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Anxiety and trauma-related disorders are described in terms of maladaptive response patterns that largely consist of avoidance of various threat cues. Following an introduction to the classes of disorders and primary behavioral processes that maintain them, the authors briefly review traditional conceptualizations of etiology and associated treatments, followed by a theoretical rationale that underscores acceptance and commitment therapy (ACT) as a conceptually sound and comprehensive treatment for these disorders. An overview of empirical research supporting the efficacy of ACT for these disorders is then provided, followed by clinical considerations and examples of implementation as they relate to specific disorders within the overarching classes. Lastly, the authors discuss limitations in the extant literature and provide recommendations for future research, including a shift to a more process-based approach of conceptualization and treatment of these classes of disorders.

Objectives: Most research on mindfulness and meditation has focused on structured therapeutic interventions, such as mindfulness-based stress reduction, or meditation retreats. Such programs have received moderate empirical support for improving psychological outcomes in clinical and nonclinical populations, but there remains a paucity of research on intensive or long-term mindfulness or meditation programs for experienced practitioners, especially those that incorporate Buddhist teachings. The purpose of the current study was to investigate the effects of a long-term integrated mindfulness/meditation and Buddhism program, Dharma in Daily Life (DIDL). Methods: Well-being, quality of life, valued living, and theorized processes of change were measured using a naturalistic, quasi-experimental design over the course of the 2-year program and 6-month follow-up. Participants included 17 individuals enrolled in the program and 14 individuals recruited from community meditation groups. Results: Participation in the program predicted increases in subjective well-being and mindfulness over time compared to the control group. Regardless of condition, frequency of meditation predicted lower psychological inflexibility and higher mindfulness, well-being, and progress toward values. Length of meditation session predicted a greater ability to observe experience, and prior meditation experience predicted greater non-reactivity to experience. Conclusions: Although preliminary, results suggest that participation in a long-term integrated mindfulness/meditation and Buddhism program may positively impact mindfulness and general well-being. Frequency of meditation sessions appears to be a particularly important variable. These findings warrant further investigation of such programs and practice parameters, as well as how each may affect key outcomes.

The feasibility of implicitly assessing medical student burnout was explored, using the Implicit Relational Assessment Procedure (IRAP), to measure longitudinal student burnout over the first two years of medical school and directly comparing it with an existing explicit measure of burnout (Maslach Burnout Inventory; MBI). Three successive cohorts of medical students completed both implicit and explicit measures of burnout at several time points during their first two years of medical school. Both assessments were conducted via the internet within a one-week period during the first week of medical school, the end of the first year of medical school, and the end of the second year, though not all cohorts were able to complete the assessments at all time points. Mixed linear models were used to compare the two measures directly, as well as to evaluate changes over time in each measure separately. Minimal correspondence was observed between the implicit and explicit measures of burnout on a within-subject basis. However, when analyzed separately, all subscales of both measures detected significant change over time in the direction of greater levels of burnout, particularly during the first year of medical school. These results provide preliminary evidence the IRAP is able to assess implicit attitudes related to burnout among medical students, though additional research is needed. The IRAP detected consistent improvements in positive implicit attitudes toward medical training during students' second year of medical school, which was not detected by the MBI. Possible implications of these findings are discussed.

Excessive fear and avoidance in relatively safe situations can lead to a narrowing of one's behavioral repertoire and less engagement with valued aspects of living. Ultimately, these processes can reach clinical levels, as seen in anxiety, trauma, and obsessive-compulsive disorders. Research on the basic behavioral processes underlying successful treatment with exposure therapy is growing, yet little is known about the mechanisms contributing to clinical relapse. Until recently, these mechanisms have largely been conceptualized in terms of Pavlovian return of fear, with relatively little research into operant processes. In the current paper, we briefly review translational research in anxiety disorders and the connections between fear and avoidance, focusing on recent work in the acquisition, extinction, and relapse of avoidance behavior and the generalization of this learning through arbitrary symbolic relations. We then introduce one possible treatment approach to mitigating clinical relapse, acceptance and commitment therapy (ACT), and provide a conceptual analysis for why ACT may be especially well-situated to address this issue. Finally, we end with potential directions for future research on treatment and relapse of anxiety disorders.

Research has demonstrated that values and acceptance interventions can increase distress tolerance, but the individual contribution of each remains unclear. The current study examined the isolated effect of a values intervention on immersion time in a cold pressor. Participants randomized to Values ( n = 18) and Control ( n = 14) conditions completed two cold pressor tasks, separated by a 30-min values or control intervention. Immersion time increased 51.06 s for participants in the Values condition and decreased by 10.79 s for those in the Control condition. Increases in self-reported pain and distress predicted decreases in immersion time for Control, but not Values, participants. The best-fitting model accounted for 39% of the variance in immersion time change. Results suggest that a brief isolated values exercise can be used to improve distress tolerance despite increased perceptions of pain and distress, such that values alone may be sufficient to facilitate openness to difficult experiences.

Objective The purpose of this study was to examine the psychometric properties of the Body Image-Acceptance and Action Questionnaire in a severe eating disorder population, as previous validation has occurred only with nonclinical samples. Method Data on body image psychological flexibility, general psychological flexibility, eating disorder severity, and other related constructs were gathered from 72 adolescent and 60 adult female, residential patients diagnosed with an eating disorder. Psychometrics were examined through the use of exploratory and confirmatory factor analyses, Cronbach's alpha, correlations, and hierarchical multiple regressions to assess model fit, reliability, and validity. Results The BI-AAQ demonstrated excellent convergent, discriminant, and incremental validity as well as excellent internal reliability, however, factor analyses resulted in overall poor model fit. Removal of item 6 from the BI-AAQ resulted in improved psychometric properties in all regards, yet still demonstrated overall poor model fit. Discussion This study suggests that the BI-AAQ is psychometrically sound in many areas and provides some clinical utility; however, it may be somewhat problematic when used in severe eating disorder populations. When using the measure in clinical settings, removal of item 6 is recommend. Recommendations for future measurement and utilization of body image flexibility are discussed.

Despite the success of exposure-based psychotherapies in anxiety treatment, relapse remains problematic. Resurgence, the return of previously eliminated behavior following the elimination of an alternative source of reinforcement, is a promising model of operant relapse. Nonhuman resurgence research has shown that higher rates of alternative reinforcement result in faster, more comprehensive suppression of target behavior, but also in greater resurgence when alternative reinforcement is eliminated. This study investigated rich and lean rates of alternative reinforcement on response suppression and resurgence in typically developing humans. In Phase 1, three groups (Rich, n = 18; Lean, n = 18; Control, n = 10) acquired the target response. In Phase 2, target responding was extinguished and alternative reinforcement delivered on RI 1 s, RI 3 s, and extinction schedules, respectively. Resurgence was assessed during Phase 3 under extinction conditions for all groups. Target responding was suppressed most thoroughly in Rich and partially in Lean. Target responding resurged in the Rich and Lean groups, but not in the Control group. Between groups, resurgence was more pronounced in the Rich group than the Lean and Control groups. Clinical implications of these findings, including care on the part of clinicians when identifying alternative sources of reinforcement, are discussed.

Our commentary on the article by Fixsen and Blase (2018) highlights some of the converging and diverging strategies between the Teaching-Family Model (TFM) and the dissemination and implementation of acceptance and commitment therapy (ACT). We focus primarily on the potential benefits of flexibility in areas including theory, methodology, and intervention protocols. Examples include the use of middle level terms, randomized controlled trial methods, protocols focused more on function than specific topography, and an open, collaborative approach to dissemination. We also note how this broader set of strategies can be made coherent and progressive through a careful connection back to contextual behavioral science as an underlying scientific strategy and its associated philosophy of science. We hope this approach contributes to an ongoing conversation on potentially useful strategies for dissemination and implementation.

This study examined the transdiagnostic effect of acceptance and commitment therapy (ACT) on impulsive decision-making in a community sample. A total of 40 adults were randomized to eight individual sessions of ACT or an inactive control. Participants completed pre-, mid-, and post-assessments for psychological symptoms; overall behavior change; valued living; delay discounting; psychological flexibility; and distress tolerance. Data were analyzed with multilevel modeling of growth curves. Significant interaction effects of time and condition were observed for psychological flexibility, distress tolerance, psychological symptoms, and the obstruction subscale of valued living. No significant interaction effect was found for two delay discounting tasks nor the progress subscale of valued living. The ACT condition had a significantly larger reduction of problem behavior at post-assessment. The results support use of ACT as a transdiagnostic treatment for impulsive behaviors. The lack of change in delay discounting contrasts previous research.

The present study evaluated moderators and processes of change in a randomized controlled trial comparing exposure and response prevention (ERP) delivered from a traditional framework versus ERP from an acceptance and commitment therapy framework (ACT + ERP) for obsessive-compulsive disorder (OCD). This paper presents baseline, weekly session, posttreatment, and follow-up data from the study. We examined (a) moderation effects of anxiety, depression, psychological inflexibility, and interpretation of intrusions and (b) the role of psychological inflexibility and interpretation of intrusions respectively as processes of change. Participants with less dysfunctional appraisals at pretreatment performed consistently better in ERP relative to ACT + ERP. In process analyses, psychological inflexibility and interpretation of intrusions positively influenced OCD severity over time in both conditions but OCD symptom severity also positively influenced psychological inflexibility and interpretation of intrusions in both conditions. Furthermore, whereas OCD symptom severity strongly and positively predicted dysfunctional appraisals over the course of treatment in ERP, symptom severity had a weaker positive effect on dysfunctional appraisals in ACT + ERP. Clinical and theoretical implications as well as study limitations are discussed.

The objective of this study was to test whether treatment acceptability, exposure engagement, and completion rates could be increased by integrating acceptance and commitment therapy (ACT) with traditional exposure and response prevention (ERP). 58 adults (68% female) diagnosed with obsessive-compulsive disorder (OCD; M age = 27, 80% white) engaged in a multisite randomized controlled trial of 16 individual twice-weekly sessions of either ERP or ACT + ERP. Assessors unaware of treatment condition administered assessments of OCD, depression, psychological flexibility, and obsessional beliefs at pretreatment, posttreatment, and six-month follow-up. Treatment acceptability, credibility/expectancy, and exposure engagement were also assessed. Exposure engagement was high in both conditions and there were no significant differences in exposure engagement, treatment acceptability, or dropout rates between ACT + ERP and ERP. OCD symptoms, depression, psychological inflexibility, and obsessional beliefs decreased significantly at posttreatment and were maintained at follow-up in both conditions. No between-group differences in outcome were observed using intent to treat and predicted data from multilevel modeling. ACT + ERP and ERP were both highly effective treatments for OCD, and no differences were found in outcomes, processes of change, acceptability, or exposure engagement.

This article addresses the use of exposure therapy for OCD as informed by an acceptance and commitment therapy (ACT) framework. The model on which ACT is based is covered, including its philosophy, basic research, targeted process of change, individual treatment components, and general manual. Specific suggestions for how to prepare, select, set up, and conclude exposure exercises from an ACT perspective are included and illustrated using the case of Monica as an example. Empirical support for this approach is briefly covered.

Current versions of cognitive behavior therapy have been shown to be effective for obsessive compulsive and related disorders. Recently there has been an increased shift toward targeting the function of inner experiences (e.g. obsessions, urges to hair pull) over their form or content. A handful of treatments target the function of inner experiences to such a large extent that they might be considered a shift. This paper reviews these treatments and their supporting data in the treatment of obsessive compulsive and related disorders.

This chapter summarizes mindfulness-based therapies for observe-compulsive disorder (OCD). Mindfulness and acceptance interventions focus on the way in which individuals with OCD address or experience their obsessions, anxiety, uncertainty, and bodily sensations, and how this impacts their behavior. Mindfulness and acceptance interventions include a variety of procedures and treatment packages that center around the common goals of being open, aware, and present with emotional, cognitive, and bodily experiences that can otherwise derail intended actions. Although more evidence is needed, there is sufficient data to suggest that mindfulness and acceptance interventions are reasonable options for the treatment of OCD and related disorders. This chapter summarizes the theory and application of mindfulness and acceptance therapies and the data examining their use for OCD and related disorders.

The present study examined persistence and relapse of reinforced behavioral variability in pigeons. Pigeons emitted four‐response sequences across two keys. Sequences produced food according to a lag schedule, in which a response sequence was followed by food if it differed from a certain number of previous sequences. In Experiment 1, food was delivered for sequences that satisfied a lag schedule in both components of a multiple schedule. When reinforcement was removed for one component (i.e., extinction), levels of behavioral variability decreased for only that component. In Experiment 2, food was delivered for sequences satisfying a lag schedule in one component of a multiple schedule. In the other component, food was delivered at the same rate, but without the lag variability requirement (i.e., yoked). Following extinction, levels of behavioral variability returned to baseline for both components after response‐independent food delivery (i.e., reinstatement). In Experiment 3, one group of pigeons responded on a lag variability schedule, and the other group responded on a lag repetition schedule. For both groups, levels of behavioral variability increased when alternative reinforcement was suspended (i.e., resurgence). In each experiment, we observed some evidence for extinction‐induced response variability and for variability as an operant dimension of behavior.