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

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.

This is a preview of subscription content, access via your institution.

References

  1. 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.

    PubMed  Article  Google Scholar 

  2. 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.

    Google Scholar 

  3. 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.

    Article  Google Scholar 

  4. 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.

    PubMed  Article  Google Scholar 

  5. 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.

    PubMed  Article  Google Scholar 

  6. Cukor, J., Spitalnick, J., Difede, J. A., Rizzo, A., & Rothbaum, B. O. (2009). Emerging treatments for PTSD. Clinical Psychology Review, 29(8), 715–726.

    PubMed  Article  Google Scholar 

  7. 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.

    Google Scholar 

  8. 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.

    PubMed  Article  CAS  Google Scholar 

  9. 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.

    Google Scholar 

  10. 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.

    Google Scholar 

  11. 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.

    PubMed  Article  Google Scholar 

  12. 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.

    Google Scholar 

  13. 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.

    PubMed  Article  Google Scholar 

  14. Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press.

    Google Scholar 

  15. 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.

    PubMed  Article  CAS  Google Scholar 

  16. 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.

    PubMed  Article  Google Scholar 

  17. 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.

  18. 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.

    PubMed  Article  Google Scholar 

  19. 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.

    PubMed  Article  Google Scholar 

  20. 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.

    Article  Google Scholar 

  21. 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.

    Google Scholar 

  22. 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.

    PubMed  Article  Google Scholar 

  23. 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.

    Google Scholar 

  24. 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.

    PubMed  Article  Google Scholar 

  25. Orsillo, S. M., & Batten, S. V. (2005). Acceptance and Commitment Therapy in the treatment of posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

    PubMed  Article  Google Scholar 

  26. 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.

    Article  Google Scholar 

  27. 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.

    PubMed  Article  Google Scholar 

  28. 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.

    PubMed  Article  Google Scholar 

  29. 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.

    PubMed  Article  Google Scholar 

  30. Shipherd, J. C., & Beck, J. G. (2005). The role of thought suppression in posttraumatic stress disorder. Behavior Therapy, 36, 277–287.

    Article  Google Scholar 

  31. 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.

    PubMed  Article  Google Scholar 

  32. 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.

    Article  Google Scholar 

  33. 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.

    PubMed  Article  Google Scholar 

  34. 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.

    Google Scholar 

  35. 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.

    PubMed  Article  Google Scholar 

  36. 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.

    Google Scholar 

Download references

Acknowledgments

We would like to thank Amy Wagner and Michael Twohig for reading and commenting upon earlier drafts of this manuscript. We would also like to thank Monica Bahan for proofreading the final draft.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Brian L. Thompson.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Thompson, B.L., Luoma, J.B. & LeJeune, J.T. Using Acceptance and Commitment Therapy to Guide Exposure-Based Interventions for Posttraumatic Stress Disorder. J Contemp Psychother 43, 133–140 (2013). https://doi.org/10.1007/s10879-013-9233-0

Download citation

Keywords

  • Posttraumatic stress disorder
  • Exposure
  • Acceptance and commitment therapy
  • Prolonged exposure