3. COGNITIVE
BEHAVIOR
THERAPY

5. COGNITIVE
BEHAVIOR
THERAPY
Applying Empirically Supported
Techniques in Your Practice
Second Edition
Edited by
William O’Donohue
Jane E. Fisher
John Wiley & Sons, Inc.

6. This book is printed on acid-free paper.
Copyright  2008 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.
Published simultaneously in Canada.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any
means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under
Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the
Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center,
Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750–8400, fax (978) 676–8600, or on the web at
www.copyright.com. Requests to the Publisher for permission should be addressed to the Permissions
Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748–6011, fax (201) 748–6008.
Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in
preparing this book, they make no representations or warranties with respect to the accuracy or completeness of
the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a
particular purpose. No warranty may be created or extended by sales representatives or written sales materials.
The advice and strategies contained herein may not be suitable for your situation. You should consult with a
professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other
commercial damages, including but not limited to special, incidental, consequential, or other damages.
This publication is designed to provide accurate and authoritative information in regard to the subject matter
covered. It is sold with the understanding that the publisher is not engaged in rendering professional services. If
legal, accounting, medical, psychological or any other expert assistance is required, the services of a competent
professional person should be sought.
Designations used by companies to distinguish their products are often claimed as trademarks. In all instances
where John Wiley & Sons, Inc. is aware of a claim, the product names appear in initial capital or all capital letters.
Readers, however, should contact the appropriate companies for more complete information regarding
trademarks and registration.
For general information on our other products and services please contact our Customer Care Department within
the U.S. at (800) 762–2974, outside the United States at (317) 572–3993 or fax (317) 572–4002.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be
available in electronic books. For more information about Wiley products, visit our website at www.wiley.com.
Library of Congress Cataloging-in-Publication Data:
Cognitive behavior therapy : applying empirically supported techniques in your practice / edited by William
O’Donohue, Jane E. Fisher.–2nd ed.
p. ; cm.
Includes bibliographical references and indexes.
ISBN 978-0-470-22778-7 (cloth : alk. paper)
1. Cognitive therapy. I. O’Donohue, William T. II. Fisher, Jane E. (Jane Ellen), 1957-
[DNLM: 1. Cognitive Therapy–methods. 2. Mental Disorders–therapy. WM 425.5.C6 C67677 2009]
RC489.C63C6277 2009
616.89’1425–dc22
2008026325
Printed in the United States of America.
10 9 8 7 6 5 4 3 2 1

7. CONTENTS
Preface xiii
Acknowledgments xv
Contributors xvii
1 Introduction 1
William O’Donohue and Jane E. Fisher
2 Psychological Acceptance 4
James D. Herbert, Evan M. Forman, and Erica L. England
3 Anger (Negative Impulse) Control 17
Brad Donohue, Kendra Tracy, and Suzanne Gorney
4 Assertiveness Skills and the Management of Related Factors 26
Melanie P. Duckworth
5 Attribution Change 35
Rebecca S. Laird and Gerald I. Metalsky
6 Behavioral Activation for Depression 40
Christopher R. Martell
7 Response Chaining 46
W. Larry Williams and Eric Burkholder
8 Behavioral Contracting 53
Ramona Houmanfar, Kristen A. Maglieri, Horacio R. Roman, and Todd A. Ward
9 Bibliotherapy Utilizing CBT 60
Negar Nicole Jacobs
v

8. vi CONTENTS
10 Breathing Retraining and Diaphragmatic Breathing Techniques 68
Holly Hazlett-Stevens and Michelle G. Craske
11 Classroom Management 75
Steven G. Little and Angeleque Akin-Little
12 Cognitive Defusion 83
Jason B. Luoma and Steven C.Hayes
13 Cognitive Restructuring of the Disputing of Irrational Beliefs 91
Albert Ellis
14 Cognitive Restructuring: Behavioral Tests of Negative Cognitions 96
Keith S. Dobson and Kate E. Hamilton
15 Communication/Problem-Solving Skills Training 101
Pamella H. Oliver and Gayla Margolin
16 Compliance with Medical Regimens 109
Elaine M. Heiby and Maxwell R. Frank
17 Contingency Management Interventions 116
Claudia Drossel, Christina G. Garrison-Diehn, and Jane E. Fisher
18 Daily Behavior Report Cards: Home–School Contingency Management
Procedures 123
Mary Lou Kelley and Jennette L. Palcic
19 Dialectics in Cognitive and Behavior Therapy 132
Armida Rubio Fruzzetti and Alan E. Fruzzetti
20 Differential Reinforcement of Low-Rate Behavior 142
Mark Alavosius, Joseph Dagen, and William D. Newsome
21 Differential Reinforcement of Other Behavior and Differential Reinforcement
of Alternative Behavior 147
Michele D. Wallace and Adel C. Najdowski
22 Directed Masturbation: a Treatment of Female Orgasmic Disorder 158
Stephanie Both and Ellen Laan

9. CONTENTS vii
23 Distress Tolerance 167
Michael P. Twohig and Katherine A. Peterson
24 Emotion Regulation 174
Alan E. Fruzzetti, Wendy Crook, Karen M. Erikson, Jung Eun Lee,
and John M. Worrall
25 Encopresis: Biobehavioral Treatment 187
Patrick C. Friman, Jennifer Resetar, and Kim DeRuyk
26 Expressive Writing 197
Jenna L.Baddeley and James W. Pennebaker
27 Flooding 202
Lori A. Zoellner, Jonathan S. Abramowitz, Sally A. Moore, and David M. Slagle
28 Experimental Functional Analysis of Problem Behavior 211
James E. Carr, Linda A. LeBlanc, and Jessa R. Love
29 Functional Communication Training to Treat Challenging Behavior 222
V. Mark Durand and Eileen Merges
30 Functional Self-Instruction Training to Promote Generalized Learning 230
Frank R. Rusch and DouglasKostewicz
31 Group Interventions 236
Claudia Drossel
32 Habit Reversal Training 245
Amanda Nicolson Adams, Mark A. Adams, and Raymond G. Miltenberger
33 Harm Reduction 253
Arthur W. Blume and G. Alan Marlatt
34 Putting It on the Street: Homework in Cognitive Behavioral Therapy 260
Patricia Robinson
35 The Prolonged CS Exposure Techniques of Implosive (Flooding) Therapy 272
Donald J. Levis

10. viii CONTENTS
36 Cognitive Behavioral Treatment of Insomnia 283
Wilfred R. Pigeon and Michael L. Perlis
37 Interoceptive Exposure for Panic Disorder 296
John P. Forsyth, Tiffany Fus´ , and Dean T. Acheson
e
38 Live (In Vivo) Exposure 309
Holly Hazlett-Stevens and Michelle G. Craske
39 Applications of the Matching Law 317
John C. Borrero, Michelle A. Frank, and Nicole L. Hausman
40 Mindfulness Practice 327
Sona Dimidjian and Marsha M. Linehan
41 Moderate Drinking Training for Problem Drinkers 337
Frederick Rotgers
42 Multimodal Behavior Therapy 342
Arnold A. Lazarus
43 Positive Psychology: A Behavioral Conceptualization and Application to
Contemporary Behavior Therapy 347
Alyssa H. Kalata and Amy E. Naugle
44 Motivational Interviewing 357
Eric R. Levensky, Brian C. Kersh, Lavina L. Cavasos, and J. Annette Brooks
45 Noncontingent Reinforcement as a Treatment for Problem Behavior 367
Timothy R. Vollmer and Carrie S. W. Borrero
46 Pain Management 375
Robert J. Gatchel and Richard C. Robinson
47 Parent Training 383
Kevin J. Moore and Gerald R. Patterson
48 Self-Efficacy Interventions: Guided Mastery Therapy 390
Walter D. Scott and Daniel Cervone

11. CONTENTS ix
49 Positive Attention 396
Stephen R. Boggs and Sheila M. Eyberg
50 Problem-Solving Therapy 402
Arthur M. Nezu, Christine Maguth Nezu, and Mary McMurran
51 Punishment 408
David P. Wacker, Jay Harding, Wendy Berg, Linda J. Cooper-Brown,
and Anjali Barretto
52 Rapid Smoking 415
Elizabeth V. Gifford and Deacon Shoenberger
53 Relapse Prevention 422
Kirk A. B. Newring, Tamara M. Loverich, Cathi D. Harris, and Jennifer Wheeler
54 Relaxation 434
Kyle E. Ferguson and Rachel E. Sgambati
55 Response Prevention 445
Martin E. Franklin, Deborah A. Ledley and Edna B. Foa
56 Satiation Therapy 452
CrissaDraper
57 Identifying and Modifying Maladaptive Schemas 457
Cory F. Newman
58 Self-Management 466
Lynn P. Rehm and Jennifer H. Adams
59 Safety Training/Violence Prevention Using the SafeCare Parent
Training Model 473
Daniel J. Whitaker, Dan Crimmins, Anna Edwards, and John R. Lutzker
60 Self-Monitoring as a Treatment Vehicle 478
Kathryn L. Humphreys, Brian P. Marx, and Jennifer M. Lexington
61 Sensate Focus 486
Lisa Regev and Joel Schmidt

12. x CONTENTS
62 Shaping 493
Kyle E. Ferguson and Kim Christiansen
63 Social Skills Training 502
Chris Segrin
64 Squeeze Technique for the Treatment of Premature Ejaculation 510
Claudia Avina
65 Stimulus Control 516
Alan Poling and Scott T. Gaynor
66 Stimulus Preference Assessment 523
Jane E. Fisher, Jeffrey A. Buchanan, and Stacey Cherup-Leslie
67 Stress Inoculation Training 529
Donald Meichenbaum
68 Stress Management Intervention 533
Victoria E. Mercer
69 Systematic Desensitization 542
Lara S. Head and Alan M. Gross
70 Think-Aloud Techniques 550
Gerald C. Davison, Jennifer L. Best, and Marat Zanov
71 Time-Out, Time-In, and Task-Based Grounding 557
Patrick C. Friman
72 Guidelines for Developing and Managing a Token Economy 565
Patrick M. Ghezzi, Ginger R. Wilson, Rachel S. F. Tarbox, and Kenneth
R. MacAleese
73 Urge Surfing 571
Andy Lloyd
74 Validation Principles and Strategies 576
Kelly Koerner and Marsha M. Linehan

13. CONTENTS xi
75 Values Clarification 583
Michael P. Twohig and Jesse M. Crosby
Author Index 589
Subject Index 623

15. PREFACE
Over the last three decades there has been a significant increase in interest in cognitive behavior
therapy. This has occurred for several reasons: 1) Mounting experimental evidence supports the
effectiveness of cognitive behavioral therapy for certain psychological problems induding high
incidence problems such as depression and the anxiety disorders. The well-known Chambless report,
for example, identifies many cognitive behavioral therapies as being empirically supported. In fact,
cognitive behavioral techniques comprise most of the list. 2) Cognitive behavior therapy tends to be
relatively brief and often can be delivered in groups. Therefore it can be more cost-effective than some
alternatives and be seen to offer good value. These qualities have become particularly important in
the era of managed care with its emphasis upon cost containment. 3) Cognitive behavior therapy has
been applied with varying success to a wide variety of problems (see Fisher and O’Donohue, 2006
for over 70 behavioral health problems in which CBT can be considered an evidence based treatment.
Thus, it has considerable scope and utility for the practitioner in general practice or the professional
involved in the training of therapists. 4) Cognitive behavior therapy is a relatively straight forward
and clearly operationalized approach to psychotherapy. This does not mean that case formulation
or implementing these techniques is easy. However, CBT is more learnable that techniques such as
psychoanalysis or Gestalt therapy. 5) Cognitive behavioral therapy is a therapy system comprised of
many individual techniques, with researchers and practitioners constantly adding to this inventory.
A given behavior therapist, because of his or her specialty, may know or use only a small subset of
these. A clinician or clinical researcher may want to creatively combine individual techniques to treat
some intransigent problem or an unfamiliar or complicated clinical presentation.
This volume attempts to bring together all of the specific techniques of cognitive behavior therapy.
It does this in an ecumenical fashion. Historically, and currently, there are divisions inside behavior
therapy that this book attempts to ignore. For example, cognitive and more traditionally behavioral
techniques are included. This offended some prospective authors who were clearly warriors in the
cognitive-behavioral battle. We wanted to be inclusive, particularly because pragmatically the outcome
research favors both sides of this particular battle.
Our major interest in compiling this book was twofold: First we noted the lack of a volume
that provides detailed descriptions of the techniques of cognitive behavioral therapy. Many books
mentioned these but few described the techniques in detail. The absence of a comprehensive collection
of the methods of cognitive-behavior therapy creates a gap in the training of students and in the
faithful practice of cognitive behavior therapy. Second, with the increased interest in cognitive behavior
therapy, particularly by the payers in managed care, there has been an increasing bastardization of
behavior therapy. Some therapists are claiming they are administering some technique (e.g., relapse
prevention or contingency management) when they clearly are not. This phenomenon, in our
experience, rarely involves intentional deception but instead reflects an ignorance of the complexities
of faith-fully implementing these techniques. This book is aimed at reducing this problem.
There is an important question regarding the extent to which a clinician can faithfully implement
these techniques without a deeper understanding of behavior therapy. The evidence is not clear and of
course the question is actually more complicated. Perhaps a generically skilled therapist with certain
kinds of clients and certain kinds of techniques can implement the techniques well. On the other
hand, a less skilled therapist dealing with a complicated clinical presentation utilizing a more subtle
technique might not do so well. There is certainly a Gordon Paul type ultimate question lurking here.
Something like: ‘‘What kind of therapist, with what type of problem, using what kind of cognitive
xiii

16. xiv PREFACE
behavior therapy technique, with what kind of training, can have what kinds of effects. . .’’ With
the risk of being seen as self-promoting, the reader can learn about the learning and conditioning
underpinnings of many of thes techniques in O’Donohue (1998); and more of the theories associated
with these techniques in O’Donohue and Krasner (1995). Fisher and O’Donohue (2006) provide a
description of particular problems that these techniques can be used with.
References
Fisher, J.E.,& O’Donohue, W.T. (2006) Practitioner’s guide to evidence based psychotherapy. New York: Springer.
O’Donohue, W., & Krasner, L. (Eds.). (1995). Theories of behavior therapy. Washington: APA Books.
O’Donohue, W. (Ed.). (1998). Learning and behavior therapy. Boston: Allyn & Bacon.

17. ACKNOWLEDGMENTS
We wish to thank all the chapter authors. They uniformly wrote excellent chapters and completed
these quickly.
We’d also like to thank our editor at John Wiley & Sons, Patricia Rossi. She shared our vision for
this book, gave us some excellent suggestions for improvement, and has been wonderful to work
with.
We’d also like to thank Linda Goddard for all her secretarial skills and expert assistance in all
aspects of the manuscript preparation; she was invaluable.
Finally, we’d like to thank our families for their support, and especially our children, Katie and
Annie, for their enthusiasm and delightfulness.
xv

19. CONTRIBUTORS
Jonathan S. Abramowitz Jennifer L. Best, Ph.D.
University of North Carolina University of North Carolina
Chapel Hill, NC Charlotte, NC
Arthur W. Blume, Ph.D.
Dean T. Acheson University of North Carolina
University at Albany, SUNY Charlotte, NC
Albany, NY
Stephen R. Boggs, Ph.D.
University of Florida
Jennifer H. Adams
Gainesville, FL
University of Colorado at Denver
Denver, CO John C. Borrero, Ph.D.
University of Maryland
Mark A. Adams, Ph.D., B.C.B.A
Baltimore, MD
Best Consulting, Inc.
Fresno, CA
Carrie S.W. Borrero, Ph.D.
K. Angeleque Akin-Little Kennedy-Krieger Institute
Massey University Baltimore, MD
Auckland, New Zealand
Stephanie Both, Ph. D.
Mark Alavosius, Ph.D. Leiden University Medical Center
University of Nevada, Reno Leiden, Netherlands
Reno, NV
J. Annette Brooks, Ph. D.
Claudia Avina, Ph.D. New Mexico VA Healthcare System
University of Nevada, Reno Albuquerque, NM
Reno, NV
Jeffery A. Buchanan
Jenna L. Baddeley, M.A. Minnesota State University
The University of Texas at Austin Mankato, MN
Austin, TX
Eric Burkholder
Anjali Barretto, Ph.D. Dublin Unified School District
Gonzaga University Department of Special Education
Spokane, WA Dublin, CA
Wendy K. Berg, M.A. James E. Carr, Ph.D.
University of Iowa Western Michigan University
Iowa City, IA Kalamazoo, MI
xvii

20. xviii CONTRIBUTORS
Lavina L. Cavasos Sona Dimidjian, Ph.D.
New Mexico VA Healthcare System University of Colorado
Albuquerque, NM Boulder, CO
Daniel Cervone, Ph.D. Keith S. Dobson, Ph.D.
University of Illinois at Chicago University of Calgary
Chicago, IL Calgary, Canada
Stacey M. Cherup Brad Donohue, Ph.D.
University of Nevada, Reno University of Nevada, Las Vegas
Reno, NV Las Vegas, NV
Kim Christiansen Crissa Draper
Carson City, NV University of Nevada, Reno
Reno, NV
Linda J. Cooper-Brown, Ph.D.
University of Iowa Children’s Hospital Claudia Drossel, Ph.D.
Iowa City, IA University of Nevada, Reno
Reno, NV
Michelle G. Craske, Ph.D.
UCLA Melanie P. Duckworth, Ph.D.
Los Angeles, CA University of Nevada, Reno
Reno, NV
Dan Crimmins, Ph.D.
The Marcus Institute V. Mark Durand
Atlanta, GA University of South Florida
St. Petersburg, FL
Wendy Crook
University of Nevada, Reno Anna Edwards, Ph.D.
Reno, NV The Marcus Institute
Atlanta, GA
Jesse M. Crosby
Utah State University Albert Ellis, Ph.D.
Logan, UT Deceased
Joseph Dagen Erica L. England
University of Nevada, Reno Drexel University
Reno, NV Philadelphia, PA
Gerald C. Davison, Ph.D. Sheila M. Eyberg, Ph.D.
UCLA University of Florida
Los Angeles, CA Gainesville, FL
Kim DeRuyk, Ph.D. Kyle E. Ferguson, M.A.
Boys’ Town Riverview Hospital
Boys’ Town, NE Coquitlam, BC, Canada

21. CONTRIBUTORS xix
Jane E. Fisher, Ph.D. Robert J. Gatchel, Ph.D.
University of Nevada, Reno University of Texas at Arlington
Reno, NV Arlington, TX
Edna B. Foa, Ph.D. Scott Gaynor, Ph.D.
University of Pennsylvania Western Michigan University
Philadelphia, PA Kalamazoo, MI
Evan M. Forman Patrick M. Ghezzi, Ph.D.
Drexel University University of Nevada, Reno
Philadelphia, PA Reno, NV
John P. Forsyth, Ph.D. Elizabeth V. Gifford, Ph.D.
University at Albany (SUNY) University of Nevada, Reno
Albany, NY Reno, NV
Maxwell R. Frank Alan M. Gross
University of Hawaii at Manoa University of Mississippi
Honolulu, HI University, MI
Michelle A. Frank Kate E. Hamilton
Kennedy-Krieger Institute Peter Lougheed Centre
Baltimore, MD Calgary, Canada
Martin E. Franklin, Ph.D. Jay Harding, Ed.S.
University of Pennsylvania University of Iowa
Philadelphia, PA Iowa City, IA
Patrick C. Friman, Ph.D. Cathi D. Harris, M.A.
Father Flanagan’s Boys’ Home Washington Special Commitment Center
Boys’ Town, NE Steilacoom, WA
Armida R. Fruzzetti Nicole L. Hausman
University of Nevada, Reno Kennedy-Krieger Institute
Reno, NV Baltimore, MD
Alan E. Fruzzetti, Ph.D. Steven C. Hayes
University of Nevada, Reno University of Nevada, Reno
Reno, NV Reno, NV
Tiffany Fuse, Ph.D. Holly Hazlett-Stevens
National Center for PTSD University of Nevada, Reno
Jamaica Plain, MA Reno, NV
Christina G. Garrison-Diehn Lara S. Head, Ph.D.
University of Nevada, Reno University of Wisconsin
Reno, NV Madison, WI

22. xx CONTRIBUTORS
Elaine M. Heiby Linda A. LeBlanc, Ph.D.
University of Hawaii at Manoa Western Michigan University
Honolulu, HI Kalamazoo, MI
James D. Herbert, Ph.D. Deborah A. Ledley, Ph.D.
Drexel University University of Pennsylvania
Philadelphia, PA Penn Valley, PA
Ramona Houmanfar, Ph.D. Jung Eun Lee
University of Nevada, Reno University of Nevada, Reno
Reno, NV Reno, NV
Eric R. Levensky, Ph.D.
Kathryn L. Humphreys, Ph.D.
New Mexico VA Healthcare System
National Center for PTSD,
Albuquerque, NM
VA Boston Healthcare System
Boston, MA Donald J. Levis, Ph.D.
Binghamton University
Nicole N. Jacobs, Ph.D. Binghamton, NY
University of Nebraska
Jennifer M. Lexington, Ph.D.
Alyssa H. Kalata, M.A. University of Massachusetts Amherst
Western Michigan University Amherst, MA
Kalamazoo, MI
Marsha M. Linehan, Ph.D.
Mary Lou Kelley, Ph.D. University of Washington
Louisiana State University Seattle, WA
Baton Rouge, LA
Steven G. Little, Ph.D.
Brian C. Kersh, Ph.D. Massey University
New Mexico VA Healthcare System Auckland, New Zealand
Albuquerque, NM
Andy Lloyd, Ph.D.
Kelly Koerner U.S. Army
EBP
Jessa R. Love
Seattle, WA
Western Michigan University
Kalamazoo, MI
Douglas Kostewicz, Ph.D.
University of Pittsburgh Tamara M. Loverich, Ph.D.
Pittsburgh, PA Eastern Michigan University
Ellen Laan, Ph.D. Jason B. Luoma, Ph.D.
University of Amsterdam Portland Psychotherapy Clinic
Amsterdam, Netherlands Portland, OR
Arnold A. Lazarus, Ph.D. John R. Lutzker, Ph.D.
Rutgers, The State University of New Jersey The Marcus Institute
Piscataway, NJ Atlanta, GA

23. CONTRIBUTORS xxi
Kenneth R. MacAleese, M.A., B.C.B.A. Raymond G. Miltenberger, Ph.D., B.C.B.A.
Reno, NV University of South Florida
Tampa, FL
Kristen A. Maglieri, Ph.D.
Trinity College Sally A. Moore
Dublin, Ireland University of Washington
Seattle, WA
Christine Maguth Nezu, Ph.D.
Drexel University Kevin J. Moore
Philadelphia, PA Oregon Social Learning Center,
Community Programs
Gayla Margolin, Ph.D. Eugene, OR
UCLA
Los Angeles, CA Karen Murphy
University of Nevada, Reno
G. Alan Marlatt, Ph.D. Reno, NV
University of Washington
Seattle, WA Adel C. Najdowski
Center for Autism and Related
Christopher Martell Disorders, Inc.
Private Practice Tarzana, CA
Seattle, WA
Amy E. Naugle, Ph.D.
Western Michigan University
Brian P. Marx, Ph.D.
Kalamazoo, MI
National Center for PTSD,
VA Boston Healthcare System
Cory F. Newman, Ph.D.
Boston, MA
University of Pennsylvania
Philadelphia, PA
Mary McMurran
University of Nottingham Kirk A.B. Newring, Ph.D.
Nottingham, United Kingdom Nebraska Dept. of Correctional Services
Donald Meichenbaum, Ph.D. William D. Newsome
University of Waterloo University of Nevada, Reno
Waterloo, Ontario, Canada Reno, NV
Victoria E. Mercer Arthur M. Nezu, Ph.D.
University of Nevada, Reno Drexel University
Reno, NV Philadelphia, PA
Eileen Merges Amanda Nicholson-Adams, Ph.D., B.C.B.A.
St. John Fisher College California State University at Fresno
Rochester, NY Fresno, CA
Gerald I. Metalsky, Ph.D. William T. O’Donohue, Ph.D.
Lawrence University University of Nevada, Reno
Appleton, WI Reno, NV

24. xxii CONTRIBUTORS
Pamella H. Oliver, Ph.D. Richard C. Robertson, Ph.D.
California State University, Fullerton Baylor University Medical Center
Fullerton, CA Dallas, TX
Jennette L. Palcic Frederick Rotgers, Psy.D., ABPP
Louisiana State University Philadelphia College of Osteopathic
Baton Rouge, LA Medicine
Philadelphia, PA
Gerald R. Patterson, Ph.D.
Oregon Social Learning Center Frank R. Rush, Ph.D.
Eugene, OR Pennsylvania State University
University Park, PA
James W. Pennebaker
The University of Texas at Austin Joel Schmidt, Ph.D.
Austin, TX VA Northern California Healthcare System
Oakland, CA
Michael L. Perlis, Ph.D.
Walter D. Scott, Ph.D.
University of Rochester
University of Wyoming
Rochester, NY
Laramie, WY
Katherine A. Peterson
Christine Segrin
Utah State University
University of Arizona
Logan, UT
Tucson, AZ
Wilfred R. Pigeon, Ph.D.
Rachel E. Sgambati
University of Rochester Medical Center
Carson City, NV
Rochester, NY
Deacon Shoenberger
Alan Poling, Ph.D. University of Nevada, Reno
Western Michigan University Reno, NV
Kalamazoo, MI
David M. Slagle
Lisa Regev, Ph.D. University of Washington
University of Nevada, Reno Seattle, WA
Reno, NV
Rachel S.F. Tarbox
Lynn P. Rehm, Ph.D. The Chicago School of Professional
University of Houston Psychology at Los Angeles
Houston, TX Los Angeles, CA
Jennifer Resetar, Ph.D. Kendra Tracy
Boys’ Town University of Nevada, Las Vegas
Boys’ Town, NE Las Vegas, NV
Patricia Robinson, Ph.D. Michael P. Twohig, Ph.D.
Mountainview Consulting Group, Inc. Utah State University
Zillah, WA Logan, UT

25. CONTRIBUTORS xxiii
Timothy R. Vollmer, Ph.D. Larry W. Williams, Ph.D.
University of Florida University of Nevada, Reno
Gainesville, FL Reno, NV
David P. Wacker, Ph.D. Ginger R. Wilson, Ph.D.
University of Iowa Children’s Hospital The ABRITE Organization
Iowa City, IA Santa Cruz, CA
Michelle D. Wallace, Ph.D. J. M. Worrall
California State University, Los Angeles University of Nevada, Reno
Los Angeles, CA Reno, NV
Todd A. Ward Marat Zanov
University of Wellington University of Southern California
Wellington, New Zealand Los Angeles, CA
Jennifer Wheeler, Ph.D. Lori A. Zoellner, Ph.D.
Private Practice University of Washington
Seattle, WA Seattle, WA
Daniel J. Whitaker, Ph.D.
The Marcus Institute
Atlanta, GA

27. COGNITIVE
BEHAVIOR
THERAPY

30. 1 INTRODUCTION
William O’Donohue and Jane E. Fisher
Cognitive behavior therapy (CBT) is an approach recent decades there has been an unfortunate
to human problems that can be viewed from sev- trend away from a philosophical understanding
eral interrelated perspectives: philosophical, the- of behavior therapy to a more technique-oriented
oretical, methodological, assessment oriented, understanding.
and technological. This book focuses on the last The second aspect of behavior therapy is its
aspect, so crucial to clinical practice, but sit- theoretical structure. Here the issues are less
uated in the other four, much as any one of philosophical—less about general epistemic
a cube’s six sides is situated among all of the issues—and more about substantive assertions
others. regarding more specific problems as well as
Philosophically, CBT can be viewed as being the principles appealed to in making these
associated (or, according to some who put it more assertions. What is panic? What are its causes?
strongly, derived) with one or another variety What is the role of operant conditioning in
of behaviorism (O’Donohue & Kitchener, 1999). children’s oppositional behavior? How does one
The behaviorisms are generally philosophies of prevent relapse? Should cognitions be modified
science and philosophies of mind—that is, ways or accepted?
of defining and approaching the understand- There are also a wide variety of theories
ing of the problems traditionally associated with associated with behavior therapy (O’Donohue
psychology. & Krasner, 1995), including:
There are at least two broad issues at the
philosophical level: (1) What particular form of • Reciprocal inhibition
behaviorism is being embraced (O’Donohue & • Response deprivation
Kitchener, 1999, have identified at least 14), and • Molar regulatory theory
(2) what is the nature of the relationship or associ- • Two-factor fear theory
ation between this philosophy and the practice of • Implosion theory
CBT? Some have argued that behaviorism is irrel- • Learned alarms
evant to behavior therapy—that one can practice • Bioinformational theory
behavior therapy and either reject behaviorism • Self-control theory
or be agnostic with regard to all forms of it. • Developmental theories
While an individual practitioner can behave in • Coercion theory
this way, some of the deeper structure that can • Self-efficacy theory
be generative and guiding is lost. One can drive • Attribution theory
a car without an understanding of its workings, • Information processing theory
but one probably can’t design a better car or • Relational frame theory
modify an existing car without such an under- • Relapse prevention
standing. Similarly, a knowledge of behaviorism • Evolutionary theory
allows greater understanding of the choice points • Marxist theory
implicit in any technology. For example, why not • Feminist theory
view the client’s problem as a neurological dif- • Dialectical theory
ficulty and intervene at this level? Behaviorism • Acceptance theory
often provides possible answers to this kind of • Functional analytic theory
general challenge. However, we suggest that in • Interbehavioral theory
1

31. 2 COGNITIVE BEHAVIOR THERAPY
Theories can provide answers or at least & Jarrett, 1987). Some of the chapters in this
testable hypotheses for questions regarding more volume deal with assessment techniques either
specific problems, such as these: What is the basic because they are central to therapy or because
nature of this kind of clinical problem? How assessment methods themselves are so reactive
does this problem develop? What maintains this that they may be seen, in part, as treatment.
problem? What are its associated features and However, in the main, this book does not focus
why? How is this problem possibly modified? on the measurement aspect, leaving that task to
What makes this technique work? What are con- other fine anthologies (e.g., Haynes & Heiby , in
traindications? What are boundary conditions? press).
The third aspect of CBT is its program for The final aspect of CBT is techne—skilled
knowledge generation. In the main, CBT is exper- practice. No amount of philosophy or theory
imental and relies on a mixture of group experi- will relieve clinicians from this level of analy-
mental designs (e.g., the randomized controlled sis. A surgeon may be a biological determinist
trial) and single-subject experimental designs philosophically and may hold to certain the-
(although in the largest perspective it can be ories of cancer and cancer treatment, but to
seen to include correlational designs and even help patients the surgeon still needs to imple-
case studies). Methodologically, CBT generally ment surgical technique in a skilled manner.
embraces constructs such as social validity, clin- Similarly, cognitive behavior therapists need to
ical significance, follow-up measurements, man- be skilled in the execution of their techniques.
ualized treatment, adherence and competence In fact, an interesting set of research questions
checks, the measurement of process variables, involves the relationship between the degree of
independent replications, and real-world effec- skill (e.g., poor, novice, experienced, master) and
tiveness research. This toolbox is complex, but therapy outcome. This may also be a function
one can discern a few distinct styles—such as of specific technique (e.g., progressive muscle
that of the applied behavior analyst and that relaxation may have different relationship with
of the cognitive therapist (O’Donohue & Houts, skill level than emotional regulation training).
1985). Other styles can be seen when the nature For example, if a clinician arranges potential
of the question differs—for example, when the positive reinforcers that are too distal in contin-
interest is in measurement development and gency manager it will be less effective. Similarly,
validation or in the questions typically associ- if a clinician conducts systematic desensitiza-
ated with experimental psychopathology. CBT tion with only a few steps in a fear hierarchy,
is solidly in the stream of ‘‘clinical science’’ with weakly trained progressive muscle relax-
and as part of this general approach views an ation skills, and pairings that are few and of very
experimental approach as key (see Lilienfeld short duration, it is unlikely to be as effective as
and O’Donohue, 2007, for a fuller exposition it could otherwise be.
of clinical science). We’ve identified approximately 80 distinct
The fourth aspect of CBT is its approach to techniques in CBT, covering both standard
measurement. Here, a key issue is how to accu- behavior therapy and cognitive therapy
rately detect and quantify variables of interest. techniques, and relatively recently developed
Cognitive behavior therapy is associated with procedures such as acceptance strategies and
both a distinctive delineation of the domain of mindfulness. This number has to qualify CBT as
interest and distinct methods for measuring this. one of the most variegated therapy systems. This
In general, behavioral assessment can be dis- diversity no doubt derives from an interplay of
tinguished from more traditional measurement complex factors:
approaches by its focus on sampling of behavior
rather than looking for signs of more abstract • The multiple learning theories upon which
constructs. There are diverse streams of thought traditional behavior therapy is based
within the CBT tradition, however, from the (O’Donohue, 1998).
embrace of traditional psychometric standards • The multielemental nature of each of these
to the radically functional (e.g., Hayes, Nelson, theories (e.g., setting events, discrimination

32. 1 • INTRODUCTION 3
training, schedules of reinforcement, general- (i.e., what process or pathway it may be asso-
ization processes, fading, etc.). ciated with), and some of the evidence for its
• The influence of other elements of experimen- effectiveness. The major section of the chapter is
tal psychology such as experimental cognitive a step-by-step guide that explains exactly how
science. to implement the technique. Finally, we asked
• The influence of other branches of psychology authors to include a brief table outlining the
such as social psychology. major elements of the technique.
• The influences of other intellectual domains The very number and diversity of CBT tech-
(dialectics) or other fields of inquiry (mind- niques place a significant burden on any practi-
fulness). tioner of CBT and, even more so, on the student.
• The interface of these with a particular kind of It is our hope that this volume, by clearly and
clinical problem (e.g., borderline personality concisely describing these techniques, will ease
disorder). this burden. We also hope that precision about
• The creativity and ambitions of the devel- techniques can help the field continue to keep
opers. its eye on Gordon Paul’s (1969) classic ques-
tion: What techniques, delivered by what type
But whatever the source of this tremendous of therapist, for what kind of client, with what
variety, the presence of such a large number kind of clinical problem, in what kind of setting,
of major distinctive techniques leaves no doubt produces what kind of result, by what kind of
as to the multifactorial nature of contemporary process?
CBT. It leaves an interesting question regarding
how broad competence ought to be across these
References
techniques in order for one to be considered a
well-trained cognitive behavior therapist. One Haynes, S., & Heiby, E. (in press). The encyclopedia of
of the key variables emerging in the medical behavioral assessment.
Hayes, S. C., Nelson, R. O., & Jarrett, R. (1987). Treat-
literature regarding quality is number of times
ment utility of assessment: A functional approach
the physician has implemented the particular
to evaluating the quality of assessment. American
technique. One generally finds that hundreds Psychologist, 42, 963–974.
or thousands of times produces outcomes better Lilienfeld, S., & O’Donohue, W. (Eds.). (2007). The great
than those in the dozens. Thus, there can be a ideas of clinical science. New York: Routledge.
bandwith/fidelity trade-off in behavior therapy O’Donohue, W. (Ed.). (1998). Learning and behavior ther-
that can have interesting associations with qual- apy. Boston: Allyn and Bacon.
O’Donohue, W., & Houts, A. C. (1985). The two dis-
ity. Those that know more techniques may be
ciplines of behavior therapy. Psychological Record,
less skilled at implementing any particular one.
35(2), 155–163.
We’ve asked each of the chapter authors to fol- O’Donohue, W., & Kitchener, R. (1999). Handbook of
low a standard format, because we thought these behaviorism. San Diego: Academic Press.
main topics would delineate a bit of the context O’Donohue, W., & Kramer, L. (Eds.). (1995). Theories of
and all of the essential features needed to com- behavior therapy. Washington, DC: APA Books.
petently execute these techniques. We wanted Paul, G. L. (1969). Behavior modification research:
Design and tactics. In C. M. Franks (Ed.),
them to describe who might benefit from this
Behavior therapy: Appraisal and status (pp. 29–62).
technique, contraindications, other factors rele-
New York: McGraw-Hill.
vant to making the decision to use or not to use
the technique, how the technique might work

33. 2 PSYCHOLOGICAL ACCEPTANCE
James D. Herbert, Evan M. Forman,
and Erica L. England
In one form or another, all psychotherapies conceived to include distressing thoughts and
seek to produce change. Individuals seek con- feelings in addition to overt behavior. Although
sultation from psychotherapists when they are one might need to accept temporary, short-term
experiencing emotional pain, struggling with life distress associated with certain interventions,
problems, or when they are not functioning well the overall focus was on changing the form or
in school, work, or relationships. The explicit goal frequency of distressing behaviors rather than
is to achieve changes that will reduce pain or suf- accepting them. This approach was dramatically
fering, resolve outstanding problems, or enhance successful. Effective technologies were devel-
functioning. There has also been a longstand- oped to increase social skills, desensitize fears,
ing recognition that such change requires some and manage disruptive behavior among chil-
sense of self-acceptance, understood as the ability dren, as well as to address many other problems
to respond less self-critically and judgmentally, (Bongar & Beutler, 1995; Goldfried & Davison,
thereby establishing the context for more effec- 1994). As behavior therapy matured through
tive functioning. Prior to the advent of behavior the last decades of the twentieth century, there
therapy, psychotherapists traditionally focused evolved an increased focus on changing thoughts
less on changing distressing symptoms them- and beliefs, and the field itself came to be known
selves, concentrating instead on modifying other by the term cognitive behavior therapy (CBT). The
processes on the assumption that changes in various clinical strategies and techniques falling
such processes would result in more fundamen- under the rubric of CBT all shared a focus on
tal, profound, and permanent improvements in directly targeting problems using instrumental
distress (Sulloway, 1983). Psychoanalysts sought change strategies. Although acceptance of one’s
to increase insight into the developmental ori- distressing experiences was indirectly targeted
gins of unconscious conflicts. By rendering the in some cases (e.g., acceptance of anxious sen-
unconscious conscious, unacceptable drives and sations during exposure-based therapies), even
fantasies become acceptable to the ego. Humanis- then the ultimate goal was change (e.g., anxiety
tic therapists likewise sought to increase congru- reduction), and the overall focus of clinical inter-
ence between different facets of the self, thereby ventions remained squarely on direct change.
promoting a sense of self-acceptance. Although
the ultimate goal was change, the prevailing
clinical wisdom was that targeting distressing THE GROWTH OF PSYCHOLOGICAL
thoughts, feelings, or behavior directly would be ACCEPTANCE IN CBT
ineffective at best, and possibly even counter-
productive. It is perhaps ironic, then, that the field of CBT
Early behavior therapists rejected the idea that currently finds itself at the forefront of a move-
change required interventions focusing on pro- ment that questions the utility of such direct
cesses not directly related to actual presenting change strategies under certain circumstances
problems. Instead, they directly targeted their and promotes instead the rather paradoxical
patients’ difficulties. Behavior therapists focused idea that more pervasive and enduring improve-
on modifying environmental factors thought to ments in suffering and quality of life may
be responsible for problematic behavior, broadly result from accepting, rather than attempting to
4

34. 2 • PSYCHOLOGICAL ACCEPTANCE 5
40
35
30
25
20
15
10
5
0
2000 2001 2002 2003 2004 2005 2006 2007
Publication Year
FIGURE 2.1 PsychInfo Citations for Keywords ‘‘Experiential Acceptance,’’ ‘‘Psychological Acceptance,’’ or
‘‘Experiential Avoidance.’’
change, one’s distressing subjective experience. The recent growth of interest in these ap-
This distinction between direct change efforts proaches is undeniable. For example, as illus-
and psychological acceptance as a vehicle for trated in Figure 2.1, the PsychInfo database
change has been described in various ways, reveals a steady growth in the hits of the
including first-order versus second-order keywords experiential acceptance, its synonym
change, change in content versus context, and psychological acceptance, and experiential avoidance
change in form versus function (Hayes, 2001). (which is an antonym for the first two) from 2
Regardless of terminology, a number of CBT in 2000 to 35 in 2007. Parallel increases can be
models have emerged over the past decade that found in related databases (e.g., Medline), and
highlight efforts to accept, rather than directly in the titles of conference proceedings (e.g., the
annual meeting of the Association for Behavioral
change, distressing experiences, including
and Cognitive Therapies).
thoughts, beliefs, feelings, memories, and sen-
This increased emphasis on psychological
sations. These approaches have not abandoned
acceptance is the result of several factors (Hayes,
all direct change strategies. Rather, as described
2004; Longmore & Worrell, 2007). First, an
later, they suggest that changes in some areas
accumulating body of experimental research
are best facilitated by acceptance in others. It
demonstrates that efforts to suppress thoughts
is worth noting that there is no hard-and-fast generally result in rebound effects in which the
distinction between traditional change-oriented frequency and intensity of thoughts increase
and acceptance-oriented models of CBT (Orsillo, upon termination of active suppression efforts
Roemer, Lerner, & Tull, 2004). A key ultimate (Abramowitz, Tolin, & Street, 2001; Wenzlaff
goal of both approaches is behavior change & Wegner, 2000). Such findings suggest that
(broadly writ), and both draw on technologies CBT interventions such as thought stopping,
that either implicitly or explicitly seek to increase in which distressing thoughts are deliberately
psychological acceptance. Rather, the models suppressed, might be seriously misguided.
differ in the relative degree of emphasis on In fact, most CBT scholars now disavow this
acceptance versus change processes. technique (Marks, 1987). Thought suppression

35. 6 COGNITIVE BEHAVIOR THERAPY
studies (in which individuals who deliberately ago (see Dobson, 1989, for a review of these
suppress thoughts demonstrate increased older studies). Finally, preliminary component
rebound of these thoughts relative to those control studies, in which direct cognitive
who do not engage in suppression strategies) change interventions were extracted from
have been cited as evidence to suspect the larger CBT protocols, have generally failed to
advisability of cognitive restructuring, one support the incremental effects of such cognitive
of the most commonly used CBT techniques interventions (e.g., Dimidjian et al., 2006; Hope,
(Hayes, in press). The concern is that attempting Heimberg, & Bruch, 1995; Jacobson et al., 1996).
to restructure distressing thoughts may lead These observations led several psychotherapy
patients to suppress them, resulting in inten- innovators to develop approaches that highlight
sification and elaboration. However, it is not acceptance of distressing experiences. Such
clear that cognitive restructuring is analogous to innovations include comprehensive psycho-
thought suppression (Arch & Craske, in press; therapy models such as acceptance and
Hofmann & Admundson, 2008). Second, some commitment therapy (ACT; Hayes, Strosahl,
cognitive therapists have recently challenged & Wilson, 1999), dialectical behavior therapy
on theoretical grounds the idea that directly (DBT; Linehan, 1993a), mindfulness-based stress
targeting thoughts can produce cognitive reduction (MBSR; 1990) and functional analytic
or affective changes (Teasdale, 1997). Third, psychotherapy (FAP; Kohlenberg & Tsai, 1991),
experimental psychopathology studies have as well as models focused on a particular clinical
found that instructions to accept experimentally domain, such as integrative couples therapy
induced distress resulted in better outcomes (ICT; Jacobson et al., 2000), mindfulnesss-based
than instructions to control such distress. cognitive therapy (MBCT; Coelho, Canter, &
For example, acceptance-oriented instructions, Ernst, 2007; Segal, Williams, & Teasdale, 2002)
relative to distraction or control-oriented instruc- for recurrent depression, and the work of leading
tions, have been shown to result in greater pain CBT theorists such as Borkovec (1994), Wells
tolerance in cold pressor tasks (Hayes et al., (2000), Marlatt and colleagues (2004), and others.
1999), in lower behavioral avoidance and fear
response following exposure to CO2 enriched air
among high anxiety–sensitivity women (Eifert CONCEPTUALIZATIONS OF ACCEPTANCE
& Heffner, 2003) and panic disorder patients
(Levitt, Brown, Orsillo, & Barlow, 2004), and in No consensus definition of psychological
reducing chocolate cravings in food-responsive acceptance has yet emerged, although existing
individuals (Forman, Hoffman, et al., 2007). definitions share several common themes. Butler
Fourth, psychotherapy process studies often and Ciarrochi (2007) define acceptance as ‘‘a
have failed to support the theorized mechanism willingness to experience psychological events
of cognitive mediation, raising questions about (thoughts, feelings, memories) without having
the centrality of cognitive change as a prereq- to avoid them or let them unduly influence
uisite for changes in other areas (Longmore & behavior’’ (p. 608). These authors also note that
Worrell). Fifth, although standard CBT strategies acceptance is the mirror image of Hayes and col-
have been applied to an increasing number of leagues’ (1999) concept of experiential avoidance,
problems and psychological disorders over the which is defined as maladaptive attempts to alter
past 30 years, outside of a few specific areas (e.g., the form or frequency of internal experiences
panic disorder, Craske & Barlow, 2008; social even when doing so causes behavioral harm.
anxiety disorder, Clark et al., 2006, Herbert Cordova (2001), writing from a behavior analytic
et al., 2005) progress has slowed or even perspective, defines acceptance as ‘‘allowing, tol-
stalled in many key areas. For example, it erating, embracing, experiencing, or making con-
is not clear that recent studies of CBT (e.g., tact with a source of stimulation that previously
DeRubeis et al., 2005; Dimidjian et al., 2006) for provoked escape, avoidance, or aggression’’
depression produced larger effect sizes than (p. 215), and also as ‘‘a change in the behavior
studies conducted two or even three decades evoked by a stimulus from that functioning to

36. 2 • PSYCHOLOGICAL ACCEPTANCE 7
avoid, escape, or destroy to behavior functioning Likewise, the prohibition against experiential
to pursue or maintain contact’’ (p. 215). avoidance in ACT is neither absolute nor
These definitions share several common dogmatic, but rather pragmatic. (In fact, while
themes. First, they specify that psychological ACT practitioners are skeptical of experiential
acceptance is relevant in those situations avoidance, including many cognitive change
that evoke escape, avoidance, or aggressive strategies, their use is explicitly advised when
behaviors designed to modify or otherwise they work without undue costs.) Second,
terminate contact with a stimulus. There is a acceptance is conceptualized as an active
class of subjective experiences (thoughts, images, process, more akin to an embracing of one’s
feelings, sensations) that are experienced as ongoing process of experiencing, rather than as
unpleasant and distressing to the point at which passive resignation. Finally, consistent with the
one becomes highly motivated to reduce or historical focus in CBT on change, psychological
eliminate them through either direct mental acceptance is generally viewed as a means to
efforts or through environmental modification an end rather than an end in-and-of itself. In
such as escape or avoidance. Acceptance is fact, this last point is one of the key features
generally not relevant to situations that are that distinguishes psychological acceptance
not experienced as aversive, which are usually in CBT from acceptance in certain spiritual
naturally embraced without difficulty. Second, or religious contexts, and even in popular
psychological acceptance refers primarily to the culture. Meditative practices in Eastern religious
internal experience of distress rather than to the traditions view acceptance as part of a desired
situations evoking this distress. In the case of a state of consciousness. Within CBT, the value of
phobia of heights, for example, acceptance refers acceptance is as a tool to reduce overall suffering
to a willingness to experience anxiety—without and especially to foster behavior change that
attempting to control or otherwise change it—in will lead to better functioning.
the presence of heights, and not an acceptance
that one can never approach heights. Third,
the conceptualizations of acceptance implicitly CLINICAL INTERVENTIONS TO PROMOTE
challenge the rule that overt behavior is a direct PSYCHOLOGICAL ACCEPTANCE
product of cognition and affect, and that the
latter must therefore necessarily be changed in A number of techniques have been developed
order to produce a change in behavior. to promote psychological acceptance. Although
In addition, several additional aspects of psy- comprehensive review of such techniques is well
chological acceptance emerge from the literature. beyond the scope of this chapter, we provide
On the basis of the literature on thought sup- representative examples of such strategies below.
pression, experimental psychopathology, and Barlow and colleagues (1989) introduced
psychotherapy outcome and process described the technique of interoceptive exposure in the
earlier, including the preliminary effectiveness context of their treatment of panic disorder.
of newer CBT interventions that eschew direct Interoceptive exposure refers to the graduated,
cognitive change, many acceptance-oriented systematic exposure to somatic sensations
psychotherapists have come to believe that associated with panic attacks. Various exercises
direct efforts to suppress or otherwise change are used that reliably elicit panic-like symptoms,
highly distressing internal experiences will often including cardiovascular exercises, inhalation
prove ineffective, will result in unacceptable of carbon dioxide, spinning in an office chair,
costs, or both (e.g., Eifert & Forsyth, 2005; breathing through a cocktail straw, and shaking
Segal, Teasdale, & Williams, 2004). This is not one’s head vigorously side to side. The patient
to suggest that all such efforts are doomed is instructed to notice the sensations that arise
to failure. DBT, for example, is based on the dispassionately. Although not specifically
careful, ongoing balance between acceptance framed as a technique to promote psychological
and change and does not abandon the possibility acceptance, interoceptive exposure is consistent
of direct cognitive or affective change efforts. with an acceptance focus.

37. 8 COGNITIVE BEHAVIOR THERAPY
One of the most common approaches to pro- skills, emotional regulation skills, interpersonal
moting psychological acceptance is mindfulness effectiveness skills, and distress tolerance
meditation. The use of meditation was spear- skills. Each module outlines specific clinical
headed by Jon Kabat-Zinn in the context of techniques. Mindfulness skills are generally
MBSR, which was initially introduced in 1979 taught first, as they are foundational for the
as a complement to medical treatment of a vari- other skill areas. The DBT mindfulness module
ety of chronic conditions. MBSR incorporates emphasizes observing and labeling emotional
the practice of mindfulness meditation with cer- states from a detached, nonjudgmental, accept-
tain core principles and ‘‘key attitudes,’’ such as ing perspective. Patients are taught to integrate
acceptance, patience, and the ‘‘beginner’s mind,’’ the ‘‘emotional mind’’ and ‘‘reasonable mind’’
that is, viewing experiences as though for the into the ‘‘wise mind’’ that can inform decisions
first time (Kabat-Zinn, 1990). The typical for- from an informed, balanced, holistic perspective.
mat through which MBSR is delivered consists A potentially unresolved issue with DBT
of eight weekly classes (often with 30 or more concerns the reconciliation of experiential
participants), and a ‘‘Day of Mindfulness,’’ a acceptance and change. DBT explicitly teaches
full-day retreat focusing on the practice of medi- a number of emotion regulation strategies, such
tation and yoga. A key technique used in MBSR is as the principle of ‘‘opposite action,’’ which
‘‘sitting meditation,’’ in which participants prac- refers to attempting to change an emotional
tice nonjudgmental awareness and acceptance of state by behaving in a way that is contrary to
their thoughts and other experiences. In addi- its usual behavioral manifestation. For example,
tion to meditation and yoga, participants are a phobic who approaches rather than avoids
taught various techniques designed to promote a fear-inducing stimulus is displaying the
mindfulness, such as the ‘‘body scan,’’ which principle of opposite action. The emphasis
involves gradually shifting awareness through- on emotion regulation in DBT highlights the
out the body, taking notice of any feelings and dialectic between acceptance and change that
sensations (Tacon, Caldera, & Ronaghan, 2004). is characteristic of the model. However, as
Although similar to the traditional behavior ther- discussed above, there may be situations in
apy technique of relaxation training, in the case which attempting to change one’s experience
of mindfulness meditation relaxation is not the only intensifies it. Thoroughgoing acceptance
goal, but rather the adoption of a nonjudgmen- of distressing thoughts or feelings may be
tal stance with respect to one’s experience as it precluded if one remains focused on changing
occurs in real time. Mindfulness meditation is such experiences. An obese individual suffering
also contrasted with other meditative traditions from episodes of binge eating, for example,
in which one attempts to narrow the focus of may not fully accept distressing emotional
attention to a specific area (e.g., an image or states that trigger binges, and therefore may
vocal mantra). By fostering the observation of not completely disconnect links between such
one’s experience without reactively attempting experiences and her behavior, if in the back
to escape from or otherwise change it, mind- of her mind she is still struggling with trying
fulness meditation is believed to interrupt mal- to change her experience. As described below,
adaptive behavioral habits and to set the context ACT takes a more radical—although arguably
for more effective responding. more consistent—stance with respect to efforts
Mindfulness meditation is also a key feature to control distressing experiences.
of DBT, developed by Linehan (1993a) as a Working from a cognitive perspective, Wells
comprehensive treatment model for borderline (2000) proposes that psychopathology is related
personality disorder. DBT proposes that the to problematic self-regulation of attentional
change-oriented emphasis in traditional CBT control, resulting in rumination, increased
can be perceived as invalidating of the expe- threat monitoring (including self-focused
rience of patients with borderline personality attention), and coping behaviors that fail to
disorder. Linehan (1993b) describes modules provide corrective experiences. The roots of
for teaching four key skill areas: mindfulness these self-regulatory attentional problems are

38. 2 • PSYCHOLOGICAL ACCEPTANCE 9
dysfunctional metacognitive beliefs, or beliefs could simply observe his urge, and say to
about beliefs. For example, a person with himself, ‘‘I’m having the thought of shouting out
generalized anxiety disorder might hold a right now. That’s an interesting thought.’’ The
metabelief such as ‘‘if I review things over idea is to help the patient to achieve distance
and over again it will reduce the chances of from his experience and to accept the thought as
something bad happening.’’ Wells distinguishes simply a mental event, rather than as necessarily
such metacognitions from the conscious, reflecting anything whatsoever about his world.
propositional beliefs that are the typical targets Another example derived from ACT is the
of standard cognitive therapy. He suggests inter- ‘‘cards’’ exercise. In one variation of this exercise,
vention efforts to target such metacognitions, the patient is instructed to carry on a con-
while simultaneously accepting the stream of versation with the therapist. As she does so,
one’s ongoing conscious thoughts and feelings. the therapist tosses index cards, on each of
Unlike traditional CBT approaches, such change which is written one of the patient’s typical
is not accomplished by questioning the beliefs distressing thoughts, one-by-one at the patient,
directly, but by encouraging greater attentional who is then instructed either to deflect them
control while simultaneously encouraging a away, or to gather them and stack them neatly
heightened sense of awareness of, and an together, all while continuing the conversation.
accepting stance toward, one’s thoughts as mere Needless-to-say, this is a difficult task, and the
mental events. As part of his metacognitive conversation is inevitably negatively impacted.
therapy, Wells describes a procedure known as The exercise is then repeated, this time with the
the attention training technique (ATT), in which patient instructed simply to let the cards fall
various sounds are presented as distractions where they may, without trying to catch or orga-
while subjects remain focused on a visual nize them. Following the exercise, the therapist
fixation point, accept whatever thoughts enter and patient note how much more difficult the
consciousness without struggling with them, conversation was to maintain in the first sce-
and attempt to direct their attention in various nario, and the effort to gather and organize the
ways as directed by the therapist. ATT has cards is framed as analogous to the effort to con-
been shown in preliminary studies to result in trol one’s distressing thoughts. The ACT model
changes in distressing thoughts and symptoms, is rich with similar exercises designed to promote
despite not directly targeting them, as well as psychological acceptance.
in increases in metacognitive awareness (for a Roemer and Orsillo (2002) utilize the ACT
recent review, see Wells, 2007). framework to develop an acceptance-based
ACT makes use of a variety of metaphors intervention for generalized anxiety disorder.
and experiential exercises in order to promote Their model draws on the work of Borkovec
acceptance. A great number of such exercises (1994), who conceptualizes worry as an
have been developed, and clinical innovations avoidance method that serves to reduce the
in this area continue apace. One technique has perceived likelihood of feared future events, as
the patient precede discussions of distressing well as to distract the worrier from distressing
thoughts or feelings by verbally (and subse- internal anxiety. Worry, in turn, is negatively
quently subvocally) inserting the phrase ‘‘I’m reinforced by the resulting decrease in distress.
having the thought [or feeling] that . . . ’’ before According to Roemer and Orsillo, by learning
thoughts. For example, an individual who to accept unpleasant internal events rather
imagines that he might suddenly shout out a than struggling with them, individuals can
profanity-laced, heretical statement in church reduce their experiential avoidance of perceived
would be highly motivated to suppress the future threats. Roemer and Orsillo’s treatment
urge to do so as well as the linked thoughts incorporates various techniques to promote
and images. Attempts to suppress thoughts mindfulness, acceptance, and behavior change.
or images of such behavior would likely only For example, the ‘‘mindfulness of sound’’
increase their salience and intensity, thereby exercise, borrowed from Segal and colleagues
further increasing distress. Instead, this person (2002), encourages patients to notice aspects of

39. 10 COGNITIVE BEHAVIOR THERAPY
sound without labeling and judgment (Orsillo, noting that acceptance is rarely appropriate for
Roemer, & Holowka, 2005). the former but almost always for the latter. For
Marlatt and colleagues have incorpo- example, an individual suffering from depres-
rated mindfulness and acceptance into their sion can distance herself from and accept feelings
work on substance abuse treatment (Leigh, of dysphoria and thoughts of worthlessness and
Bowen, & Marlatt, 2005; Marlatt et al., 2004; suicide, but without accepting her behavior of
Witkiewitz, Marlatt, & Walker, 2005). Marlatt’s staying in bed all day. Historically important
relapse-prevention model involves mindful memories (e.g., one’s memories of a traumatic
acceptance of urges and cravings. A key experience) are especially important to accept,
intervention of their program is known as ‘‘urge as considerable research suggests that avoidant
surfing,’’ in which the patient is instructed to coping strategies are problematic for such mem-
imagine a craving as an ocean wave (Larimer, ories (Folette et al., 1998; Hayes et al., 1996).
Palmer, & Marlatt, 1999). Rather than allowing Likewise, one’s ongoing stream of thoughts, feel-
urges to overwhelm them, patients are taught ings, and sensations also tend to be appropriate
that cravings surge to a peak relatively quickly targets for acceptance. For example, Hayes and
and will then subside. By focusing on the Pankey (2003) note that a pedophile’s sexual
idea that distressing emotions will eventually behavior toward children should be directly tar-
subside, they are more readily tolerated while at geted for change, whereas his associated feelings
their most intense. The patient is encouraged to and urges are unlikely to be amenable to direct
observe the craving as though detached from it, change, and should therefore be accepted. It is in
and to practice mindful acceptance of the urge fact precisely this decoupling of subjective expe-
until it dissipates. riences from overt behavior that is at the heart of
Regardless of approach, the ultimate goal of acceptance-based CBTs.
each of these techniques is the promotion of It is critical to distinguish psychological
acceptance toward one’s experience on an ongo- acceptance of a thought from belief in the
ing basis in real time. literal truth of that thought. Acceptance implies
the willingness to experience a thought while
simultaneously refraining from evaluating its
WHEN IS ACCEPTANCE RECOMMENDED, truth value. This distinction is critical when
AND WHEN IS IT LIKELY TO BE LESS EFFECTIVE? considering the patient’s personal narrative, or
what Hayes et al. (1999) term the self-as-content.
As noted above, efforts to exert direct control Given the powerful human drive to make
over one’s experience can be considered adaptive sense of one’s experience, we inevitably
when they work and do not result in excessive construct narratives that tie together important
costs. Of course, this begs the question of how historical events, and that crystallize into broad
one might ascertain when direct control efforts personality descriptors. The problem with such
are likely to be effective and when psychological narratives is that once formed, they tend to
acceptance is instead indicated. Several theorists be taken literally and strongly defended from
have addressed this question, although a clear question, which can in turn lead to a narrowing
consensus has yet to emerge. Cordova (2001) of one’s behavioral repertoire. For example, a
suggests that the decision is a judgment call, college student may recall academic successes
made collaboratively by the patient and ther- in school, attribute these to her intelligence
apist, on whether aversion behavior (escape, and strong work ethic, and develop an identity
avoidance, or aggression toward a stimulus) is as an ‘‘exceptionally smart, hardworking
more likely to be effective, or lead to excessive student.’’ Imagine that she then finds herself
negative consequences, over the long term. Of in a difficult class and not understanding the
course, this begs the question of exactly what fac- lecture material. If she holds strongly to her
tors should determine such a judgment. Hayes personal narrative, she may refrain from asking
(2001) distinguishes maladaptive overt behavior a question because doing so would conflict
from acceptance of one’s subjective experiences, with her self-identity as an exceptionally bright

40. 2 • PSYCHOLOGICAL ACCEPTANCE 11
student. As verbal animals, humans have all cognitive and affective control efforts are nec-
evolved to seek patterns in the ongoing barrage essarily doomed to failure, which may not be the
of sensory input (Shermer, 2002), and as part of case. Some experiences are neither fully volun-
this process, we construct stories that weave key tary (like hand/feet movements) nor involuntary
details of our lives into a seamless narrative. (such as heart rate). Attention is a prime example.
Once constructed, there is a natural tendency In fact, a number of experiences (e.g., thought
to believe such narratives and to defend them contents, muscle tension) are on a continuum of
from challenge. Psychological acceptance in controllability. Psychological acceptance can be
this context means accepting one’s personal understood as gentle attempts to influence such
narrative as an inevitable product of an active, experiences where possible, while acknowledg-
pattern-seeking mind without either believing ing without struggle the inevitable limitations of
or disbelieving it. this influence.
Farmer and Chapman (2008) propose three Consider the case of test anxiety. As with other
principles in deciding if psychological accep- anxiety disorders, it is easy to appreciate how
tance is indicated. First, is acceptance ‘‘justified’’? an accepting stance with respect to catastrophic
A justified response is one that is warranted thoughts and anxious sensations evoked by tests
by the situation, such as a fear response in the could be beneficial. However, to be successful it
presence of a phobic stimulus. If the response is not enough to accept one’s subjective distress;
is justified, then acceptance is in order; if the one must also focus one’s attention in order to
response is not justified, then one either attempts orient toward the test itself. Approaches such
to change the response or at least to change as Wells’ (2000) attentional training technique,
the behavior elicited by the response (consistent in which flexible attentional control is targeted
with the DBT principle of ‘‘opposite action’’). For without attempting to change ongoing thoughts
example, distressing thoughts about being over- or feelings, may provide a useful approach to
weight are justified in an obese individual, but such cases.
the same thoughts are unjustified in a woman Finally, consistent with Farmer and Chap-
suffering from anorexia. Of course, determina- man’s (2008) notion of justified responses, there
tion of whether a thought is justified requires at are situations in which the literal truth of a
least some degree of analysis of the truth value thought or belief is, in fact, critical to evaluate. A
of the thought, which runs the risk of interfering man with tachycardia, shortness of breath, and
with attempts to accept it. Second, is the reaction chest pains needs to know whether he is dying
or situation changeable or unchangeable? Obvi- of a heart attack or simply having a panic attack.
ously, acceptance is indicated for unchangeable A woman who believes that she is being stalked
experiences. Finally, are the patient’s responses by an ex-boyfriend must evaluate the evidence
effective or ineffective? Effective responses are for this belief before simply accepting her feel-
conceptualized as those that are consistent with ings dispassionately. In such cases, psychological
valued goals, whereas ineffective responses are acceptance becomes relevant after an objective
inconsistent. When responses are ineffective in evaluation of the relevant evidence (e.g., a med-
this sense, they call for acceptance. ical workup for the individual with chest pains,
A common rule of thumb among acceptance- consultation with appropriate law enforcement
oriented CBT clinicians is that psychological authorities for the woman who believes she is
acceptance is indicated for any distressing per- being stalked). In many other cases, however,
sonal experiences, such as painful memories, one may be tempted to evaluate the truth of
disturbing thoughts, and difficult feelings or thoughts when doing so may not be necessary.
sensations, as well as for personal narratives. By An individual with public speaking anxiety will
contrast, direct change efforts should be reserved almost certainly have thoughts concerning nega-
for overt behaviors, that is, things involving one’s tive evaluation by the audience in anticipation of
hands, feet, mouth, and so on. Although superfi- a speech. An objective evaluation of the evidence
cially appealing, such a distinction becomes more for such beliefs would not only be difficult to
difficult upon closer examination. It assumes that achieve, but is not necessary. The individual can

41. 12 COGNITIVE BEHAVIOR THERAPY
learn simply to notice his catastrophic thoughts value of cognitions is clearly necessary. Although
and associated feelings of anxiety and to give the at first glance such efforts may appear incom-
speech anyway. The issue of determining when patible with experiential acceptance, acceptance
to evaluate versus when to accept distressing may actually enhance one’s efforts along these
thoughts is discussed further below. lines. Many existing acceptance-based innova-
tions have not attended sufficiently to the inte-
gration of change and acceptance strategies, and
UNRESOLVED ISSUES AND DIRECTIONS the reconciliation of these apparently inconsis-
FOR FUTURE RESEARCH tent themes.
It may in fact be the case that even the most
Given the relatively recent emphasis of staunch acceptance-oriented therapists covertly
acceptance-based therapies within CBT, there or implicitly do evaluate the validity of their
remain a number of unresolved questions patients’ thoughts, and then promote accep-
and directions for future research and clinical tance only when thoughts are inaccurate. In the
innovations. First, there is a need for new case of the man with chest pains described ear-
technologies to promote psychological accep- lier, for example, no acceptance-based therapist
tance. Given the pervasiveness of psychological would suggest that he simply acknowledge and
change-oriented strategies in Western culture, accept the pain without first referring him for an
the notion of fully accepting one’s experience appropriate medical evaluation to rule out car-
while simultaneously engaging in behavior that diac disease. We propose that the determination
is seemingly inconsistent with that experience of whether acceptance versus engagement with
can be counterintuitive. A range of clinical thoughts is indicated is best made on the strength
strategies and techniques are needed to foster of one’s knowledge that (1) one has already sys-
psychological acceptance. It is likely that there tematically evaluated a thought before, and/or
is untapped clinical wisdom among both (2) one’s mind routinely emits this exact thought
practicing cognitive behavior therapists and without good cause. An example of a workable
those from other theoretical orientations that strategy along these lines would be to reach an
would be helpful in promoting acceptance. agreement with patients to undertake a thorough
Similarly, the best methods of training practi- evaluation of a troubling thought once and only
tioners in acceptance-based technologies require once, after which the thought is simply noticed
further development. Many leading innovators, and accepted without further elaboration.
including Kabat-Zinn, Linehan, and Teasdale, In addition to clinical developments, there
all stress the importance of therapists cultivating remain a number of unresolved conceptual
their own mindfulness practice (Lau & McMain, issues. For example, is acceptance best concep-
2005). Likewise, Hayes incorporates various tualized as an overt behavior that can be directly
experiential exercises in his training workshops assessed, as suggested by Cordova (2001), or
with the purpose of developing a deeper as a private experience that is only indirectly
appreciation of ACT principles. Although there reflected in overt behavior? An individual with
is clear logic to the notion that such efforts will social anxiety disorder may attend a party
be helpful in therapists’ efforts to understand but may engage in a variety of covert ‘‘safety
and transmit acceptance-based strategies, the behaviors’’ that render her not fully engaged in
importance of such training strategies is not the experience. A purely behavioral assessment
known empirically. of the topography of her behavior would erro-
Second, the development of more explicit neously conclude that she was highly accepting
guidelines is needed in order to distinguish of her anxiety. The quality of one’s experience
when psychological acceptance is likely to be with respect to a distressing stimulus is also
helpful, and conversely, when direct change unclear. Cordova (2001) argues that ‘‘genuine’’
strategies are indicated. As discussed above, acceptance involves a ‘‘change in the stimulus
there are situations in which a certain level of function from aversive to more attractive’’ and
attentional control and evaluation of the truth similarly as ‘‘ . . . change in stimulus function

42. 2 • PSYCHOLOGICAL ACCEPTANCE 13
of a situation toward that which inclines the and terminological confusion (Zvolensky,
person to seek or remain in contact’’ (p. 221). Feldner, Leen-Feldner, & Yartz, 2005).
According to this analysis, if one remains in A review of the outcome research on
contact with an aversive stimulus without the acceptance-based CBTs is beyond the scope
stimulus losing its aversive properties, one is of this chapter; several reviews of the litera-
effectively in a state of hopeless resignation ture are now available (e.g., Brantley, 2005;
rather than true acceptance. It is noteworthy ¨
Coelho et al., 2007; Hayes et al., 2006; Ost,
that this perspective effectively requires that 2008). In general, the status of this body of
the stimulus be experienced as less aversive evidence can be summarized as preliminary
to qualify as ‘‘genuine’’ acceptance. Yet it but promising. Acceptance-based methods
seems entirely plausible that one could learn tend to fare at least as well as traditional
to remain in psychological contact with an change-oriented approaches, although only a
aversive stimulus without requiring that one’s handful of direct head-to-head comparisons
reactions to it necessarily change. For example, have been conducted to date (e.g., Forman,
a patient with chronic pain may learn to accept Herbert, et al., 2007; Lappalainen et al., 2007).
rather than fight his pain. This may or may not Clearly, more outcome research utilizing larger
result in a change in his pain perception, but it samples and more sophisticated methodological
¨
controls is needed (see Ost, 2008, for a detailed
is not clear that the degree of perceived pain
should distinguish ‘‘real’’ acceptance from mere discussion of methodological controls within
published studies on ACT and DBT). Likewise,
resignation. What seems important instead is
much more psychotherapy process research
his abandoning ineffective struggles with the
is needed to evaluate the extent to which
pain and his simultaneously pursuing other
psychological acceptance mediates changes in
activities that will enrich his life.
acceptance-based models of CBT, as well as
There also remains confusion about how the
perhaps even in more traditional models of
construct of psychological acceptance differs
CBT. Although initial studies are encouraging
from related constructs such as mindfulness.
(Hayes, Levin, Yadavaia, & Vilardaga, 2007),
Some theorists view acceptance as a necessary
much more work remains to be done.
feature of mindfulness. Brown and Ryan (2003),
for example, propose that mindful awareness
necessarily involves a nonjudgmental, accepting CONCLUSION
stance toward one’s experience. However, this
perspective fails to acknowledge that acceptance The field of CBT has recently witnessed an
does not always accompany awareness, as increased interest in theoretical and techno-
in the case of heightened awareness of one’s logical developments related to psychological
physiological arousal in panic disorder. This acceptance. Acceptance-based models of CBT
has led other theorists to deconstruct the are quickly growing in popularity. Preliminary
concept of mindfulness such that acceptance data not only support the efficacy of such
is only one aspect. For example, Herbert and approaches, but also support the conclusion
Cardaciotto (2005) argue that mindfulness is that changes in psychological acceptance may
best viewed bidimensionally as consisting of mediate more general changes produced by
psychotherapy, although much more work
ongoing awareness of one’s experience and
remains to be done with respect to both outcome
nonjudgmental acceptance of that experience,
and process. In addition, a number of theoretical
and that these two components are in fact con-
and practical issues remain outstanding and
ceptually and empirically distinct (Cardaciotto,
await further development.
Herbert, Forman, Moitra, & Farrow, in press).
This conceptual and terminological confusion
References
stems in part from the fact that investigators
are approaching these questions from diverse Abramowitz, J. S., Tolin, D. F., & Street, G. P. (2001).
theoretical perspectives, resulting in conceptual Paradoxical effects of thought suppression: