Current Psychiatry Reports

, 15:410 | Cite as

Mindfulness and Acceptance-Based Behavioral Therapies for Anxiety Disorders

  • Lizabeth Roemer
  • Sarah K. Williston
  • Elizabeth H. Eustis
  • Susan M. Orsillo
Anxiety Disorders (DJ Stein, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Anxiety Disorders


This article presents a brief conceptual overview of acceptance-based behavioral therapies (ABBTs) for anxiety disorders, followed by a review and summary of the recent efficacy studies of ABBTs for anxiety and comorbid disorders. We discuss clinical implications, including the importance of targeting reactivity and experiential avoidance in interventions for anxiety disorders through the use of mindfulness and other acceptance-based strategies, as well the encouragement of engagement in meaningful activities or valued action. We also address future directions for research, such as expanding research to include more randomized control trials comparing ABBTs for specific anxiety disorders to other active treatments, examining mechanisms of change, exploring adaptations in different care-delivery contexts, as well as determining the applicability of these approaches to clients from marginalized or non-dominant statuses.


Mindfulness Acceptance Experiential avoidance Decentering Anxiety disorders Acceptance and commitment therapy Mindfulness-based cognitive therapy Mindfulness-based stress reduction Acceptance-based behavioral therapies Treatment review Psychological treatments Psychosocial treatments Psychiatry 


Compliance with Ethics Guidelines

Conflict of Interest

Lizabeth Roemer has received grants from National Institute of Mental Health (NIMH); payment for lectures from NJ Association of Cognitive-Behavioral Therapists, Williams College, Harvard School of Education, and Dorchester House; and royalties from Guilford and Springer.

Sarah K. Williston declares that she has no conflict of interest.

Elizabeth H. Eustis declares that she has no conflict of interest.

Susan M. Orsillo has received grants from NIMH, payment for lectures from NJ Association of Cognitive-Behavioral Therapists, and royalties from Guilford and Springer.

Human and Animal Rights and Informed Consent

This article does not contain any unpublished studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593–602.PubMedCrossRefGoogle Scholar
  2. 2.
    Tolin DF, Gilliam CM, Dufresne D. The economic and social burden of anxiety disorders. In: Stein DJ, Hollander E, Rothbaum BO, editors. Textbook of anxiety disorders. 2nd ed. Arlington, VA: American Psychiatric; 2010. p. 731–46.Google Scholar
  3. 3.
    Brandes M, Bienvenu O. Anxiety disorders and personality disorders comorbidity. In: Antony MM, Stein MB, editors. Handbook of anxiety and related disorders. New York: Oxford University Press; 2009. p. 587–95.Google Scholar
  4. 4.
    Hupert JD. Anxiety disorders and depression comorbidity. In: Antony MM, Stein MB, editors. Handbook of anxiety and related disorders. New York: Oxford University Press; 2009. p. 576–86.Google Scholar
  5. 5.
    Zahradnik M, Stewart SH. Anxiety disorders and substance use disorder comorbidity. In: Antony MM, Stein MB, editors. Handbook of anxiety and related disorders. New York: Oxford University Press; 2009. p. 565–75.Google Scholar
  6. 6.
    Roy-Byrne PP, Davidson KW, Kessler RC, et al. Anxiety disorders and comorbid medical illness. Gen Hosp Psychiatry. 2008;30(3):208–25.PubMedCrossRefGoogle Scholar
  7. 7.
    Hofmann SG, Asnaani A, Vonk IJJ, et al. The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognit Ther Res. 2012;36(5):427–40.PubMedCrossRefGoogle Scholar
  8. 8.
    Roshanaei-Moghaddam B, Pauly MC, Atkins DC, et al. Relative effects of CBT and pharmacotherapy in depression versus anxiety: is medication somewhat better for depression, and CBT somewhat better for anxiety? Depress Anxiety. 2011;28(7):560–7.PubMedCrossRefGoogle Scholar
  9. 9.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington DC: Author; 2000.Google Scholar
  10. 10.
    Olatunji BO, Wolitzky-Taylor KB. Anxiety sensitivity and the anxiety disorders: a meta-analytic review and synthesis. Psychol Bull. 2009;135(6):974–99.PubMedCrossRefGoogle Scholar
  11. 11.
    Cisler JM, Koster EHW. Mechanisms of attentional biases towards threat in anxiety disorders: An integrative review. Clin Psychol Rev. 2010;30(2):203–16.PubMedCrossRefGoogle Scholar
  12. 12.
    Mennin DS, Holaway RM, Fresco DM, et al. Delineating components of emotion and its dysregulation in anxiety and mood psychopathology. Behav Ther. 2007;38(3):284–302.PubMedCrossRefGoogle Scholar
  13. 13.
    Farnsworth JK, Sewell KW. Fear of emotion as a moderator between PTSD and firefighter social interactions. J Trauma Stress. 2011;24(4):444–50.PubMedCrossRefGoogle Scholar
  14. 14.
    Sauer-Zavala S, Boswell JF, Gallagher MW, et al. The role of negative affectivity and negative reactivity to emotions in predicting outcomes in the unified protocol for the transdiagnostic treatment of emotional disorders. Behav Res Ther. 2012;50(9):551–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Roemer L, Orsillo SM. Mindfulness and acceptance-based behavioral therapies in practice. New York: Guilford Press; 2009.Google Scholar
  16. 16.
    Hayes SC. Acceptance and commitment therapy, relational frame theory, and the third wave of. Behav Ther. 2004;35:639–65.CrossRefGoogle Scholar
  17. 17.
    Hayes SC, Wilson KG, Gifford EV, et al. Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. J Consult Clin Psychol. 1996;64(6):1152–68.PubMedCrossRefGoogle Scholar
  18. 18.
    Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: The process and practice of mindful change. 2nd ed. New York: Guilford Press; 2012.Google Scholar
  19. 19.
    Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression. 2nd ed. New York: Guilford Press; 2013.Google Scholar
  20. 20.
    Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press; 1993.Google Scholar
  21. 21.
    Roemer L, Orsillo SM. An acceptance-based behavioral therapy for generalized anxiety disorder. In: Barlow DH, editor. Clinical handbook of psychological disorders. 5th ed. New York: Guilford Press; 2013. In press.Google Scholar
  22. 22.
    Wegner DM. Setting free the bears: Escape from thought suppression. Am Psychol. 2011;66(8):671–80.PubMedCrossRefGoogle Scholar
  23. 23.
    Hayes SC, Levin ME, Plumb-Vilardaga J, et al. Acceptance and commitment therapy and contextual behavioral science: Exploring the progress of a distinctive model of behavioral and cognitive therapy. Behav Ther. 2013;44(2):180–98.PubMedCrossRefGoogle Scholar
  24. 24.
    Rogers CR. Client-centered therapy. Oxford, England: Houghton Mifflin; 1951.Google Scholar
  25. 25.
    Linehan MM. Skills training for treating borderline personality disorder. New York: Guilford Press; 1993.Google Scholar
  26. 26.
    Kabat-Zinn J. Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion; 1994.Google Scholar
  27. 27.
    Kabat-Zinn J. Mindfulness-based interventions in context: Past, present, and future. Clin Psychol Sci Pract. 2003;10(2):144–56.CrossRefGoogle Scholar
  28. 28.
    Dymond S, Roche B, editors. Advances in relational frame theory: Research and application. Oakland, CA: New Harbinger; 2013.Google Scholar
  29. 29.
    Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Dell; 1990.Google Scholar
  30. 30.
    Harned MS, Korslund KE, Foa EB, Linehan MM. Treating PTSD in suicidal and self-injuring women with borderline personality disorder: Development and preliminary evaluation of a dialectical Behav Ther. prolonged exposure protocol. Behav Res Ther. 2012;50(6):381–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Chapman AL, Gratz KL, Tull MT. The dialectical Behav Ther. skills workbook for anxiety: Breaking free from worry, panic, PTSD, and other anxiety symptoms. New Harbinger.: Oakland, CA; 2011.Google Scholar
  32. 32.
    Teasdale JD, Segal ZV, Williams JMG. Mindfulness training and problem formulation. Clin Psychol Sci Pract. 2003;10:157–60.CrossRefGoogle Scholar
  33. 33.
    Mennin DS, McLaughlin KA, Flanagan TJ. Emotion regulation deficits in generalized anxiety disorder, social anxiety disorder, and their co-occurrence. J Anxiety Disord. 2009;23(7):866–71.PubMedCrossRefGoogle Scholar
  34. 34.
    Turk CL, Heimberg RG, Luterek JA, et al. Emotion dysregulation in generalized anxiety disorder: A comparison with social anxiety disorder. Cognit Ther Res. 2005;29(1):89–106.CrossRefGoogle Scholar
  35. 35.
    Buhr K, Dugas MJ. Fear of emotions, experiential avoidance, and intolerance of uncertainty in worry and generalized anxiety disorder. Int J Cognit Ther. 2012;5(1):1–17.CrossRefGoogle Scholar
  36. 36.
    Macatee RJ, Cougle JR. The roles of emotional reactivity and tolerance in generalized, social, and health anxiety: A multi-method exploration. Behav Ther. 2013;44(1):39–50.PubMedCrossRefGoogle Scholar
  37. 37.
    Lee JK, Orsillo SM, Roemer L, Allen LB. Distress and avoidance in generalized anxiety disorder: Exploring the relationships with intolerance of uncertainty. Cognit Behav Ther. 2010;39(2):126–36.CrossRefGoogle Scholar
  38. 38.
    Tull MT, Jakupcak M, McFadden, Roemer L. The role of negative affect intensity and the fear of emotions in posttraumatic stress symptom severity among victims of childhood interpersonal violence. J Nerv Ment Dis. 2007;195(7):580–7.PubMedCrossRefGoogle Scholar
  39. 39.
    Shafran R, Rachman S. Thought-action fusion: A review. J Behav Ther Exp Psychiatry. 2004;35(2):87–107.PubMedCrossRefGoogle Scholar
  40. 40.
    Kashdan TB, Steger M. Expanding the topography of social anxiety: An experience sampling assessment of positive emotions and events, and emotion suppression. PsychologSci. 2006;17:120–8.Google Scholar
  41. 41.
    Mahaffey BL, Wheaton MG, Fabricant LE, et al. The contribution of experiential avoidance and social cognitions in the prediction of social anxiety. Behav Cogn Psychother. 2013;41(1):52–65.PubMedCrossRefGoogle Scholar
  42. 42.
    Michelson SE, Lee JK, Orsillo SM, Roemer L. The role of values-consistent behavior in generalized anxiety disorder. Depress Anxiety. 2011;28(5):358–66.PubMedCrossRefGoogle Scholar
  43. 43.
    Roemer L, Borkovec TD. Effects of suppressing thoughts about emotional material. J Abnorm Psychol. 1994;103(3):467–74.PubMedCrossRefGoogle Scholar
  44. 44.
    Wolgast M, Lundh L, Viborg G. Cognitive reappraisal and acceptance: An experimental comparison of two emotion regulation strategies. Behav Res Ther. 2011;49:858–66.PubMedCrossRefGoogle Scholar
  45. 45.
    • Arch JJ, Eifert GH, Davies C, et al. Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. J Consult Clin Psychol. 2012;80(5):750–65. In this study (N = 128), the authors conducted a randomized controlled trial comparing ACT to CBT (with both treatments including behavioral exposures) for participants whose primary diagnosis was an anxiety disorder. All participants demonstrated comparable, significant improvements in all outcomes over the course of treatment, which were maintained at one year follow-up. At one year follow-up, participants in the ACT condition received significantly lower clinical severity ratings, while those in the CBT condition reported significantly better quality of life. Findings suggest that ACT, an acceptance-based behavior therapy, is efficacious in treating clients with a range of anxiety disorders, although insufficient sample size precluded analyses within specific anxiety disorders.PubMedCrossRefGoogle Scholar
  46. 46.
    Arch JJ, Ayers CR, Baker A, et al. Randomized clinical trial of adapted mindfulness-based stress reduction versus group cognitive behavioral therapy for heterogeneous anxiety disorders. Behav Res Ther. 2013;51(4–5):185–96.PubMedCrossRefGoogle Scholar
  47. 47.
    • Hayes-Skelton SA, Roemer L, Orsillo SM. A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder. J Consult Clin Psychol. 2013. In this study (N = 81), participants with a principal diagnosis of generalized anxiety disorder (GAD) were randomly assigned to receive an acceptance-based behavioral therapy (ABBT) that incorporated mindfulness practice and values clarification and action or applied relaxation, an evidence-based treatment for GAD. Participants demonstrated comparable, significant improvements in outcomes (including comorbid disorders) at post and follow-up assessment, with two-thirds of participants in the ABBT condition meeting criteria for high end-state functioning at six month follow-up. Findings suggest that ABBT is an efficacious treatment for GAD. Google Scholar
  48. 48.
    Roemer L, Orsillo SM, Salters-Pedneault K. Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: Evaluation in a randomized controlled trial. J Consult Clin Psychol. 2008;76(6):1083–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Craigie MA, Rees CS, Marsh A, Nathan P. Mindfulness-based cognitive therapy for generalized anxiety disorder: A preliminary evaluation. Behav Cogn Psychother. 2008;36(5):553–68.CrossRefGoogle Scholar
  50. 50.
    Evans S, Ferrando S, Findler M, et al. Mindfulness-based cognitive therapy for generalized anxiety disorder. J Anxiety Disord. 2008;22(4):716–21.PubMedCrossRefGoogle Scholar
  51. 51.
    Twohig MP, Hayes SC, Plumb JC, et al. A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. J Consult Clin Psychol. 2010;78(5):705–16.PubMedCrossRefGoogle Scholar
  52. 52.
    Woods DW, Wetterneck CT, Flessner CA. A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behav Res Ther. 2006;44(5):639–56.PubMedCrossRefGoogle Scholar
  53. 53.
    Flessner CA, Busch AM, Heideman PW, Woods DW. Acceptance-enhanced behavior therapy (AEBT) for trichotillomania and chronic skin picking: exploring the effects of component sequencing. Behav Modif. 2008;32(5):579–94.PubMedCrossRefGoogle Scholar
  54. 54.
    Koszycki D, Benger M, Shlik J, Bradwejn J. Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behav Res Ther. 2007;45(10):2518–26.PubMedCrossRefGoogle Scholar
  55. 55.
    Jazaieri H, Goldin PR, Werner K, et al. A randomized trial of MBSR versus aerobic exercise for social anxiety disorder. J Clin Psychol. 2012;68(7):715–31.PubMedCrossRefGoogle Scholar
  56. 56.
    Kocovski NL, Fleming JE, Rector NA. Mindfulness and acceptance-based group therapy for social anxiety disorder: An open trial. Cogn Behav Pract. 2009;16(3):276–89.CrossRefGoogle Scholar
  57. 57.
    Ossman WA, Wilson KG, Storaasli RD, McNeill JW. A preliminary investigation of the use of Acceptance and Commitment Therapy in a group treatment for social phobia. Int J Psychol Psycholog Ther. 2006;6(3):397–416.Google Scholar
  58. 58.
    Dalrymple KL, Herbert JD. Acceptance and commitment therapy for generalized social anxiety disorder: A pilot study. Behav Modif. 2007;31(5):543–68.PubMedCrossRefGoogle Scholar
  59. 59.
    Kim YW, Lee SH, Choi TK, et al. Effectiveness of mindfulness-based cognitive therapy as an adjuvant to pharmachotherapy in patients with panic disorder or generalized anxiety disorder. Depress Anxiety. 2009;26(7):601–6.PubMedCrossRefGoogle Scholar
  60. 60.
    Meuret AE, Twohig MP, Rosenfield D, et al. Brief acceptance and commitment therapy and exposure for panic disorder: A pilot study. Cogn Behav Pract. 2012;19(4):606–18.CrossRefGoogle Scholar
  61. 61.
    Niles BL, Klunk-Gillis J, Ryngala DJ, et al. Comparing mindfulness and psychoeducation treatments for combat-related PTSD using a telehealth approach. Psychol Trauma: Theory Res Pract Policy. 2012;4(5):538–47.CrossRefGoogle Scholar
  62. 62.
    • King AP, Erickson TM, Giardino ND, et al. A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Depress Anxiety. 2013;30(7):638–45. In this pilot study (N = 37), participants with chronic PTSD were consecutively assigned to an adapted MBCT for combat veterans or treatment as usual. Analyses indicated significant improvements in clinician-rated PTSD symptoms in the MBCT condition but not treatment as usual, with significant differences between change in the two conditions. The sizable improvements among these veterans with chronic PTSD are encouraging and suggest that future research on this adapted MBCT are warranted.PubMedCrossRefGoogle Scholar
  63. 63.
    Blevins D, Roca JV, Spencer T. Life guard: Evaluation of an ACT-based workshop to facilitate reintegration of OIF/OEF veterans. Professional Psychology: Research and Practice. 2011;42(1):32–9.CrossRefGoogle Scholar
  64. 64.
    Kearney DJ, McDermott K, Malte C, et al. Association of participation in a mindfulness program with measures of PTSD, depression and quality of life in a veteran sample. J Clin Psychol. 2012;68(1):101–16.PubMedCrossRefGoogle Scholar
  65. 65.
    Kimbrough E, Magyari T, Langenberg P, et al. Mindfulness intervention for child abuse survivors. J Clin Psychol. 2010;66(1):17–33.PubMedGoogle Scholar
  66. 66.
    Steil R, Dyer A, Priebe K, et al. Dialectical behavior therapy for posttraumatic stress disorder related to childhood sexual abuse: a pilot study of an intensive residential treatment program. J Trauma Stress. 2011;24(1):102–6.PubMedCrossRefGoogle Scholar
  67. 67.
    Hofmann SG, Sawyer AT, Witt AA, Oh D. The effects of mindfulness-based therapy on anxiety and depression: A meta-analytic review. J Consult Clin Psychol. 2010;78(2):169–83.PubMedCrossRefGoogle Scholar
  68. 68.
    Treanor M, Erisman SM, Salters-Pedneault K, et al. Acceptance-based behavioral therapy for GAD: effects on outcomes from three theoretical models. Depress Anxiety. 2011;28(2):127–36.PubMedCrossRefGoogle Scholar
  69. 69.
    Hayes SA, Orsillo SM, Roemer L. Changes in proposed mechanisms of action during an acceptance-based behavior therapy for generalized anxiety disorder. Behav Res Ther. 2010;48(3):238–45.PubMedCrossRefGoogle Scholar
  70. 70.
    Arch JJ, Craske MG. Acceptance and commitment therapy and cognitive behavioral therapy for anxiety disorders: different treatments, similar mechanisms? Clin Psychol Sci Pract. 2008;15(4):263–79.CrossRefGoogle Scholar
  71. 71.
    Fresco DM, Segal ZV, Buis T, Kennedy S. Relationship of posttreatment decentering and cognitive reactivity to relapse in major depression. J Consult Clin Psychol. 2007;75(3):447–55.PubMedCrossRefGoogle Scholar
  72. 72.
    Bieling PJ, Hawley LL, Bloch RT, et al. Treatment-specific changes in decentering following mindfulness-based cognitive therapy versus antidepressant medication or placebo for prevention of depressive relapse. J Consult Clin Psychol. 2012;80(3):365–72.PubMedCrossRefGoogle Scholar
  73. 73.
    Arch JJ, Wolitzky-Taylor KB, Eifert GH, et al. Longitudinal treatment mediation of traditional cognitive behavioral therapy and acceptance and commitment therapy for anxiety disorders. Behav Res Ther. 2012;50(7–8):469–78.PubMedCrossRefGoogle Scholar
  74. 74.
    Hayes-Skelton SA, Roemer L, Orsillo SM. Decentering as a common mechanism across two behavioral treatments for generalized anxiety disorder. In: SA Hayes-Skelton (Chair), Processes and mechanisms of action in a randomized controlled trial of two behavioral therapies for generalized anxiety disorder. Presented at the annual meeting of the Society for Psychotherapy Research. Virginia Beach, VA; 2012.Google Scholar
  75. 75.
    Nhat Hanh T. Peace is every step: The path of mindfulness in everyday life. Edited by Kotler A. New York: Bantam Books; 1992.Google Scholar
  76. 76.
    Orsillo SM, Roemer L. The mindful way through anxiety: Break free from chronic worry and reclaim your life. New York: Guilford Press; 2011.Google Scholar
  77. 77.
    The mindful way through anxiety: Break free from chronic worry and reclaim your life. Available at: Accessed July 2013.
  78. 78.
    Fuchs C, Lee JK, Roemer L, Orsillo SM. Using mindfulness-and acceptance-based treatments with clients from nondominant cultural and/or marginalized backgrounds: Clinical considerations, meta-analysis findings, and introduction to the special series: Clinical considerations in using acceptance-and mindfulness-based treatments with diverse populations. Cogn Behav Pract. 2013;20(1):1–12.CrossRefGoogle Scholar
  79. 79.
    Sobczak LR, West LM. Clinical considerations in using mindfulness-and acceptance-based approaches with diverse populations: Addressing challenges in service delivery in diverse community settings. Cogn Behav Pract. 2013, In press.Google Scholar
  80. 80.
    Woidneck MR, Pratt KM, Gundy JM, et al. Exploring cultural competence in acceptance and commitment therapy outcomes. Professional Psychology: Research and Practice. 2012;43(3):227–33.CrossRefGoogle Scholar
  81. 81.
    Fuchs C, West L, Graham JR, et al. Exploring the acceptability of two behavior therapies for GAD among individuals from nondominant cultural backgrounds. In SM Orsillo (Chair), Acceptance-based behavioral therapy compared to applied relaxation in the treatment of GAD. Presented at the annual meeting of the Association for Behavioral and Cognitive Therapies. National Harbor, MD; 2012.Google Scholar
  82. 82.
    Graham JR, West L, Roemer L. The experience of racism and anxiety symptoms in an African American Sample: Moderating effects of trait mindfulness. Mindfulness 2013, In press.Google Scholar
  83. 83.
    West LM, Graham JR, Roemer L. Functioning in the face of racism: Preliminary findings of the buffering role of values clarification in a Black American sample. J Context Behav Sci. 2013, In press.Google Scholar
  84. 84.
    Goisman RM, Warshaw MG, Keller MB. Psychosocial treatment prescriptions for generalized anxiety disorder, panic disorder, and social phobia, 1991-1996. Am J Psychiatry. 1999;156(11):1819–21.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Lizabeth Roemer
    • 1
  • Sarah K. Williston
    • 1
  • Elizabeth H. Eustis
    • 1
  • Susan M. Orsillo
    • 2
  1. 1.University of Massachusetts BostonBostonUSA
  2. 2.Suffolk UniversityBostonUSA

Personalised recommendations