Acceptance and Commitment Therapy as a Treatment for Anxiety and Depression: A Review

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Key points

  • Acceptance and commitment therapy (ACT) is a modern form of cognitive behavioral therapy based on a distinct philosophy (functional contextualism) and basic science of cognition (relational frame theory).

  • This article reviews the core features of ACT’s theoretic model of psychopathology and treatment as well as its therapeutic approach. It then provides a systematic review of randomized controlled trials (RCTs) evaluating ACT for depression and anxiety disorders.

  • Summarizing across a total of 36

Contextual Behavioral Science

CBS references a specific approach to science grounded in functional contextualism and behavior analysis. CBS focuses on the role of context in understanding and influencing human behavior, with a reticulated approach that integrates basic and applied scientific activities. A book-length review of CBS exists.5

Functional Contextualism

Clarifying philosophic assumptions is critical for ensuring the coherence and effectiveness of a program of research,6 as well as understanding differences between therapeutic approaches.7

Psychological flexibility and anxiety and depression

Like many forms of cognitive behavior therapy, ACT conceptualizations are function based, not topography based. ACT is an intervention for issues in which psychological inflexibility is a large factor in the disorder. Thus, a functional assessment is necessary to determine if psychological inflexibility has a large role in any particular case of anxiety or depression, but it is very likely that it would be the case. There are book-length discussions of ACT for anxiety16 and depression,5 and the

Anxiety disorders

The ultimate goal of ACT for anxiety disorders is to help those in treatment function better with the anxiety (or related symptoms) that they are experiencing. Learning how to function with these inner experiences (eg, worry in GAD, obsessions in obsessive compulsive disorder [OCD]) is not a means to necessarily lessen those experiences; it is the process through which clients are able to function better. When anxiety is experienced from a psychologically flexible posture, it has less impact on

Mixed anxiety

Starting with mixed anxiety disorders is appropriate because ACT has always been a unified treatment protocol for issues in which psychological inflexibility is a core concern. RCTs have shown the utility of ACT as administered by student therapists at a college counseling center for clients with anxiety and depression,19 in a large well-controlled RCT,20 for children,21 and finally in a bibliotherapy format.22 Additionally, a Web-based intervention for college students with mixed issues also

Generalized anxiety disorder

Most of the research on ACT for GAD comes from the work of Roemer and Orsillo, who named their treatment acceptance-based behavior therapy (ABBT) rather than ACT because it is informed by multiple avenues of research. Their work is commonly included in reviews because ABBT shares techniques and processes of changes with ACT.17 In their first work, Roemer and Orsillo26 tested ABBT in an open trial with 16 adults diagnosed with GAD. Results were promising, with large effect sizes at post and

Panic disorder

In a unique open trial, the utility of exposure exercises done from an ACT standpoint were tested with 11 adults diagnosed with panic disorder.34 Each adult participated in 4 sessions of ACT, then 6 sessions of self-guided exposure exercises. They were asked to use only the ACT training they had received to guide their exposure work. A significant decrease in panic disorder was seen after the first 4 sessions, with additional significant gains found in the following 6 sessions. Eight of the 11

Social anxiety disorder

A study so small (n = 11) that randomization could not be used showed equivalent results for group ACT and group CBT.36 In addition, there have been 4 open trials evaluating ACT in a face-to-face therapy format.37, 38, 39, 40 Furthermore, Yuen and colleagues41 tested ACT for social anxiety when delivered through a virtual environment and using video-conferencing software.42 In addition to these 7 uncontrolled studies, there have been 5 RCTs of ACT. Three of these were compared with WLs,43, 44,

Obsessive compulsive disorder

ACT as a treatment for OCD has been tested in handful of single case designs.48, 49, 50, 51 This includes OCD in general,50 scrupulsosity,49 and child and adolescent OCD.48, 51 The first randomized trial of ACT compared an 8-week protocol with an active control.52 Since then, researchers out of Iran have continued much of this work and have compared this protocol with a long list of control conditions.53, 54, 55 Their work is interesting, as it shows the protocol can be useful across cultures

Health anxiety and specific phobia

An open trial showed strong results with a 49% reduction in health anxiety.57 This was followed by an RCT comparing ACT for health anxiety with a WL, with positive results.58 Two studies tested ACT protocols for individuals with school-related anxiety. In the first study of ACT for math anxiety, 24 college students were randomized to ACT or systematic desensitization delivered over 6 weeks.59 The conditions had equivalent effects on math anxiety. In the second study, 16 students were assigned

Depressive disorders

Depression was one of the first clinical problems evaluated with ACT61 and one of the most studied problems since, with 17 RCTs published over the past 3 decades. ACT overlaps with behavioral activation in emphasizing a goal of increasing engagement in meaningful patterns of activity among depressed clients. Similar to anxiety disorders, the goals of ACT for depression are not to eliminate depression per se, but to increase clients’ engagement in effective, valued activities in their life. Yet,

Depression randomized controlled trial comparison conditions

Several RCTs have been conducted comparing ACT with various control conditions, including WLs, treatment-as-usual (TAU), placebo conditions, and CT/CBT. Seven RCTs compared ACT with WL conditions on depression, with every study showing that ACT improves depression relative to no treatment up to 6-month follow-up. Between-condition effect sizes ranged widely across studies (Cohen’s d ranging from 0.32 to 1.18).

Five RCTs compared ACT with TAU on depression, with 4 of 5 studies showing ACT

Depression randomized controlled trial sample types

ACT has been adopted internationally, which is demonstrated by the range of countries that have published RCTs on ACT for depression (even when this article was restricted to English-language publications). Overall, 8 depression RCTs were conducted in Europe (3 in the Netherlands, 2 in Finland, 2 in Sweden, 1 in Spain), 6 in the United States, 2 in Australia, and 1 in Iran. An additional 5 depression RCTs were excluded because they were not available in English: 1 from Iran,62 1 from China,63

Depression randomized controlled trial treatment formats

Individual (one-on-one) therapy is the most common treatment format ACT has been evaluated in for depression, with a total of 7 RCTs. These studies found ACT outperforms WL, TAU, and a minimal support group, with largely equivalent effects relative to CT/CBT. Among studies reporting rates, ACT response rates ranged from 50% to 58%, with depression recovery rates ranging from 24% to 82%.

ACT has also been evaluated in 6 RCTs in a group format, one of which used a single-day workshop format.67

Depression randomized controlled trial outcomes with positive mental health and quality of life

Although showing ACT reduces depressive symptoms helps demonstrate its relevance for depressed populations, it is important to also consider whether this treatment improves positive mental health and quality of life, which are also important outcomes that fit particularly well with the goals of ACT. Nine of the 17 RCTs evaluated the impact of treatment on quality of life (including quality of life, positive mental health, and/or functioning). ACT improved quality of life relative to WL in 4 of

Depression randomized controlled trial processes of change

Twelve of 17 depression ACT RCTs examined processes of change (psychological flexibility and its specific component processes). Studies found that ACT produced greater improvements in psychological flexibility relative to WL in 3 RCTs (Cohen’s d ranging from 0.50 to 0.67), relative to TAU in 3 RCTs (d ranging from 0.64 to 0.76), and relative to placebo conditions (expressive writing d = 0.43, minimal support group d = 0.77). However, only 2 of 4 RCTs found that ACT improved psychological

Summary

The goal for this article was to present the model from which ACT research occurs as well as provide an exhaustive list of all published work on ACT for anxiety disorders and depression, as ACT is a unified treatment protocol and there are a growing number of trials testing ACT across anxiety and depression issues. This base of knowledge provides initial support for ACT. There is a larger amount of work on ACT for GAD, social anxiety, and OCD. The work in panic disorder and health anxiety is in

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