Acceptance-Based Behavioral Therapy for Generalized Anxiety Disorder

ABBT is consistent with ACT, as it is with other mindfulness and acceptance-based behavioral treatments. ABBT was initially developed specifically to target GAD and comorbid disorders and drew upon existing evidence-based treatments for GAD. As a result, we generally do more psychoeducation than many ACT practitioners do, and we focus specifically on the nature of worry and how to help clients reduce their entanglement with worry. But we incorporate many aspects of ACT and resonate with that approach to treatment.

Thank you so much for your concern for students during these challenging times. I think that teachers can notice when students seem to be lost in their “what ifs” about their school work or other aspects of their lives, validate that the uncertainty and difficulty of our current context make it easy to get lost in our thoughts about what might go wrong and help them to refocus on what they are doing, what gives them a sense of purpose, and what matters to them. It can be helpful to share that being on edge or worried are human and natural responses and that it can take practice to put down that kind of reactivity and more fully engage in what we are doing. Although this video is from the beginning of the pandemic, so it’s a little outdated, it’s a really nice overview of an acceptance-based response (by Russ Harris https://psychwire.com/ask/profiles/ls7ym2/russ-harris, an ACT therapist) - https://www.youtube.com/watch?v=BmvNCdpHUYM

Acceptance-based approaches have also been used, typically integrated with cognitive behavioral elements, to treat other anxiety disorders, so mindfulness and acceptance can be relevant there as well. However, Sue Orsillo and I turned to these approaches for GAD in particular because other anxiety disorders have more focused avoidance – of social situations, one’s own physical symptoms, etc. – while in GAD there aren’t the same clear targets for exposure-based strategies. Instead, it seems like avoidance of internal distress more broadly may be the central feature. This then lends itself to mindfulness and acceptance as a kind of exposure strategy. In addition, the worry that characterizes GAD is difficult to stop with control efforts, and so also lends itself to mindfulness practice so that clients can notice the thoughts and not follow them in quite the same way.

The practices of identifying thoughts, asking questions about them to increase cognitive flexibility, and even identifying the distortions tied to them, again to loosen the rigidity of the thought, are all consistent with an acceptance-based behavioral approach. The key distinction is not to help the client attach to new thoughts in place of the old. When I was trained in cognitive restructuring, I was encouraged to help clients think of 5 possible thoughts, or 10, to help them see that a thought isn’t necessarily true. This practice also cultivates decentering (a central construct in acceptance-based approaches that comes originally from cognitive therapy) or defusion (a similar concept from ACT). So we can use the strategies of cognitive restructuring with a goal of loosening associations and seeing thoughts just as thoughts, not as self-existent truths and that is consistent with these approaches to therapy.

Given the existing outcome data, ABBT is a reasonable first line treatment for GAD, as is CBT. Both have demonstrated efficacy for both GAD and comorbid conditions. I would particularly lean toward using ABBT when an experiential avoidance model explains their presenting problems well, and mindfulness and acceptance-based emotional exposure seem to be particularly relevant to their clinical presentation (e.g., they are clearly emotionally avoidant, not staying in the present, and these rigid habits are interfering with their lives). I would also choose ABBT if a client had a particularly rigid cognitive style that might get caught up in cognitive restructuring, furthering their emotional avoidance rather than targeting it.

Inviting a difficulty in and working it through the body, from MBCT, is a particularly effective practice for acceptance (http://mindfulwaythroughanxiety.com/exercises/ has recordings of exercises we regularly use). In this exercise, clients bring up a distressing memory and then practice accepting the reactions it elicits in their body. This practice helps to build the ability to respond this way in the moment when challenges arise. For uncertainty, the Mountain Meditation, by Jon Kabat-Zinn, can be helpful as it helps clients to connect to the ever changing nature of things, which reduces some of the distress associated with uncertainty. I also often draw on my mentor Tom Borkovec’s work and talk to clients about how surprise can be better than suspense – when we don’t know what is coming next, we allow for a host of possibilities, while when we use our minds to try to create certainty (e.g., through worry), we live instead with a sense of dread and suspense. So we can recognize that uncertainty is unsettling while also recognizing that it is freeing to truly see uncertainty rather than creating an illusion of certainty.

We do use formal practices, usually relatively brief practices to help clients develop the skill of mindful responding (http://mindfulwaythroughanxiety.com/exercises/). We do these with clients in session and then ask them to practice outside of the session. When clients find it difficult to practice, we try to problem solve with them to help them find time, space, and ways to remember their practice. For instance, we might suggest they wake up 10 minutes early and practice for 10 minutes. When clients can’t find time for formal practice, we help them to plan informal practices, such as washing the dishes, riding the subway, or riding the elevator mindfully. We provide a rationale for the practice – it is hard to learn new skills, and practice when we are in a relatively neutral state will help us to use these skills when we are more distressed. We have found that clients who practice informally have sustained improvements from treatment (https://www.researchgate.net/publication/262878331_Relationships_Between_Amount_of_Post-Intervention_of_Mindfulness_Practice_and_Follow-up_Outcome_Variables_in_an_Acceptance-Based_Behavior_Therapy_for_Generalized_Anxiety_Disorder_The_Importance_of_Inf)

Yes, emotion dysregulation is a central feature of GAD (and many distress disorders), as Doug Mennin and colleagues and others have shown. Mindfulness and acceptance practices both target emotion dysregulation by helping clients to see their emotions as naturally occurring responses that do not have to be avoided and by encouraging meaningful actions regardless of emotional state. These practices reduce emotional reactivity, which is a central aspect of dysregulation. And values-based action helps to override emotion-driven behaviors, another central aspect of dysregulation. We use a slightly altered version of relaxation practice that emphasizes awareness and gentle movement toward reduced tension rather than trying to get to an end-state of relaxation, (several examples are recorded at the bottom of this page: http://mindfulwaythroughanxiety.com/exercises/). Relaxation can be an excellent way to reduce reactivity and increase values-driven actions, as long as clients don’t come to believe they have to be in a certain state in order to do what is important to them. Sue Orsillo and I describe these integrations in our Acceptance-based Behavioral Therapy book published by Guilford in 2020 (https://www.guilford.com/books/Acceptance-Based-Behavioral-Therapy/Roemer-Orsillo/9781462544875).