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Published in: Journal of Contemporary Psychotherapy 3/2013

01-09-2013 | Original Paper

Using Acceptance and Commitment Therapy to Guide Exposure-Based Interventions for Posttraumatic Stress Disorder

Authors: Brian L. Thompson, Jason B. Luoma, Jenna T. LeJeune

Published in: Journal of Contemporary Psychotherapy | Issue 3/2013

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Abstract

Exposure is considered one of the most effective interventions for PTSD. There is a large body of research for the use of imaginal and in vivo exposure in the treatment of PTSD, with prolonged exposure (PE) therapy being the most researched example. Acceptance and commitment therapy (ACT) has sometimes been called an exposure-based treatment, but how exposure is implemented in ACT for PTSD has not been well articulated. Although support for the use of ACT in PTSD treatment is limited to a handful of case studies and open trials, research suggests ACT is particularly useful in flexibly targeting avoidance behavior—arguably the most important process in the continued maintenance of PTSD symptoms. The purpose of this paper is to explore the use of exposure within ACT in PTSD treatment. Through an overview of PE and ACT, and with the use of case examples, we describe how ACT principles and techniques may inform exposure-based treatments for PTSD in order to create more flexible approaches. In addition, understanding exposure within an ACT framework may also contribute to clarifying processes of change.
Literature
go back to reference Arch, J. J., Eifert, G. H., Davies, C., Vilardaga, J. C. P., Rose, R. D., & Craske, M. G. (2012). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology, 80(5), 750–765.PubMedCrossRef Arch, J. J., Eifert, G. H., Davies, C., Vilardaga, J. C. P., Rose, R. D., & Craske, M. G. (2012). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology, 80(5), 750–765.PubMedCrossRef
go back to reference Batten, S. V., DeViva, J. C., Santanello, A. P., Morris, L. J., Benson, P. R., & Mann, M. A. (2009). Acceptance and commitment therapy for comorbid PTSD and substance use disorders. In J. C. J. Blackledge & F. Deane (Eds.), Acceptance and commitment therapy: Contemporary theory, research, and practice (pp. 311–328). Bowen Hills: Australian Academic Press. Batten, S. V., DeViva, J. C., Santanello, A. P., Morris, L. J., Benson, P. R., & Mann, M. A. (2009). Acceptance and commitment therapy for comorbid PTSD and substance use disorders. In J. C. J. Blackledge & F. Deane (Eds.), Acceptance and commitment therapy: Contemporary theory, research, and practice (pp. 311–328). Bowen Hills: Australian Academic Press.
go back to reference Batten, S. V., & Hayes, S. C. (2005). Acceptance and commitment therapy in the treatment of comorbid substance abuse and post-traumatic stress disorder: A case study. Clinical Case Studies, 4(3), 246–262.CrossRef Batten, S. V., & Hayes, S. C. (2005). Acceptance and commitment therapy in the treatment of comorbid substance abuse and post-traumatic stress disorder: A case study. Clinical Case Studies, 4(3), 246–262.CrossRef
go back to reference Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., et al. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688.PubMedCrossRef Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., et al. (2011). Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy, 42(4), 676–688.PubMedCrossRef
go back to reference Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5–27.PubMedCrossRef Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46(1), 5–27.PubMedCrossRef
go back to reference Cukor, J., Spitalnick, J., Difede, J. A., Rizzo, A., & Rothbaum, B. O. (2009). Emerging treatments for PTSD. Clinical Psychology Review, 29(8), 715–726.PubMedCrossRef Cukor, J., Spitalnick, J., Difede, J. A., Rizzo, A., & Rothbaum, B. O. (2009). Emerging treatments for PTSD. Clinical Psychology Review, 29(8), 715–726.PubMedCrossRef
go back to reference Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety disorders: A practitioner’s treatment guide to using mindfulness, acceptance, and values-based behavior change. Oakland: New Harbinger Publications. Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety disorders: A practitioner’s treatment guide to using mindfulness, acceptance, and values-based behavior change. Oakland: New Harbinger Publications.
go back to reference Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67(2), 194–200.PubMedCrossRef Foa, E. B., Dancu, C. V., Hembree, E. A., Jaycox, L. H., Meadows, E. A., & Street, G. P. (1999). A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology, 67(2), 194–200.PubMedCrossRef
go back to reference Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide. New York: Oxford University Press. Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences therapist guide. New York: Oxford University Press.
go back to reference Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing theory: An update. In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment (pp. 3–24). New York: Guilford Press. Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emotional processing theory: An update. In B. O. Rothbaum (Ed.), Pathological anxiety: Emotional processing in etiology and treatment (pp. 3–24). New York: Guilford Press.
go back to reference Hagenaars, M. A., van Minnen, A., & Hoogduin, K. A. L. (2010). The impact of dissociation and depression on the efficacy of prolonged exposure treatment for PTSD. Behaviour Research and Therapy, 48(1), 19–27.PubMedCrossRef Hagenaars, M. A., van Minnen, A., & Hoogduin, K. A. L. (2010). The impact of dissociation and depression on the efficacy of prolonged exposure treatment for PTSD. Behaviour Research and Therapy, 48(1), 19–27.PubMedCrossRef
go back to reference Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. New York: Plenum Press. Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). Relational frame theory: A post-Skinnerian account of human language and cognition. New York: Plenum Press.
go back to reference Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–25.PubMedCrossRef Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1–25.PubMedCrossRef
go back to reference Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.
go back to reference Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6), 1152–1168.PubMedCrossRef Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6), 1152–1168.PubMedCrossRef
go back to reference Hembree, E. A., Foa, E. B., Dorfan, N. M., Street, G. P., Kowalski, J., & Tu, X. (2003). Do patients drop out prematurely from exposure therapy for PTSD? Journal of Traumatic Stress, 16(6), 555–562.PubMedCrossRef Hembree, E. A., Foa, E. B., Dorfan, N. M., Street, G. P., Kowalski, J., & Tu, X. (2003). Do patients drop out prematurely from exposure therapy for PTSD? Journal of Traumatic Stress, 16(6), 555–562.PubMedCrossRef
go back to reference Institute of Medicine (US) (2007). Committee on treatment of posttraumatic stress disorder. Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press. Institute of Medicine (US) (2007). Committee on treatment of posttraumatic stress disorder. Treatment of posttraumatic stress disorder: An assessment of the evidence. Washington, DC: The National Academies Press.
go back to reference Kashdan, T. B., Barrios, V., Forsyth, J. P., & Steger, M. F. (2006). Experiential avoidance as a generalized psychological vulnerability: Comparisons with coping and emotion regulation strategies. Behaviour Research and Therapy, 44(9), 1301–1320.PubMedCrossRef Kashdan, T. B., Barrios, V., Forsyth, J. P., & Steger, M. F. (2006). Experiential avoidance as a generalized psychological vulnerability: Comparisons with coping and emotion regulation strategies. Behaviour Research and Therapy, 44(9), 1301–1320.PubMedCrossRef
go back to reference Kircanski, K., Mortazvi, A., Castriotta, N., Baker, A. S., Mystkowski, J. L., Yi, R., et al. (2012). Challenges to the traditional exposure paradigm: Variability in exposure therapy for contamination fears. Journal of Behavior Therapy and Experimental Psychiatry, 43(2), 745–751.PubMedCrossRef Kircanski, K., Mortazvi, A., Castriotta, N., Baker, A. S., Mystkowski, J. L., Yi, R., et al. (2012). Challenges to the traditional exposure paradigm: Variability in exposure therapy for contamination fears. Journal of Behavior Therapy and Experimental Psychiatry, 43(2), 745–751.PubMedCrossRef
go back to reference Levitt, J. T., Brown, T. A., Orsillo, S. M., & Barlow, D. H. (2004). The effects of acceptance versus suppression of emotion on subjective physiological response to carbon dioxide challenge in patients with panic disorder. Behavior Therapy, 35(4), 747–766.CrossRef Levitt, J. T., Brown, T. A., Orsillo, S. M., & Barlow, D. H. (2004). The effects of acceptance versus suppression of emotion on subjective physiological response to carbon dioxide challenge in patients with panic disorder. Behavior Therapy, 35(4), 747–766.CrossRef
go back to reference Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance and commitment therapy skills-training manual for therapists. Oakland: New Harbinger Publications. Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance and commitment therapy skills-training manual for therapists. Oakland: New Harbinger Publications.
go back to reference Marshall, R. D., Turner, J. B., Lewis-Fernandez, R., Koenan, K., Neria, Y., & Dohrenwend, B. P. (2006). Symptom patterns associated with chronic PTSD in male veterans: New findings from the National Vietnam Veterans Readjustment Study. The Journal of Nervous and Mental Disease, 194(4), 275–278.PubMedCrossRef Marshall, R. D., Turner, J. B., Lewis-Fernandez, R., Koenan, K., Neria, Y., & Dohrenwend, B. P. (2006). Symptom patterns associated with chronic PTSD in male veterans: New findings from the National Vietnam Veterans Readjustment Study. The Journal of Nervous and Mental Disease, 194(4), 275–278.PubMedCrossRef
go back to reference Moscovitch, D. A., Antony, M. M., & Swinson, R. P. (2009). Exposure-based treatments for anxiety disorders: Theory and process. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 461–475). New York: Oxford University Press. Moscovitch, D. A., Antony, M. M., & Swinson, R. P. (2009). Exposure-based treatments for anxiety disorders: Theory and process. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 461–475). New York: Oxford University Press.
go back to reference Nemeroff, C. B., Bremner, J. D., Foa, E. B., Mayberg, H. S., North, C. S., & Stein, M. B. (2006). Posttraumatic stress disorder: A state-of-the-science review. Journal of Psychiatric Research, 40(1), 1–21.PubMedCrossRef Nemeroff, C. B., Bremner, J. D., Foa, E. B., Mayberg, H. S., North, C. S., & Stein, M. B. (2006). Posttraumatic stress disorder: A state-of-the-science review. Journal of Psychiatric Research, 40(1), 1–21.PubMedCrossRef
go back to reference Orsillo, S. M., & Batten, S. V. (2005). Acceptance and Commitment Therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.PubMedCrossRef Orsillo, S. M., & Batten, S. V. (2005). Acceptance and Commitment Therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.PubMedCrossRef
go back to reference Polusny, M. A., & Follette, V. M. (1995). The long term correlates of child sexual abuse: Theory and review of the empirical literature. Applied and Preventive Psychology, 4(3), 143–166.CrossRef Polusny, M. A., & Follette, V. M. (1995). The long term correlates of child sexual abuse: Theory and review of the empirical literature. Applied and Preventive Psychology, 4(3), 143–166.CrossRef
go back to reference Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30(6), 635–641.PubMedCrossRef Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical Psychology Review, 30(6), 635–641.PubMedCrossRef
go back to reference Rosen, G. M., & Davison, G. C. (2003). Psychology should list empirically supported principles of change (ESPs) and not credential trademarked therapies or other treatment packages. Behavior Modification, 27(3), 300–312.PubMedCrossRef Rosen, G. M., & Davison, G. C. (2003). Psychology should list empirically supported principles of change (ESPs) and not credential trademarked therapies or other treatment packages. Behavior Modification, 27(3), 300–312.PubMedCrossRef
go back to reference Şalcıoğlu, E., Başoğlu, M., & Livanou, M. (2007). Effects of live exposure on symptoms of posttraumatic stress disorder: The role of reduced behavioral avoidance in improvement. Behaviour Research and Therapy, 45(10), 2268–2279.PubMedCrossRef Şalcıoğlu, E., Başoğlu, M., & Livanou, M. (2007). Effects of live exposure on symptoms of posttraumatic stress disorder: The role of reduced behavioral avoidance in improvement. Behaviour Research and Therapy, 45(10), 2268–2279.PubMedCrossRef
go back to reference Shipherd, J. C., & Beck, J. G. (2005). The role of thought suppression in posttraumatic stress disorder. Behavior Therapy, 36, 277–287.CrossRef Shipherd, J. C., & Beck, J. G. (2005). The role of thought suppression in posttraumatic stress disorder. Behavior Therapy, 36, 277–287.CrossRef
go back to reference Thompson, B. L., & Waltz, J. (2010). Mindfulness and experiential avoidance as predictors of posttraumatic stress disorder avoidance symptom severity. Journal of Anxiety Disorders, 24(4), 409–415.PubMedCrossRef Thompson, B. L., & Waltz, J. (2010). Mindfulness and experiential avoidance as predictors of posttraumatic stress disorder avoidance symptom severity. Journal of Anxiety Disorders, 24(4), 409–415.PubMedCrossRef
go back to reference Twohig, M. P. (2009). Acceptance and commitment therapy for treatment-resistant posttraumatic stress disorder: A case study. Cognitive and Behavioral Practice, 16(3), 243–252.CrossRef Twohig, M. P. (2009). Acceptance and commitment therapy for treatment-resistant posttraumatic stress disorder: A case study. Cognitive and Behavioral Practice, 16(3), 243–252.CrossRef
go back to reference Twohig, M. P., Hayes, S. C., Plumb, J. C., Pruitt, L. D., Collins, A. B., Hazlett-Stevens, H., et al. (2010a). A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705–716.PubMedCrossRef Twohig, M. P., Hayes, S. C., Plumb, J. C., Pruitt, L. D., Collins, A. B., Hazlett-Stevens, H., et al. (2010a). A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705–716.PubMedCrossRef
go back to reference Twohig, M. P., Whittal, M. L., Cox, J. M., & Gunter, R. (2010b). An initial investigation into the processes of change in ACT, CT, and ERP for OCD. International Journal of Behavioral Consultation and Therapy, 6(1), 67–83. Twohig, M. P., Whittal, M. L., Cox, J. M., & Gunter, R. (2010b). An initial investigation into the processes of change in ACT, CT, and ERP for OCD. International Journal of Behavioral Consultation and Therapy, 6(1), 67–83.
go back to reference van Minnen, A. V., Arntz, A., & Keijsers, G. P. J. (2002). Prolonged exposure in patients with chronic PTSD: Predictors of treatment outcome and dropout. Behaviour Research and Therapy, 40(4), 439–457.PubMedCrossRef van Minnen, A. V., Arntz, A., & Keijsers, G. P. J. (2002). Prolonged exposure in patients with chronic PTSD: Predictors of treatment outcome and dropout. Behaviour Research and Therapy, 40(4), 439–457.PubMedCrossRef
go back to reference Varra, A. A., & Follette, V. M. (2004). ACT with posttraumatic stress disorder. In S. C. Hayes & K. D. Strosahl (Eds.), A practical guide to acceptance and commitment therapy (pp. 133–152). New York: Springer.CrossRef Varra, A. A., & Follette, V. M. (2004). ACT with posttraumatic stress disorder. In S. C. Hayes & K. D. Strosahl (Eds.), A practical guide to acceptance and commitment therapy (pp. 133–152). New York: Springer.CrossRef
Metadata
Title
Using Acceptance and Commitment Therapy to Guide Exposure-Based Interventions for Posttraumatic Stress Disorder
Authors
Brian L. Thompson
Jason B. Luoma
Jenna T. LeJeune
Publication date
01-09-2013
Publisher
Springer US
Published in
Journal of Contemporary Psychotherapy / Issue 3/2013
Print ISSN: 0022-0116
Electronic ISSN: 1573-3564
DOI
https://doi.org/10.1007/s10879-013-9233-0

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