidation of Multisystemic Therapy ProgramsScott W. Henggeler ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 351

Gene-Environment Interaction in Psychological Traits and DisordersDanielle M. Dick ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 383

Psychological Treatment of Chronic PainRobert D. Kerns, John Sellinger, and Burel R. Goodin ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 411

Understanding and Treating InsomniaRichard R. Bootzin and Dana R. Epstein ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 435

Psychologists and Detainee Interrogations: Key Decisions,Opportunities Lost, and Lessons LearnedKenneth S. Pope ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 459

Disordered Gambling: Etiology, Trajectory,and Clinical ConsiderationsHoward J. Shaffer and Ryan Martin ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 483

Resilience to Loss and Potential TraumaGeorge A. Bonanno, Maren Westphal, and Anthony D. Mancini ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 511

Indexes

Cumulative Index of Contributing Authors, Volumes 1–7 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 537

Cumulative Index of Chapter Titles, Volumes 1–7 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! 540

Errata

An online log of corrections to Annual Review of Clinical Psychology articles may befound at http://clinpsy.annualreviews.org

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