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The Official Publication of the Philadelphia Behavior Therapy Association

An Acceptance-Based Behavioral Therapy for Anxiety and Related Disorders: Mindfulness and Values-Based Action

03/23/2022 9:20 AM | Anonymous

Lizabeth Roemer, PhD - University of Massachusetts Boston

Sue Orsillo and I recently (well, recently by pandemic times in which time has no meaning) published a therapist-focused book, Acceptance-based behavioral therapy: Treating anxiety and related challenges (2020, Guilford Press). This clinical guide is grounded in our two decades of collaborative work that began with developing an acceptance-based behavioral therapy for clients with a principal diagnosis of generalized anxiety disorder (GAD; along with a range of comorbid disorders; Roemer & Orsillo, 2002; Roemer, Eustis, & Orsillo, 2021) and evolved into a flexible, conceptualization-driven acceptance-based behavioral approach to a range of clinical presentations and health promotion efforts. Our initial manualized treatment drew from several evidence-based interventions that emphasize acceptance and mindfulness (e.g., acceptance and commitment therapy [ACT]: Hayes, Strosahl, & Wilson, 1999; dialectical behavior therapy [DBT]: Linehan, 1993; mindfulness-based cognitive therapy [MBCT]: Segal, Williams, & Teasdale, 2002), as well as other behavioral and cognitive interventions with extensive empirical support (e.g., Barlow, 2014; Borkovec & Sharpless, 2004).

In our work, we use the term acceptance-based behavioral therapies (ABBTs; or sometimes mindfulness- and acceptance-based behavioral therapies) to define an overarching approach that explicitly emphasizes altering the way clients relate to their internal experiences (reducing reactivity and avoidance, while promoting decentering and acceptance) as a central mechanism of therapeutic change, coupled with an emphasis on helping clients to identify what matters to them and make intentional choices consistent with those values. While we draw from ACT, DBT, and MBCT strategies in our work, we also draw from more “traditional” CBT strategies such as self-monitoring, psychoeducation, adapted relaxation practices, and behavioral activation. We focus particularly on the function of interventions (i.e., helping clients change their relationships with internal experiences, increasing clients’ willingness to experience distress, helping clients to connect to what matters to them, helping clients to choose their actions intentionally), rather than adhering to strict prescriptions of the form of interventions.

Our collaborative research with colleagues and doctoral students focused first on developing an ABBT protocol for treating clients with GAD and comorbid presenting problems. This treatment leads to significant reductions in symptoms of anxiety and depression, improvements in quality of life that is comparable to that found with applied relaxation (e.g., Roemer, Orsillo, & Salters-Pedneault, 2008; Hayes-Skelton, Roemer, & Orsillo, 2013), as well as improvements in interpersonal functioning (Millstein, Orsillo, Hayes-Skelton, & Roemer, 2015) and clinically significant increases in self-reported engagement in values-based action (Michelson, Lee, Orsillo, & Roemer, 2011). Both ABBT and applied relaxation targeted experiential avoidance and decentering and these changes predicted clinical outcomes (Eustis, Hayes-Skelton, Roemer, & Orsillo, 2016; Hayes-Skelton, Calloway, Roemer, & Orsillo, 2015), with decentering changing prior to anxiety symptoms. Clients from marginalized backgrounds reported that values clarification/action and flexibility helped with the cultural responsiveness of the therapy (Fuchs et al., 2016).  Abbreviated health promotion programs developed based on these principles also significantly reduced anxiety and depressive symptoms through programs delivered in person (Danitz & Orsillo, 2014; Danitz, Suvak, & Orsillo, 2016; Eustis, Krill Williston, Morgan, Graham, Hayes-Skelton, & Roemer, 2017) and on-line (Eustis, Hayes-Skelton, Orsillo, & Roemer, 2018; Sagon, Danitz, Suvak, & Orsillo, 2018). We also have preliminary data suggesting that individuals in the community with generalized anxiety who used our self-help workbook, Worry less, live more: The mindful way through anxiety workbook experienced significant decreases in worry, anxiety, depression and functional impairment and increases in acceptance (Serowik, Roemer, Suvak, Liverant, & Orsillo, 2019).  Correlational and experimental pilot studies have also illustrated the ways that mindfulness and values-based action may be beneficial in response to racist experiences (Graham, West, & Roemer, 2013; Graham, West, & Roemer, 2015; Miller & Orsillo, 2020; West, Graham, & Roemer, 2013). Most recently, several colleagues and I published clinical guidance for applying both mindfulness and valued living interventions to racism-related stress (Martinez, Suyemoto, Abdullah, Burnett-Ziegler & Roemer, 2022).

In my upcoming training for PBTA, I will be drawing from this body of research, from my experience supervising clinicians in the context of randomized controlled trials and in the context of clinical practica, and from the wisdom of experts in acceptance-based and other behavioral approaches (e.g., Harrell, 2018) to provide guidance on using both mindfulness and values-based action with clients who present with a range of anxiety experiences, including those experiencing racism- and other kinds of discrimination-related stress. I will focus particularly on how to clarify values with clients and develop meaningful values-based actions, taking into account systemic factors and other complexities. I look forward to seeing many of you there!

Barlow, D. H. (Ed). (2014). Clinical handbook of psychological disorders: A step by-step treatment manual (5th ed.). New York, NY: Guilford Press.

Borkovec, T. D., & Sharpless, B. (2004). Generalized anxiety disorder: Bringing cognitive-behavioral therapy into the valued present. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 209-242). New York. NY: Guilford Press.

Danitz, S. B., & Orsillo, S. M. (2014). The mindful way through the semester: An investigation of the effectiveness of an acceptance-based behavioral therapy program on psychological wellness in first-year students. Behavior Modification, 38, 549-566

Danitz, S. B., Suvak, M., Orsillo, S. M. (2016). The Mindful Way Through the Semester: Evaluating the impact of integrating an acceptance-based behavioral program into a first-fear experience course for undergraduates. Behavior Therapy, 47, 487-499.

Eustis, E.H., Hayes-Skelton, S. A., Orsillo, S. M., & Roemer, L. (2018). Surviving and thriving during stress: A randomized clinical trial comparing a brief web-based therapist assisted acceptance-based behavioral intervention versus waitlist control for college students. Behavior Therapy, 49, 889-903

Eustis, E.H., Hayes-Skelton, S. A., Roemer, L.,&Orsillo, S.M. (2016). Reductions in experiential avoidance as a mediator of change in symptom outcome and quality of life in acceptance-based behavior therapy and applied relaxation for generalized anxiety disorder. Behaviour Research and Therapy, 87, 188-195.

Eustis, E. H., Williston, S. K., Morgan, L. P., Graham, J. R., Hayes-Skelton, S. A., & Roemer, L. (2017). Development, acceptability, and effectiveness of an acceptance-based behavioral stress/anxiety management workshop for university students. Cognitive and Behavioral Practice, 24, 174-186.

Fuchs, C. H., West, L. M., Graham, J. R., Kalill, K. S., Morgan, L. P., Hayes-Skelton, S. A., ... & Roemer, L. (2016). Reactions to an acceptance-based behavior therapy for GAD: Giving voice to the experiences of clients from marginalized backgrounds. Cognitive and Behavioral Practice23(4), 473-484.

Graham, J. R., West, L., & Roemer, L. (2013). The experience of racism and anxiety symptoms in an African American Sample: Moderating effects of trait mindfulness. Mindfulness, 4, 332-341.

Graham, J. R., West, L. M., & Roemer, L. (2015). A preliminary exploration of the moderating role of valued living in the relationships between racist experiences and anxious and depressive symptoms. Journal of Contextual Behavioral Science, 4, 48-55.

Harrell, S. P. (2018). Soulfulness as an orientation to contemplative practice: Culture, liberation, and mindful awareness. The Journal of Contemplative Inquiry, 5(1), 9-40.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford Press.

Hayes-Skelton, S. A., Calloway, A., Roemer, L., & Orsillo, S. M. (2015). Decentering as a potential common mechanism across two therapies for generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 83, 395-404.

Hayes-Skelton, S. A., Roemer, L., & Orsillo, S. M. (2013). A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder. Journal of Consulting and Clinical Psychology81(5), 761-773.

Linehan, M. M. (1993). Diagnosis and treatment of mental disorders: Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.

Martinez, J.H., Suyemoto, K.L., Abdullah, T., Burnett-Ziegler, I., & Roemer, L. (2022). Mindfulness and valued living in the face of racism-related stress. Mindfulness. Advanced online publication. https://doi.org/10.1007/s12671-022-01826-6

Michelson, S. E., Lee, J. K., Orsillo, S. M., & Roemer, L. (2011). The role of values‐consistent behavior in generalized anxiety disorder. Depression and Anxiety28(5), 358-366.

Miller, A. & Orsillo, S. M. (2019). Values, acceptance, and belongingess in graduate school: Perspectives from underrepresented minority students. Journal of Contextual Behavioral Science, 15, 197-206.

Millstein, D. J., Orsillo, S. M., Hayes-Skelton, S. A., & Roemer, L. (2015). Interpersonal problems, mindfulness, and therapy outcome in an acceptance-based behavior therapy for generalized anxiety disorder. Cognitive Behaviour Therapy44(6), 491-501.

Orsillo, S. M., & Roemer, L.(2016). Worry less, live more: The mindful way through anxiety workbook. New York, NY: Guilford Press

Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9, 54-68.

Roemer, L.,& Orsillo, S. M. (2020), Acceptance-based behavioral therapy: Treating anxiety and related challenges. New York: Guilford Press.

Roemer, L., Eustis, E. H.& Orsillo, S. M. (2021). An acceptance-based behavioral therapy for generalized anxiety disorder. In D. H. Barlow (Ed). Clinical handbook of psychological disorders: A step-by-step treatment manual (6th ed., pp. 184-216). New York, NY: Guilford Press.

Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: Evaluation in a randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(6), 1083-1089.

Sagon, A. L., Danitz, S. B., Suvak, M. K., & Orsillo, S. M. (2018). The Mindful Way through the Semester: Evaluating the feasibility of delivering an acceptance-based behavioral program online. Journal of Contextual Behavioral Science9, 36-44.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). New York, NY: The Guilford Press.

Serowik, K.L., Roemer, L., Suvak, M. Liverant, G., & Orsillo, S.M. (2019).  A randomized controlled trial evaluating Worry Less, Live More: The Mindful Way through Anxiety Workbook. 49, 412-424.

West, L., Graham, J. R. & Roemer, L.(2013). Functioning in the face of racism: Preliminary findings on the buffering role of values clarification in a Black American sample. Journal of Contextual Behavioral Science, 2, 1-8.

Published March 23, 2022

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