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Integrating Acceptance-based Behavior Therapy into Exposure-based therapy for PTSD. Acknowledgments. Susan Orsillo, PhD Suffolk University Lizabeth Roemer, PhD University of Massachusetts, Boston. The third wave . Behavior Therapy Cognitive Therapy Acceptance-based models

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Susan Orsillo, PhD

Suffolk University

Lizabeth Roemer, PhD

University of Massachusetts, Boston

the third wave
The third wave
  • Behavior Therapy
  • Cognitive Therapy
  • Acceptance-based models
    • Acceptance and Commitment Therapy (ACT)
    • Mindfulness-based Cognitive Therapy (MBCT)
    • Acceptance-based Behavior Therapy for GAD
    • Dialectical Behavior Therapy (DBT)
    • Integrative Behavioral Couple Therapy (IBCT)
    • Behavioral Activation (BA)
    • Functional Analytic Psychotherapy (FAP)
    • Mindfulness-based Relapse Prevention (MBRP)
an etiological model of ptsd
An etiological model of PTSD
  • Generalized psychological vulnerability
  • Generalized biological vulnerability
  • Experience of trauma
    • Developed by classical conditioning
    • Maintained by operant conditioning
  • Anxious apprehension
  • Avoidance or numbing of emotional response
  • Moderated by social support and ability to cope

(Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)

evidence based psychological treatments for ptsd
Evidence-based psychological treatments for PTSD
  • General aims
    • Extinction of conditioned fear and anxiety responses through repeated, non-reinforced exposure to CS
    • Development of alternative, competing responses to anxiety and fear
    • Emphasis on symptom reduction through mastery experiences and internal control strategies
evidence based treatments
Evidence-based treatments
  • Exposure Therapy
  • Anxiety Management Training (AMT)
  • Combination treatments

(Foa, Keane & Friedman, 2000; Keane et al, 2006; Roth & Fonagy, 2005)

exposure therapy
Exposure Therapy
  • Patient is guided through a vivid remembering of the trauma until extinction occurs
  • Goal is to reduce avoidance of anxiety and promote control/mastery over trauma-related cues

(Foa and Rothbaum, 1998)

anxiety management training
Anxiety Management Training
  • Package of behavioral and cognitive strategies to reduce and control anxiety
    • Progressive muscle relaxation
    • Diaphragmatic breathing
    • Cognitive restructuring
    • Communication skills training
    • Time management
    • Anger management/assertion training

(Meichenbaum, 1994)

combination treatments
Combination treatments
  • Package of CT, exposure and emotion regulation skills
  • Essential components of CT
    • Self-monitoring
      • Identification and labeling of thoughts and associated emotions
    • Cognitive restructuring
      • Changing the content of a ‘dysfunctional’ cognition through logical analysis
    • Hypothesis testing
      • Conducting behavioral experiments to evaluate the validity of dysfunctional thoughts
combination treatments10
Combination treatments
  • Cognitive Processing Therapy (CPT)
    • Written exposure trials
    • cognitive restructuring of trauma related erroneous cognitions and schemas, particularly regarding safety, trust, power, control, self-esteem and intimacy
    • Emotion regulation and distress tolerance skills
    • Prolonged exposure
    • CSA related PTSD

(Resick et al. 2002; Cloitre et al., 2002)

the good news about ebts for ptsd
The good news about EBTs for PTSD
  • Treatments are efficacious when compared to TAU, wait list control and active placebo treatments
    • 67% of completers no longer meet criteria for PTSD
    • 56% of intent-to-treat patients no longer meet criteria for PTSD
  • Exposure and CBT are generally equally efficacious

(Bradley, 2005)

limitations of current treatments
Limitations of current treatments
  • 44% of intent-to-treat patients continue to meet criteria for PTSD (Bradley, 2005)
  • Using DSM criteria as treatment outcome may not be relevant to clinically significant change
  • Generalization of findings limited by study exclusion rates averaging 30%
    • Co-morbid Axis I disorder
    • Current substance abuse
    • Suicidal ideation or behavior
more limitations
More limitations
  • Relative lack of effectiveness research
  • RCTs generally compare monotherapies and not multimodal therapies
  • lack of evidence regarding long-term maintenance of gains
  • Vast majority of community sample patients do not receive EBTs
    • Due to lack of dissemination
    • Due to lack of treatment acceptance by patients
and still more
And still more
  • Lowest effect sizes for patients with combat-related PTSD compared to other traumas
  • Focus on symptom reduction and not functional improvement
    • Interpersonal relationships
    • Vocational functioning
    • General quality of life
limitations specific to cbt
Limitations specific to CBT
  • Relatively difficult to train therapists to adherence (Kohlenberg, 2004; Dimidjian et al, 2006)
  • Emphasis on control and mastery strategies can have paradoxical effect in anxiety disorders (Roemer & Borkovec, 1994)
limitations specific to exposure
Limitations specific to exposure
  • Requires memory of a specific trauma event
  • May have low acceptability to patients and providers
  • PTSD patients have more negative attitudes toward emotional expression
  • Exposure less effective for patients:
    • High levels of anger at pre-treatment
    • High levels of avoidance at pre-treatment
    • Perpetrators of harm who experience guilt/shame as primary symptoms
potential limitations of standard therapies for oif oef veterans
Potential limitations of standard therapies for OIF/OEF veterans
  • Stigma associated with mental health care
  • Reluctance to participate in exposure
  • Presence of co-morbid conditions
  • Lack of a single traumatic event
  • Associated feelings of guilt, loss, anger, sadness, grief
  • Potential for iatrogenic effects of exposure
the challenge in treating oif oef veterans
The challenge in treating OIF/OEF veterans
  • How do we provide secondary prevention?
    • Proper treatment may help prevent the development or progression of symptoms, or the underlying mechanisms leading to pathology(Zatzick et al. 2004)
    • what are these mechanisms?
    • What is the natural course of resilience, remission and recovery? (Bonanno 2004)
    • How can we use current treatments in secondary prevention?
    • How can we adapt or elaborate on these treatments for use with recently returned veterans?
spectrum of post deployment mental disorders n 46 571

Spectrum of Post-Deployment Mental Disorders (N = 46,571)

Disorder N %

PTSD 20,638 44%

Drug Abuse 17,768 38%

Depression 14,317 31%

Neurotic Disorders 11,481 25%

Affective Psychosis 7,460 16%

Alcohol Dependence 3,116 7%

Acute Stress Reaction 1,327 3%

VHA Office of Public Health and Environmental Hazards, February 14, 2006

the cautionary tale of critical incident stress debriefing cisd
The cautionary tale of Critical Incident Stress Debriefing (CISD)
  • Intervention intended as secondary prevention for occupational trauma exposure (Mitchell 1983;1993)
  • Proprietary; dramatic claims of effectiveness
  • Basic assumptions
    • Exposure to traumatic stressor is sufficient to cause symptoms that can escalate to a pathological condition
    • Early and proximal intervention involving emotional catharsis (exposure) is prophylactic
cisd procedures
CISD procedures
  • Format
    • Group administration
    • Delivered by a mental health provider assisted by non-professional peers
    • Conducted in one 2-3 hour session within 24-72 hours of traumatic event
    • Mandatory attendance customary
    • Non-attendees or drop-outs typically retrieved by peer facilitator
cisd treatment protocol
CISD treatment protocol
  • Introduction of the debriefing
  • Statement of facts regarding the traumatic event
  • Disclosure of thoughts regarding the event
  • Disclosure of emotional reactions, with focus on strong negative affects
  • Specification of possible symptoms
  • Education regarding consequences of trauma exposure
  • Planned re-entry to social environment

(Mitchell & Everly, 1993)

cisd outcome research
CISD outcome research
  • No clinically significant improvement for participants at long-term follow-up
  • Slight but statistically significant worsening on outcome measures for those accepting debriefing
  • Preference for informal sources of support and assistance correlated strongly with improved outcome
  • Those with highest levels of both avoidance and intrusive recollection deteriorated most after debriefing; recovery better among those not receiving treatment (Mayou et al. 2000)
  • “CISD is inert at best and iatrogenic at worst” (Lohr et al. 2003)
an etiological model of ptsd24
An etiological model of PTSD
  • Generalized psychological vulnerability
  • Generalized biological vulnerability
  • Experience of trauma
    • Developed by classical conditioning
    • Maintained by operant conditioning
  • Anxious apprehension
  • Avoidance or numbing of emotional response
  • Moderated by social support and ability to cope

(Keane & Barlow, 2002; Keane, Marshall & Taft, 2006)

approaches to providing secondary prevention
Approaches to providing secondary prevention
  • Watch and wait
    • Respect the natural course of recovery among the resilient
    • Support naturally occurring restorative factors in patient’s life
    • Provide supportive treatments that do not interfere with natural resilience and are not iatrogenic
  • Wellness
    • Provide treatments that enhance naturally occurring restorative factors
    • Example: Behavioral Activation (BA)
secondary prevention approaches
Secondary prevention approaches
  • Rehabilitation
    • Support naturally occurring curative factors in patient’s life +
    • Provide treatments that prevent or inhibit pathological mechanisms implicated in the development and maintenance of psychological distress
      • Experiential avoidance
      • Co-morbid conditions that serve the function of experiential avoidance, especially SUDs and rumination
acceptance based behavior therapy abt
Acceptance-based Behavior Therapy (ABT)
  • Standard therapies
    • Based on a conditioning model of PTSD
    • Aim is to reduce fear and anxiety through extinction
    • Coupled with strategies to change trauma-related thought content
  • An alternative model
    • PTSD can be understood as a disorder of experiential avoidance(Hayes et al. 1999)
    • Aim is to improve quality of life
    • Coupled with strategies to change the process of cognition rather than the content

(Orsillo & Batten 2005; Batten et al. 2005; Follette et al. 2004)

experiential avoidance
Experiential avoidance
  • Attempts to change the form or frequency of internal events (thoughts, feelings, memories, sensations) (Hayes et al. 1996)
  • EA contributes to the development and maintenance of various forms of psychopathology, particularly anxiety disorders
  • Anxiety disorders develop when individuals are unwilling to experience anxiety (and associated thoughts, images, distressing emotions)
A variety of external and internal control strategies are utilized to alleviate distress via escape and avoidance

Behavioral avoidance of situations and cues (CS) that elicit unwanted internal states (CR)

Cognitive control strategies to avoid unwanted states

Thought suppression

Worried rumination


Internal and external control strategies are negatively reinforced

External control strategies generalize

lead to disengagement with the naturally rewarding contingencies in the environment

Internal control strategies generalize

Become rigid and inflexible

Lead to narrowing of attention

Control strategies maintain distress / cause rebound

thought suppression
Thought suppression
  • Effortful suppression of thoughts
    • Initially relieves distress
    • Has paradoxical long-term effect with rebound of avoided imagery
    • Leads to escalating efforts to control and master thoughts and imagery
  • Thought suppression associated with negative tx outcome (CSA, rape, MVA, Gulf War, urban violence)
  • Behavioral therapies have been adapted to specifically target experiential avoidance as a core feature of pathology
  • (Borkovec et al. 2004)
acceptance based behavior therapies abt
Acceptance-based Behavior Therapies (ABT)
  • Acceptance and Commitment Therapy (ACT)(Hayes et al. 1999, 2004; Eifert & Forsyth, 2005)
  • Mindfulness-based Cognitive Therapy (MBCT)(Segal et al. 2002)
  • Acceptance-based Behavior Therapy for GAD(Roemer& Orsillo, 2004, 2005)
  • Dialectical Behavior Therapy (DBT)(Linehan, 1993)
  • Integrative Behavioral Couple Therapy (IBCT)(Jacobson & Christensen, 1996)
  • Behavioral Activation (BA)(Jacobson et al. 1996; Dimidjian et al. 2006)
  • Functional Analytic Psychotherapy (FAP)(Kohlenberg & Tsai, 1991; Kohlenberg et al. 2004)
  • Mindfulness-based Relapse Prevention (MBRP)(Marlatt et al. 2005)
acceptance based behavior therapy abt32
Acceptance-based Behavior Therapy (ABT)
  • Basic assumptions
  • Treatment components
  • Treatment strategies and techniques
abt assumptions
ABT assumptions
  • Emotions are just emotions; thoughts are just thoughts; memories are just memories
  • Emotions are information; not good or bad
  • Control of internal events is not an option
  • Control is the problem, not the solution
similarities to exposure cbt
Similarities to Exposure/CBT
  • Both consider avoidance to be a core feature of pathology
  • Both advocate approach as an integral treatment strategy
differences from exposure cbt
Differences from Exposure/CBT
  • Approach and avoidance
    • Approach behaviors are inherently valuable
    • Approach behaviors are pragmatically valuable in order to reengage with natural reinforcers and expand domains of functioning
    • Emphasis on clinically valued change rather than symptom reduction
  • Attention
    • CBT emphasizes directing attention toward stimuli associated with disorder (or distract from)
    • ABT emphasizes directing attention broadly toward flow of experience
  • Cognition – radically different understanding of the role of cognition in development and treatment of disorders
    • Cognitions are causal vs. cognitions are responses
    • Importance of content vs. importance of function
    • Goal to change content vs. goal to change relationship to one’s own thoughts and feelings
  • Control within the CBT framework
    • Lack of perceived control and unpredictability strongly associated with distress (Mineka et al. 2006)
    • Control/predictability can be increased by
      • Attending to thoughts and associated emotions
      • Changing thoughts from irrational to rational
      • Through process of logical analysis and behavioral experimentation
  • Control within the ABT framework
    • Efforts to exert internal control maintain distress
    • Thoughts and emotions are transitory experiences of the mind and body
    • Treatment provides experiential learning of acceptance rather than control
    • Distress naturally wanes as a consequence of not being escalated by control strategies (e.g., MBCT)
abt treatment components
ABT treatment components
  • Overarching goals
    • Target experiential avoidance and expand experiential acceptance
    • Target associated behavioral restrictions and expand engagement with valued life goals and activities
  • 1. Psychoeducation
  • 2. Assessment
  • 3. Experiential acceptance
  • 4. Valued action
1 psychoeducation
1. Psychoeducation
  • Role of emotions as information (Linehan 1993)
  • Limits and costs of control strategies (Roemer & Orsilllo 2004)
  • Importance of approach and emotional engagement in therapy sessions (Jaycox et al. 1998)
2 assessment
2. Assessment
  • General assessment
    • Symptom review and diagnostic assessment
    • Self-report measures
      • PTSD
      • Anxiety
      • depression
    • Self-report functional measures
      • Life satisfaction
      • Valued life domains

(Roemer & Orsillo, 2004; Orsillo & Batten, 2005)

2 assessment43
2. Assessment
  • Avoidance and suppression
    • Self-report measures of experiential avoidance and thought suppression (Hayes et al. 2006; Eifert & Forsyth, 2005)
      • Acceptance and Action Questionnaire (AAQ)
      • White Bear Suppression Inventory
      • Thought Control Questionnaire
  • Values assessment
    • Self-report measures to identify idiographic treatment outcomes (Hayes et al. 1999, Eifert & Forsyth, 2005)
      • Generate values
      • Rate values to establish priorities
      • Identify intermediate steps, actions and barriers
3 experiential acceptance
3. Experiential acceptance
  • Mindfulness
    • Targets identification of thoughts/feelings as ‘reality’
  • Willingness
    • Encourages approach behaviors
  • Distress tolerance skills
    • Targets avoidance due to inability to tolerate emotion
  • Emotion regulation skills
    • Targets avoidance due to inability to modulate emotion
key concepts in mindfulness
Key concepts in Mindfulness
  • Decentering
    • Experiencing thoughts and feelings as mental events and not reality
  • Early problem recognition
    • Intentional awareness allows “turning toward” difficulties
  • Anti-ruminative
    • Experience is of current awareness, not elaborate thinking about implications, meaning, etc.
  • Generic skill
    • Daily practice competes with development of avoidance, escape and control strategies

(Segal et al, 2002)

steps in mindfulness training
Steps in Mindfulness training
  • Practice attention to a single sense
  • Practice attention to the flow of experience
  • Practice attention to thoughts, feelings, images as part of the flow of experience
  • Practice attention to the flow of experience during activities
mechanisms of mindfulness
Mechanisms of Mindfulness
  • Exposure to previously avoided classes or categories of emotional experience, leading to decreased distress via extinction
  • Self-monitoring associated with improved appraisal of actual contingencies, leading to increased flexibility in responding
  • State of relaxation (response prevention)
  • Change in attitude toward internal experiences leads to decreased volatility

(Baer, 2003; Teasdale et al. 2002; Segal et al. 2002)

4 valued action
4. Valued action
  • Assessment questions
    • What is important to the patient?
    • To what extent are they living life in accordance with their values?
    • How do their symptoms interfere with the pursuit of their values?
4 valued action49
4. Valued action
  • Intervention techniques
    • Writing exercises to clarify values
    • Self-monitoring to assess degree to which life is spent in valued activities (and/or degree to which patient is emotionally engaged in valued activities)
    • Goal setting
      • Identify concrete steps intermediate to valued activities
      • Commit to plan
      • Identify potential barriers
      • Review previous goals

(Roemer & Orsillo, 2004; Eifert & Forsyth, 2005; Orsillo & Batten, 2005)

integrating exposure therapy
Integrating Exposure Therapy
  • Exposure sessions for specific events as well as classes of emotion
  • Goal is acceptance rather than extinction
  • Therapist must be practiced in approaching emotional experience, and mindful of not colluding with patient in experiential avoidance
  • Therapist must be capable of achieving the metacognitive state of ‘engaged observation’
  • Acceptance-based therapies are useful extensions of exposure-based in secondary prevention of PTSD and co-morbid disorders
    • Empirical support in treatment of anxiety, depression, SUDs, couples, BPD
    • Acceptable to patients
    • Accommodates exposure for emotions other than fear & anxiety, or in absence of Criterion A
    • Teaches cognitive and behavioral skills that may prevent development of avoidant and controlling strategies associated with the exacerbation of anxiety, depressive relapse, substance use, conflict, and intimacy problems
    • Goal is broad functional improvement