Summaries of articles on Introduction to Cognitive Behavioural Therapies 20/21

The goal of this review is to outline advances in the behavioural and neurobiological bases of fear learning that contribute to the optimizing of exposure therapy in fear and anxiety disorders. A paradigmatic shift from fear reduction throughout exposure as the primary index of successful outcomes to enhancement of inhibitory learning and regulation can be observed (the latter independent of fear reduction).The Emotional Processing Theory was seen as one of the primary underlying processes of exposure therapy. More recently, instead of weakening of the original fear memories, it is now believed that the establishment of new memories that effectively compete with the original fear memories is central to extinction. Patients who fail to achieve symptom relief from traditional exposure-based therapies might have deficits in inhibitory learning and regulation. Optimizing inhibitory learning during exposure therapy might compensate deficits that are present in these individuals.

Learning based models of exposure therapy: historical overview

Wolpe (1958) used counter-conditioning or reciprocal inhibition to reduce anxiety symptoms. In systematic desensitization, individuals progress through increasingly more anxiety induced by exposure, while relaxation exercises are used to compete with the anxiety and to reciprocally inhibit this. Level of fear elicited by exposure was critical to the counter-conditioning throughout treatment. Later on, graduated imaginal exposure was shown to be equally effective whether combined with relaxation training or not. Other studies showed that relaxation was working against providing a physiological response that was antagonistic to anxious arousal.

In addition, reciprocal inhibition was challenged by the fact that flooding therapy seemed to be as effective as graduated exposure. The effectiveness of flooding challenges the premise of reciprocal inhibition, that anxiety should be kept at a sufficiently low level through which counter conditioning can take place.

Habituation, a reduction in response strength with repeated stimulus presentations, provided a descriptive framework for responses during systematic desensitization and in vivo exposure therapy because fear often disappeared as people engaged more in exposure. Habituation models gradually replaced reciprocal inhibition. However, habituation could not explain long lasting fear reduction from exposure therapy.

The Emotional processing theory states that exposure therapy is effective because the fear structure is activated and integrated information that was incompatible with it, resulting in the development of a non-fear structure that replaces or competes with the original structure. Emotional processing theory guidelines are focused on the elevation of fear followed by within-and between-session reductions of fear. However, there is not much evidence for within-and between-session habituation.

Exposure therapy: outcomes

Exposure therapy is more effective than wait-list or attention placebo controls, however, almost half of the patients remain symptomatic. Therefore, there is a need to optimize exposure therapy.

Inhibition model of extinction

It is now thought that inhibitory learning is central to extinction, although additional mechanisms, such as habituation may play a role as well. According to the inhibitory learning models, the original CS-US association learned during fear conditioning is not erased during extinction, but is left intact and a secondary inhibitory learning about the CS-US is developed.

4 processes that may lead to resurgence of fear and anxiety following treatment

First, spontaneous recovery. Bouton and colleagues propose that after extinction, the CS possess two meanings, namely, its original excitatory meaning as well as an additional inhibitory meaning. Conditional fear shows often a spontaneous recovery. Simultaneously fear often returns when a previously feared stimulus is re-encountered after treatment has been completed. Therefore, patients with fear of flying who had successful treatment will probably report a return of fear if they do not continue to practice once the treatment is completed.

Second, renewal. Fear extinction effects appear to be specific to the context in which extinction occurred. The extinction context does not become a general inhibitor or safety signal, because non-extinguished stimuli retain their value when tested in the extinction context. Thus, renewal during clinical intervention is highly relevant in order not to limit the effects of the treatment to solely one context.

Third, reinstatement of conditional fear occurs if unsignaled or unpaired US presentations occur between extinction and retest. Reinstatement means that the effect depends on the fearfulness of the context in which the CS is tested. A clinical implication is that adverse events following exposure therapy may lead to a return of fear even when this event is unrelated to the feared stimulus.

Fourth, if the CS-US pairings are repeated following extinction, it is called rapid reacquisition of the CR. The clinical application is that fears that have subsided may be easily and rapidly reacquired with re-traumatization.

Neurobiology of fear extinction: evidence for inhibitory regulation

The amygdala plays a primary role in fear conditioning. During conditioning the amygdala is activated. Also the hippocampus is involved, it processes the contextual cues of conditioning. In addition, the insular cortex is involved in interoception and awareness of and sensitivity to visceral activity. Furthermore, the dorsal and rostral ACC appear to play a role in anticipation of the CS and US. The vmPFC mediates extinction. The PFC serves as the neurobiological basis for inhibitory learning. It is also suggested that the hippocampus creates an unique representation of the context in which extinction took place modulates extinction by providing information regarding safe versus dangerous contexts.

Deficits in Extinction Learning in anxiety disorders

Individuals with anxiety disorders respond stronger to both the CS+ and the CS- during conditioning and extinction. One explanation is that individuals with anxiety disorders have impaired inhibitory learning, they do not learn to view cues as safe. A potential mechanism of this impaired inhibitory learning include an attentional bias toward threat, difficulty disengaging from threatening stimuli, interpretation of ambiguous stimuli as threatening, elevated expectancies for threat, and overgeneralization of fear responding to stimuli that resemble the threat cue.

Elevated fear CR tot the CS- or the CS during extinction could also be due to over-excitation. Evidence for this is based on adapted paradigms that view inhibition apart from excitation during fear learning. This was found to be the case in combat veterans with PTSD symptoms. In a student sample, state anxiety induction prior to fear conditioning reduced subsequent inhibitory processing compared to individuals who did not undergo anxiety induction. At neural level there is limited evidence for decreased orbitofrontal and medial PFC during extinction and at extinction retests.

Enhancing inhibitory learning

One approach is to design exposures in such a way that the experience maximally violates the negative, excitatory expectancies regarding the rate with which aversive outcomes occur and the intensity of the outcomes. This should enhance the development of inhibitory expectancies. However, when tested, mixed findings were found. Exposure durations longer than the expected duration were equally effective as standard exposure therapy, although fewer trials were conducted.

Exposure therapy is designed in such a way that it provides experiences that disconfirm expectancies. Goals are adjusted during therapy to be violating expectancies all the time. Exposure to improve inhibitory learning is partly based on cognitive models of exposure.

Different methods to improve inhibitory learning will be discussed. (1) Super-extinction means that simultaneous presentation of multiple conditioned excitors throughout extinction training. Danger expectancies are stronger disconfirmed in this way than when only one conditioned excitor would have been used. In deepened extinction multiple fear stimuli are extinguished separately before being combined. From animal and human studies it is known that this form of extinction can lead to spontaneous recovery and reinstatement effects. Using extinction as a form of exposure, the goal is to teach the client that the feared event happens less often or is less bad than expected. In extinction this is accomplished by letting the client experience more than one ‘predictor’ of the feared events.

(2) If the task on ‘what has to be learned’ varies a lot, the retention of learned non-emotional stimuli will improve. A task could be a random practice task in which success is not always occurring. Variability induced by these kind of tasks increase storage capacity of the learned information and makes the information better retrievable later on. In variable exposure, exercises are not performed according to their hierarchy but after the easiest exercises the others will follow in a random order. Variability could be applied in used stimuli, duration and intensity. (3) Also variability in fear levels experienced during the exposure session is positive. Variability of fear levels throughout exercises improves generalization because the individual learns that he/she is able to cope with the fear in different contexts. (4) Removing of safety signals and safety behaviours is important because for some individuals the perceived fear is a safety signal. If fear is experienced, perceived safety is lower, it has become dependent on fear reduction and not on the actual threat of the situation. Also, when the safety signals are removed the fear will probably return. Some clients are afraid of feeling fear, for these individuals high fear levels should be kept during the exposure session.

Enhancing inhibitory Regulation

Several conducted studies have suggested that drug agonists of the d-cycloserine receptor can increase extinction in animal studies. D-cycloserine is thought to play a role in the consolidation of newly formed extinction memories. Other studies suggest that it is about preventing reinstatement and it is also shown that d-cycloserine may augment fear in some situations. Nonetheless, d-cycloserine has shown to lead to greater reduction in symptom severity and to lead to better maintained effects after treatment. D-cycloserine is primarily correlated with long-term outcomes that are not yet assessable during treatment.

Linguistic processing is an alternative method to improve inhibitory regulation. According to disruption theory, linguistic processing activates the PFC which leads to deactivation of the amygdala. Therefore, the anxiety response will be decreased. The underlying processes are not yet fully understood but are in this direction. Research conducted on images paired with word labels found that affective labelling of stimuli during the exposure session, reduced skin conductance and increased approach behaviour one week later in another context. Thus, linguistic processing can enhance inhibitory regulation during extinction or exposure. This in contrast to traditional cognitive therapy that tries to modify appraisals.

Weakening the fear memory

Recent research suggests that the retrieving of already stored memories induces a process of reconsolidation. The memory will be written again in long term memory, therefore new neurochemical processes are needed. Research suggests that propranolol (beta-blocker) might be effective in blocking this reconsolidation of memories and thereby also the fear that would have been stored again. Another method to weaken the fear memory itself is extinction during reconsolidation. Results are mixed but one recent study indicates that the findings might be related to enhancing the retrieval of the extinction learning instead of removing acquisition learning. It might be difficult to use this paradigm in clinical practice since factors such as time of presented stimuli are hard to control.

Enhancing retrieval of inhibitory learning

A possible way to enhance retrieval of extinction learning and offset context renewal is to include retrieval cues of the CS- no US association during extinction training in other contexts once extinction is over. Mentally reinstating an instructional retrieval cue was effective in anxiety patients. Clients had to wear a wrist band, as a cue, to remind them of what the learned in the therapy when they are experience fear in other contexts. Important is that these cues should not become safety signals. In context renewal it is problematic to determine which contexts are exactly relevant. Until now, studies on the use of different contexts to induce context renewal produced mixed results.

Borderline personality disorder (BPD) is the most frequently diagnosed personality disorder. Most of the patients are female and present a pattern of labile emotions, impulsivity and unstable interpersonal behaviour and identity, often since childhood. An important aspect of BPD is the fear to be abandoned. Many, but not all individuals with BPD report childhood abuse. Research has shown that psychotherapy for BPD is better than the waiting list condition or treatment as usual (TAU). The cognitive therapy that was used has been adjusted to make it more appropriate for patients with BPD. Patients with BPD often have ambiguous and vaguely defined complaints with chronic features in addition to symptoms as depression or substance abuse. Dialectical Behaviour Therapy, Cognitive Coping therapy, Rational Emotive therapy, Cognitive therapy, Cognitive Evolutionary therapy and Schema therapy are other forms of cognitive therapy used to treat BPD. Schema therapy is developed by Young and colleagues and is meant to treat complex cases.

The model of schema therapy

Schema theory. An assumption of short-term cognitive therapy is that clients have a certain amount of cognitive and behavioural flexibility, however, this is usually not the case in patients with BPD. Patients with BPD often have deeply rooted, rigid, and implicit dysfunctional belief systems and sometimes also an inability to report thoughts or feelings that are linked to this system. How knowledge about onself and the world is organised and structured comes together in a schema. Young defined a subset of schemas called ‘’early maladaptive schema’’ (EMS), schemas that are formed during childhood as a result of needs that have not been met. The schemas have been elaborated upon during the rest of life. Young says that these schemas are used as templates for processing and activating thoughts, feelings and interpersonal behaviours. Young defined 18 EMSs that are related to Abondanment, Defectiveness, Emotional Deprivation, Insuffiient Self- Control, Mistrust/Abuse, Punitiveness, and Subjugation.

Schema mode. Patients with BPD had often many different or almost all EMS and also frequent emotional changes. A schema mode is a facet of the person’s self involving a natural grouping of EMS, mood states and coping strategies. This schema mode may be too distressing to experience and is therefore detached from the person’s self which leads to a disintegrated self-system.

Schema modes in the Borderline patient. The schema modes defined by Young are (1) abandoned child mode, (2) angry and impulsive child mode, (3) punitive parent mode (4) detached protector mode: the patient suppresses needs and detaches from own feelings and behaves obediently in order to stabilise his/her life and psyche. A dysphoric state can be the result of this. (5) healthy adult mode: tries to inhibit maladaptive coping and dysfunctional modes. Works as an executive function in relation to other modes. In patients with BPD this mode is underdeveloped. In understanding the behaviour of a person with BPD, the shift between the schema modes is the main point.

Basic principles in treatment

A collaborative relationship between the patient and the therapist is very important within Schema therapy. Fear of abandonment might be frequently present and should be addressed by the therapist from start. The primary goals of Schema therapy are to learn to cope with the schema modes through encouragement, learning of self-help techniques,

Main treatment objective: coping with the schema modes

The patients have to learn to identify and to cope with the schema modes and to learn to control behaviour. The main goal is to incorporate a healthy adult mode that can react on and ‘’regulate’’ the other modes. Additionally, social skills may be practiced and other treatments such as family intervention or medications might be provided simultaneously.

Bypassing the detached protector. It is crucial to bypass the protector mode in order to be able to restructure the other modes. The detached protector mode causes avoidance of emotions and people. In therapy it might be useful to discuss the development of this mode and the therapist can engage in a ‘’conversation’’ with the representation of the detached mode to make an appointment with the patient to put the protector aside for some time. Antidepressant medications might improve therapeutic compliance.

Limited re-parenting of the abandoned child. In the therapy, the patient learns about the developmental needs of a child. The patient learns to feel empathy for his/her inner child. The patient is helped by the therapist to endure and share feelings and needs which can lead to more openness to intimacy and closeness.

Re-channel the angry child through the therapy relationship. To identify the schemas that become activated in an anger outbursts the patient should express what annoys or irritates him/her. Afterwards the underlying schemas are empathized with and it is determined whether the anger is realistic. Anger control techniques can be teached with the help or role-play.

Combating punitive parent through cognitive restructuring. This can be done by teaching the patient about needs and feelings and to encourage expressing of emotions and needs. Dialogues can be set up between the therapist and punitive parent and later also with the patient to challenge the internalised critical voice of the patients. The therapist becomes a model of acceptance and forgiveness. The self-punitive parts become external. The relation with the existing parent can become violated, something that the therapist should keep in mind. Other nurturing bases should be provided to make the patient less dependent of the parents and if the case, positive qualities of the parents should be acknowledged.

Dealing with suicidal threats and crisis. Suicidal behaviour can have different underlying reasons. It can be a way of obtaining attention and care, self-punishment or it can function as distractor from psychological pain and distress. In each mode suicidal behaviour and self-mutilation have their own psychological meaning that has to be determined. Suicidal behaviour should always be taken seriously. The therapist has to assess the risk and the genuine relationship with the patient should be sthrenghend. Hopelessness and despair should be empathised with.

Termination of therapy and relapse prevention strategies. To avoid relapse after finishing a therapy a procedure should be followed. First, prepare the patient for a relapse and set up a plan for how to manage difficulties. Furthermore, the patient can write a plan similar to that that was used in therapy hat he/she can follow if it becomes very difficult to deal with the negative thoughts. In addition, waning sessions can help the patient to adjust to the idea of termination and can provide exercises to deal with the abandonment schema. Finally the emphasis shifts to life outside therapy and the therapist can tell the patient that he/she will not ‘’disappear from the surface of the earth.’’ Contact can be gradually reduced to give the patient time to adjust to this.

Assessment in Schema therapy

Instruments and inventories in Schema therapy. In the assessment several instruments are used. To assess schemas the Young Schema Questionnaire and the Young Parenting Inventory. The Young-Rygh avoidance inventory and the Young Compensation inventory can be used to identify schema driven behaviour. To assess different schema modes, the Schema Mode Questionnaire is used. Because patients can get in a loyalty conflict with regard to questions about parents, the Young Parenting Inventory and the Young Schema Questionnaire have been matched, therefore, information about the family can be investigated from different perspectives.

Empirical validation of Schema therapy. The schema constructs have been confirmed to be valid. However, only two Dutch studies have investigated the effectiveness of the Schema therapy model. The results of these studies show that Schema therapy was more effective than Transference-focused psychotherapy on all aspects. Also a trail study from the authors of the current article improved after treatment, three of six did not fulfil the criteria for BPD anymore. These studies suggest that Schema therapy might be effective and it creates a strong collaboration which is important in BPD patients. Further research is still needed.

The practical aspects of mindfulness have been integrated into contemporary clinical psychology. It is based on Buddhism but now integrated into Western healthcare, especially in psychotherapy and stress management. Nowadays mindfulness has become a systematic clinical intervention. In this article the stress-reducing function of mindfulness meditation in medical settings will be described.

Kabat-Zinn was the first who applied mindfulness meditation in a clinical setting. He set up a program to reduce stress in patients called Mindfulness-Based Stress Reduction (MBSR). The key of mindfulness is to focus your attention on what is happening now without judging this. Paying attention to what is happening now prevents you from extensive thinking about past experiences, which almost never increase quality of life. Ideas of Buddhism are to some extent similar to Western pragmatism, in which independency of behaviour, emotions, cognition and memory is important. In mindfulness you have to become aware of these interactions. Mindfulness is described as ‘’ learning to observe internal and external events without ending them if they are unpleasant and making them last longer if they are pleasant. This can be used to extinct anxiety and avoiding of the events or thoughts. People learn that thoughts are just thoughts, you do not have to act on them. Acceptance and Commitment Therapy (ACT) is a mindfulness based intervention that emphasizes acceptation of what is happening, clarity of perception and freedom from the judgemental aspects of language. Psychodynamic therapies can also be based on mindfulness. Meditation is nowadays more seen as a certain way of perceiving and reaction on the world. The experienced is deepened because of a focus on the present.

Two cautionary notes are important in the application of mindfulness in clinical practice. First, in clinical psychology the principles of mindfulness are applied in order to increase health and mental well-being and to reduce suffering of illness, whereas in Buddhism mindfulness is a way of ‘’being with’’ the suffering that is unavoidable a part of life. Second, in Western psychotherapy the ‘’self’’ is emphasized whereas in Buddhism the ‘self’ is seen as something artificial, a concept based on language that limits the perception. Preoccupation with the ‘self’ can prevent you from change and acceptation and it can elicit rigidity. Attachment lies at the root of suffering. This includes attachment in any context such as possessions, personal relationships or any endeavour that becomes object of deliberate attainment.

Kabat-Zinn and others emphasize the importance of acceptation which is to adopt an open and non-judgemental observational style in relation to yourself. He also describes how paying attention can lead to stress reduction. To be aware of the effects that stress have on you is required to engage in an effective coping strategy.

By engaging in mindfulness you will be able to detect minimal psychological reactions that can lead to over activation of the autonomic nervous system and elicit a fight/flight reaction. This activates a chain of dysfunctional reactions and the negative effects will accumulate. This is called allostatic load. If the allostatic load further increases, the regulatory systems will desensitize. As a result of chronic activation stress response mechanisms may contribute to stress-related diseases. Mindfulness can break through this cycle of because people have to pay attention to stress symptoms on a low level after which they can respond more consciously. The MBSR program, often in a group setting and of limited time, helps people to recognize stress symptoms and to respond to them more effectively. Aspects that are relevant in clinical practice: (1) conscious allocation of attention (2) non-judgemental awareness (3) a state of physiological hypo-arousal with the intention to (4) enhance present moment awareness and (e) diminishing habitual patterns of cognitive, behavioural, and physiological reactivity.

Regulation of attention

Regulation and allocation of attention are important principles in meditation practice. Meditation focuses on observable phenomena such as breathing, this in contrast to cognitive therapy that focuses on the content of thoughts and cognitions. Although paying attention to your breathing may sound simple, practice is needed and from here one can proceed to other objects of attention. Mindfulness focuses on a broad range of cognitions and mental states. People learn to detach from their thoughts and to observe them as objects of attention without analysing them. The idea is that the more you try to suppress a certain thought the more salient it will become.

Non-judgemental-awareness

Non-judgemental awareness is the capability to observe events, thoughts, evaluations, memories and other mental activities as they occur without judging. Evaluative self-statements can become thing-like and static rather than a moment-to-moment flow, this is called reification. As soon as judgement of other cognitive commentaries come up we are in a diminished state of awareness. Acceptation is related to non-judgemental awareness because it is a way of relating to one’s experience irrespective of its nature, pleasant or unpleasant. In psychodynamic theories this is also important. Some researchers found similarities between meditation and psychodynamic uncovering in which neutral observation is important as well as the development of a therapeutic split, becoming a witness to one’s experience.

Physiological hypoarousal

Low physiological arousal stimulates mindfulness and related techniques in a positive way. In contrast to the increased autonomic arousal that is present in our daily behaviours. Hypoarousal elicits a slower metabolism, reduced energy expenditure and broadening of awareness that promotes relaxed awareness. In people who experience chronic stress, the process of allostasis causes a continued state of vigilance, also when one is relaxing. In homeostase the bodily processes are more in balance. Meditation exercises are aimed to open up awareness without physiological inferences which can stimulate the gradual slowing of physiological and cognitive activity.

Present-moment focus

The key of mindfulness is to focus on the present moment. This can be challenging since there is a lot of competition going on usually between different stimuli that want to grab your attention. Since many actions can be done automatically without much thinking, it is possible to engage in other cognitive activities simultaneously but it take’s the focus away from the present situation. This could be illustrated by a musical analogy, careful attention to the notes of musical composition as it unfolds from moment to moment is an form of mindfulness practice.

Behavioural responsiveness (versus reactivity)

In mindfulness there is a difference between habitual patterns of reactivity and deliberate responses. Stress is seen as an automated network that causes activation without awareness. In mindfulness you have to become aware of these reactions as they are occurring to engage a more deliberate response, this has been linked to increased self-efficacy, personal agency and coherence.

Clinical and research applications of mindfulness meditation

There are three trends visible in the use of mindfulness in Western therapy. (1) in stress reduction interventions, to prevent stress related disorders. (2) In psychotherapy where it provides a framework for both the client and the therapist. An observational stance toward inner experience is being encouraged. Maybe it can be extended to cognitive factors that play a role in stress related symptoms. (3) Mindfulness contributes to research on attention, suppression and other psychological constructs that are related to consciousness.

The MBSR program

The most well-known and cited intervention that is based on mindfulness is the MBSR program developed by Kabat-Zinn. The program focuses on stress-related symptoms in medical patients. It is based on the assumption that diseases can cause a lot of stress that can be amplified beyond the direct medical consequences. The meditation techniques are aimed to reduce the suffering from stress symptoms and not to cure the disease. This approach has shown to be effective in patients with chronical pain, anxiety/panic disorder and in preventing relapse in depression. There is a difference between the structural and program oriented elements of the therapy. Structural includes a group program of a certain number of sessions in which meditation techniques are being taught and homework is given. Concerning program oriented, the emphasize lays on the fact that mediation practice can really provide relief, however, without focusing on goal orientation. A third key element is the idea of personal responsibility for self-healing through application of the taught techniques. This in contrast to the more passive attitude of patients in traditional medical settings. The participant need to practice mediation on a daily basis, motivated or not. Finally, the program is also presented in a long-term perspective, one can improve one’s health in general, not only their response to stressors.

The MBSR program has become a group intervention of 8 sessions lasting 2,5 to 3 hours and a weekend retreat at the and. Contrary to group therapy, there is little focus on group interactions but more on developing a shared sense of participating in what is essentially an inward-focusing practice. The program focuses on mediation in combination with other cognitive interventions. Formal meditation exists of three practices: (1) body scan (2) hatha yoga and (3) sitting meditation. In the body scan, the attention is being allocated to different parts of the body for 30-45 minutes. Hatha yoga concerns subtle movements through which the attention is being allocated in order to increase the awareness of the body. Sitting meditation is about the development of self-observation in which the attention is directed to different sensory stimuli, physical sensations, thoughts etc. The idea is that also in daily life you could direct your attention to activities such as driving a car, having lunch, interactions with people etc.

MBSR, as said earlier, exists of 8 sessions. The first session is to get to know each other and a first exercise will be done, namely, the participants have to eat a raisin while direction attention it. Furthermore the body scan will be introduced and a sitting meditation as well. Through the body scan participants will learn to become aware of discomfort and to accept this. They are taught how to react and to recognize how the pain sensation is related to other mental activities that also contribute to the suffering. It is practiced how physical pain can be disassociated from cognitive, affective and other experiences that collectively comprise the experience. The fundamental lesson is that forms of suffering (pain, anxiety, worry or stress) are due to difficulty accepting present moment experience. This is also reinforced by the body scan. Commitment to the program which means to practice every day is very important. It is difficult not to see this as an assignment in a goal-oriented way, something you have to become better in, but this is exactly what is taught, namely that you have to be comfortable with the situation at the present time.

In the second session the experiences of doing a body scan will be discussed. By encouraging participants to accept feelings of distress the distress will be reduced. In this session sitting meditation is included of which the duration increases every weak. During the third session yoga is introduced and practiced. This and following sessions will also include sitting mediation in which participants have to focus on their breath. Also a topic related to stress will be presented every session, such as recognizing stress reactivity or mindful eating. Between the 6^th and 7^th session there is a silent retreat held. After eight sessions the program has finished and experiences will be shared.

There are usually three phases of development experienced. (1) people participate to decrease their pain or to learn to relax. In this phase acceptation of what one is experiencing is important. (2) In this phase, the participants realize that it is the response on stress related symptoms that elicits the suffering.. (3) in this phase the participants may begin to appreciate the impermanence of experience, both distress and pleasure. This stage is associated with a progressive deepening and compassion for oneself and others. Also the importance of observing in a patient and non-judgemental way is emphasized, as mentioned earlier.

There are some directions for future research described. First, mindfulness seems a promising intervention despite of the fact that the conducted studies could be improved. For example, the use of control groups, randomisation and the predictive function could be improved. In the future a multimodal assessment strategy might be effective to study the physiological processes such as the allostatic load. In addition, in medical settings mindfulness is used reduce distress and pain but the original idea of mindfulness was different. Meditation practice emphasizes cultivating a calm, contemplative frame of mind accompanied by a corresponding state of psychophysiological tranquillity. Third, future research should focus more on culture and gender aspects that may have an influence on the working of mindfulness therapy. Finally, the program could be divided in different elements, to investigate which parts of the intervention are effective.

Over the past decade research has start to focus more on mindfulness and acceptance-based interventions. Among others, Acceptance and Commitment Therapy is one of these. In this article an application of ACT in treating anxiety disorders is described. The primary goals of ACT are (1) acceptance of problematic unhelpful thoughts and feelings cannot and maybe do not need to be controlled. (2) commitment and action toward living a life according to one’s chosen values. Therefore, ACT is both about change and acceptance. In ACT applied to anxiety disorders, the client is taught to stop being busy with discomfort but to engage in actions that bring him/her to chosen life goals/values. In ACT the clients are taught to observe distressing thoughts and feelings as they occur. According to ACT, anxiety disorders are characterized by experiential and emotional avoidance. The function of experiential avoidance is to control or reduce the influences of aversive internal experiences. Engaging in experiential avoidance can lead to relief for a short period of time. By doing so, the behaviour is also reinforced and it can become problematic when it impairs daily life. Experiential avoidance and rigid down-regulation of emotions might be core psychological diathesis that causes psychopathology to develop and maintain.

Acceptance in contrast to experiential avoidance, exists of an openness to both aversive and pleasant experiences. When individuals try to suppress and control certain events, this can lead to more involuntary thoughts and emotions. One of the main skills that are taught is how to disentangle from self-perpetuating emotional and cognitive behavioural avoidance routines. Clients do not learn how to manage or control anxiety but how to let go this attempts to control their anxiety.

Treatment Overview

The primary goal of phase 1 (session 1-3) is to create an acceptance context for anxiety-related discomfort. The goal of phase 2 (session 4-7) is to focus more on life goals of the client and to learn flexible patterns of behaviour in case of anxiety or fear. Mindfulness is taught since it can be used to treat the experiential avoidance strategies. In phase 3 (session 8-12) the focus is on engaging in value-guided actions despite anxiety-related barriers. From the values written down in the last session concrete goals are specified. There is an important focus on commitment even if anxiety shows up.

Session-by-session Treatment program and core process targets

ACT is a functional approach in which the therapist uses metaphors, concepts and exercises. The focus is to change the function instead of the content of the unwanted thoughts. In treatment the amount of the client’s actions in everyday life are enlarged. In the first session anxiety is described as adaptive emotion to the client. The therapist will indicate that trying to control the fear will probably make it worse. There is also a focus on the active, experiential and participatory nature of ACT and on misconceptions about fear and anxiety. The first step is to identify and abandon strategies that did not provide relief and also did not improve life goals of the client. This is done by the costs and effects of the coping strategies of the client. The client has to perform metaphor based experiential exercises accompanied by a therapist to experience that these strategies are not effective and may even cause more problems. An example could be the Chinese finger trap exercise, a tube of woven straw about five inches long and half an inch wide. The client and therapist have to put in their finger in before they can take them out, otherwise it will feel uncomfortable. Pushing your fingers further into the trap feels counterintuitive, so is approaching what you are feared of.

However, you have to approach it first if you want to get out of it. Tug of war with the anxiety monster is another exercise in which the client together with the therapist pull a rope, the harder the client pulls, the harder the therapists pulls back. Clients will see that they have a choice to keep fighting or to drop the rope. When the client drops the rope he/she will notice what the gains are, less strain and more room to move. Other metaphors are used to induce creative hopelessness by letting clients experience that their old strategies are ineffective. The therapist will offer a alternative strategy in which they have to accept instead of to fight with the anxiety. In a 12 minutes mindfulness exercise that has to be practiced daily, clients learn to direct their attention to a single focus, their breathing and to watch and allow other internal events to come and go. Clients also have to determine their life goals, they will probably notice that the anxiety has taken the place of the life goals. In session 4 and 5 acceptance is also taught and mindfulness skills are used to observe involuntary anxiety-related responses as they occurred.

Acceptance: developing willingness to stay with discomfort

Acceptation is taught as alternative for experiential avoidance this is an aware and active approach of the events without trying to change them, especially not when that would lead to psychological suffering. Clients learn to use mindfulness techniques through observing thoughts as thoughts and emotions as emotions. In session 4 and 5 the clients are convinced of the usefulness of mindfulness techniques. The client learns to perceive feelings and thoughts without suppressing or judging. Acceptance of anxiety is another exercise to teach the clients to take the perspective of someone else and to observe their feelings and thoughts from this perspective. The aim of this exercise is to accept the discomfort without changing this experience. It also emphasizes the choice that the client has in responding to anxiety. There are several other exercises all aimed to observe thoughts and feelings instead of changing them. Acceptation can be viewed as the ability to accept distress and to work towards one’s life goals. This skill can be learned and clients will recognize that anxiety is only a collection of sensations, feelings, thoughts and imaginations, which is the opposite of avoidance and control.

Cognitive defusion

This concept explains why people listen to thoughts although it is known that this is ineffective on the long-term. Cognitive fusion means that people tend to listen to the content of their thoughts literally. These literal evaluative thoughts dominate behavioural regulation whereas less judgemental strategies would have been more effective. Cognitive fusion involves the process in which the individual fuses and merges with the literal content of the own experiences. People do not respond to the thought as if it was just a thought but they respond to the content as if it was an own experience. In ACT clients learn to observe these thoughts instead of to listen to them.

Applying acceptance, willingness , and defusion to stay with anxiety (exposure)

The main purpose of session 6 and 7 is learn to live with the anxiety but in a way that anxiety is not a limiting factor anymore. With the help of FEEL exercises (Feeling Experiences Enriches Living) the clients learn to come to an aware observation and to let go of the avoidance or control of the anxiety related thoughts, worries of bodily symptoms. They even have to acknowledge them and to embrace them. The exercises used are similar to those used in CBT such as hyperventilation, spinning, worst-case imagery etc. the aim is to prepare the clients for the moments that they will be confronted with anxiety, when they are working towards their life goals. The exposure exercises are based on mindfulness exercises and stimulate the willingness of the clients to experience the anxiety and the acknowledgement that giving into it is a choice. However, nobody really decides for anxiety, the question is therefore, is the client willing to give up life goals because of anxiety or is he/she able to manage the anxiety and take it with him/her. Although not the main goal of exposure, reduction of the anxiety can be a positive bonus-effect.

Value-guided action (naturalistic exposure) – Moving with Barriers

In session 7 to 12 the clients learn to engage in meaningful activities that would help them to achieve their life goals. For each week a plan of action is created together with the therapist. The therapist helps with creating realistic goals, giving feedback and monitoring progress. Engaging in these activities look like exposure exercises but the goals is not to reduce anxiety but to reach life goals. Also in these sessions commitment is emphasized by the therapist. Clients learn and are encouraged to move with potential barriers rather than attempt to overcome them. The main point to learn is that it is not necessary that the anxiety has been reduced first before the client can start doing things he/she really wants to do.

Method

In order to show the flexibility of the ACT program, three clients who had very different characteristics were selected to participate. All the clients completed the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) to assess anxiety, mood and other psychiatric disorders. Also a clinical severity rating was made by the interviewer. Clients were called by their therapists for a 6-month follow up. The therapists were three advanced graduate students enrolled in the doctoral program in clinical psychology. The therapists were trained in using ACT. The treatment consisted of 12 weekly sessions lasting 1 hour. The Anxiety Sensitivity Index (ASI) assesses level of fear of anxiety related symptoms such as rapid heart. This is based on the ideas that individuals have about certain sensations. Also the PSWQ was completed to assess generality, intensity/excessiveness and uncontrollability of clinical relevant worry. It also distinguishes GAD from other anxiety disorders. The Mood and Anxiety Symptom Questionnaire, the Anxiety Control Questionnaire, the Fear Questionnaire, and the Padua Inventory-Washing State University Revision (to measure OCD) are all used in the study.

ACT Process Measures

The Acceptance and Action Questionnaire assess psychological flexibility. Other scales that are used to measure mindfulness, suppression, anxious feelings and satisfaction in different areas of life are respectively: the Mindfulness Attention Awareness Scale, the White Bear Suppression Inventory, the Believability of Anxious Feelings and Thoughts and The Quality of Life Inventory.

Case descriptions and Results

James (31-year-old, panic disorder)

James has a panic disorder and despite having experienced only few panic attacks, his life changed significantly after the first time he had such an attack. He does not drink alcohol or coffee anymore and he is having sleeping problems. He was absolutely not content with his life and felt like he failed everything. By performing the Chinese Finger Trap, James realized that his attempts to control his internal experiences was contributing to further distress. After several exercises, such as repeating the word failure over and over again, James became able to listen to this word without feeling distress. He learned that he does not have to take thoughts about failure so seriously. He also learned defusion skills to help him persist maintain value-consistent behaviour although distressing thoughts were present. His worries about panic attacks and not being able to fall asleep slowly disappeared and in the follow-up he hardly reported any panic or OCD related symptoms or distress.

Daniel (51-year-old, social phobia)

Daniel has a social phobia and is also diagnosed with dysthymia. He was afraid of speaking in public, showing assertive behaviour, talking with strangers and attending meetings. He had sleeping problems and was dissatisfied with his quality of life. Metaphors with regard to hopelessness showed Daniel that his way of managing distressing emotions made him even more hopeless. Due to mindfulness exercises he realized that emotions and bodily sensations are changing all the time. He practiced regularly, also exercise focused on acceptation or thoughts and anxiety and this helped a lot. He also reported to find the mindfulness exercises relaxing. When a client reports a relaxing effect the therapist should immediately respond because mindfulness is not aimed to relax or to relief anxiety. Mindfulness is aimed to become aware of thoughts, feelings and bodily sensations and to accept them and to act towards goals that are important for the client. Removing the anxiety completely is not the goal but a side-effect.

Janet (52-year-old, OCD and panic disorder)

Janet has always had OCD related problems. Her primary fears are contamination fear and the fear to urinate. Hence, she washes her hands excessively and avoid places from where she cannot easily escape. She is avoidant in her interaction with other people and she quit school although she was promising. Once Janet became more willing to experience, her anxiety, depressive mood and anger increased and for the first time she really experienced what was going on in her mind. Through acceptation exercises Janet learned to experience intrusive thoughts and feelings of distress but without giving in to it. Her self-acceptation and goal directed behaviour increased. She embraced her OCD-related thoughts as friends and decided to live with them. She engaged in activities that helped her moving toward her personal value of self-respect by finding a new job.

General discussion

This study shows that ACT can be adjusted to different forms of anxiety. Clients notice the change in processes they want to change, such as reduction of experiential avoidance and defusion of anxiety related thoughts and beliefs. However it is not the main purpose of ACT, many clients experience a reduction in distress after the treatment (shown by ratings of anxiety and distress scales). ACT also helps to live a more life-goal-directed life by addressing the anxiety that limits the possibility to live such a life. There continues to be a debate whether cognitions are causal factors for behaviours and feelings. Also when therapists are not sure about their own opinion they can still use ACT to change the function of thoughts. They can teach the client that cognitions do not tell them how to react, even when they are intense it is still possible to engage in life goal-directed behaviour. ACT contains different behaviour therapy interventions such as behavioural activation and exposure exercises, however, they are presented from another perspective. The emphasize does not lie on changing thoughts, feelings and sensations but on the awareness and the relation to it. ACT encourages emotional focused problem solving strategies through accept emotions rather than changing them. Acceptation is appropriate when anxious feelings and thoughts are standing in the way of achieving one’s life goals.