1

PTSD Case Conceptualization

Name

Department, University

Subject

Professor

Date
 2

PTSD Case Conceptualization

Following DSM 5 (American Psychiatric Association, 2013), post-traumatic stress

disorder (PTSD) is a severe mental condition that can be developed by an individual after his

being exposed to a traumatizing event (including warfare, sexual abuse, transport accidents, etc.).

Some symptoms of PTSD, typically, include distressing thoughts, feelings, and dreams about the

traumatizing event, neurotic reactions to trauma-related cues (with the subsequent avoidance of

the latter), increased flight-or-fight response, etc. Typically, the symptoms mentioned are

intense, thus, leading to severe impairments to the everyday life of those suffering from PTSD.

Several studies emphasize that a person with PTSD has significantly higher risks of suicide

(Bisson et al., 2015; Panagioti et al., 2015). Moreover, despite the sorrowful fact that 9% of the

population develops PTSD at some point in their lives, there is no cure for PTSD. However,

several psychotherapeutic approaches (mainly, as combined with pharmacological treatment)

were found (Reisman, 2016) to be effective in the management of its symptoms, restoring the

individual with PTSD to normal functioning.

Theoretical Orientation

Acceptance and Commitment Therapy (ACT) is a therapeutic approach of the third wave

of cognitive-behavioral therapy, along with dialectical behavior therapy, functional analytic

therapy, mindfulness-based cognitive therapy (Ost, 2008). In this sense, it is essential to

understand the evolutional dynamics of cognitive-behavioral therapy to have a profound view of

ACT and similar approaches. Following Leahy (2004), the first wave of behavior therapy was

based on the concepts of classical and operant conditioning, reinforcement and punishment. The

second wave, having emerged in the 1970s, was focused on the individual’s cognition (in the

forms of dysfunctional beliefs and irrational behaviors). The third wave shifted the therapeutic
 3

focus from the content and format of abnormal behaviors to their context: in this sense, ACT

theorists emphasize that the patients’ struggle to change their sensations, feelings, and thoughts

can only lead them to more significant distress (Hayes & Smith, 2005). In other words, instead of

encouraging their patients to work on their automatic negative thoughts (which are supposed to

produce negative feelings and subsequent dysfunctional behaviors), ACT therapists emphasize

their patients’ awareness of their current cognitive experiences. They help the patients recall their

values in the context of these experiences and encouraging their performance as based on

responsibility and commitment to these values. Thus, ACT is an empirically-based approach that

implies mindful acceptance of one’s problematic cognitive and emotional experiences with

commitment and corresponding behavior-changing strategies – for the patient to become more

psychologically flexible. Hayes (H., Strosahl, & Wilson, 2012) states that the goal of ACT is not

to eliminate the patient’s complicated feelings but instead to stay present with what life brings to

the patient and to perform a valued behavior. ACT encourages its clients to explore their feelings

carefully, not to overreact to them, giving up their avoidant behavior patterns. However, since

ACT can only be understood and, therefore, applied properly only in-the context of CBT’s

leitmotif, following which to solve a problem one need to address his consciousness and its

content, CBT can be considered the main theoretical approach with ACT’s being its significant

sub-component. This also implies the use of CBT’s specific techniques (such as exposure) during

therapeutic process.

ACT techniques resemble Buddhist mindfulness practices. They also teach the patient to

notice, accept, and embrace their inner experiences instead of confronting them, attempting to

impose control on his cognitions. One of the fundamental principles of ACT is the idea of self-

as-context. It implies that a person is not the content of his cognitions (thoughts or feelings), but
 4

rather the consciousness itself, which provides a “platform” for the existence of these cognitions.

The opposite is self-as-content, which encompasses the person’s social scripts about himself and

his operational manner in this world. Self-as-content may be understood in terms of a personal

narrative, including objective facts, personal details, and social and gender roles. Being unable to

differentiate himself from rules and restrictions of self-as-concept, a person may have many

struggles in different areas of his life. ACT’s negative attitude to sayings like “I wish I could do

this, but I am just not the kind of person to do so” brings it closer together with existential

philosophy and its “existence precedes the essence” motif.

However, whereas Western psychology has typically had its presupposition that a person

is initially healthy by nature, ACT states that psychological processes may be destructive,

leading a person to a failure to perform the needed behavior in accordance with his values. ACT

understands much of a person’s problems in the context of a juxtaposition of the acronyms

“FEAR” and “ACT.” FEAR is Fusion with thoughts, Evaluation of experience, Avoidance of

experience, Reason-giving for the behavior. ACT is: Acceptance of thoughts and emotions,

Choose of a valued direction, Take action. Harris (2006) establishes six core principles of ACT:

cognitive defusion, acceptance, contact with the present moment, value, committed action. These

principles were found (Levin et al, 2012) to increase psychological flexibility, the absence of

which predicts various forms of mental disorders, including anxiety and depression. A-Tjak (A.

et al., 2015) notices that studies demonstrate that ACT’s effectiveness is similar to CBT.

Intake Report

Jack is a head coach of a university football team. Having survived a plane crash

heroically, Jack’s personality and behavior, as observed by others: his co-workers noticed that he

has become irritable and aggressive, whereas his wife declared his resenting her presence,
 5

impaired sexual life, and increasing distance between them. However, with the beginning of

football practice, Jack immersed himself in his work, and his team had great results. After some

time, Jack, whose occupation implies frequent flights, experienced flying in a storm: the pilots

had to land the plane at the nearest airport, but when the storm passed, Jack was unable to take

the plane one more time due to his anxiety attack. Not being able to discuss the accident with his

wife, he woke her at night, complaining of chest pains and difficulty breathing. However, having

transported Jack to the hospital, the paramedics have found no evidence of cardiac problems.

That doctor recognized Jack’s having an anxiety attack and recommended him to visit a

psychologist. However, Jack could not believe that his symptoms were of psychological nature.

The other week, when he was packing to fly, Jack had another anxiety attack and another visit to

the emergency room. Understanding that his heart problems harm his occupational life, Jack

followed the doctor’s another recommendation and decided to make a visit to the university

psychologist.

First, trying to escape the dialogue about his psychological experiences, Jack asked for a

particular game plan to eliminate his attacks. However, after a few words, Jack admitted his

worries about his disconnection from other people, including his wife Lenora and son Michael.

Being asked about his actions, feelings, and thought that preceded his attacks, Jack quickly

understood their traumatizing link to the plane crash. Jack also declared having nightmares since

the accident; however, he was still unable to provide the details, attempting to avoid his terror.

For the next session, Lenora was invited: she burst into tears, accusing Jack of his distancing

from her. Astounded by her emotions, Jack answered that Lenora was not the only victim of his

social withdrawal, claiming that something had died inside him after the plane crash. He also

noticed that his excessive desire to succeed as a coach during the previous season had come from
 6

a need to fill his mind with something. Jack explained his social withdrawal, and the growing

distance between him and his wife by saying that during the plane crash he thought that he would

never see them again. Now, dismissing his feelings to his family (associatively linked to his

traumatic experience) Jack was trying to keep his psyche safe. Jack also recalled that during his

anxiety attacks, he kept thinking that he is going to die, echoing his thoughts during the crash. In

this sense, Jack’s anxiety attacks, nightmares, irritability, withdrawal from meaningful

relationships can be understood in terms of PTSD.

Following DSM 5 (American Psychiatric Association, 2013), Jack may be diagnosed

with PTSD since he meets the following set of criteria: direct imposture to threatened death

(A1); presence of recurrent, involuntary, and intrusive distressing memories (B1) and dreams of

the traumatic event (B2), flashbacks (B3), distress at exposure to external cues (B4), associated

with the event, and marked physiological reactions to them (B5); persistent avoidance of the

associated memories (C1) and reminders (C2); inability to remember important aspects of the

event (D1), constant negative emotional state (D4), diminished interest in significant activities

(D5), feelings of detachment to others (D6); arousal alterations associated with the traumatic

event, embodied in irritability (E1), exaggerated startle response (E4); duration of the

disturbance more than 1 month (F); significant distress and life impairments due to the

disturbances (G); the disturbance cannot be attributed to any effects of any substance or another

medical condition (H).

To achieve a profound understanding of Jack’s current mental condition it is essential to

restore the chain of the external events and their association with the circumstances of his inner

life. During the plane crash, Jack was exposed to significant amounts of fear for his life and the

potential loss of his loved ones; he managed to suppress his feelings and acted like a hero,
 7

helping the people around him; after the crash, he had to give several interviews in which he

recounted the story, thus, relieving his stress; to avoid his stressful memories, Jack refused to

give more interviews, attempting to bottle things up inside; he also has got used to dismissing his

emotions toward his family due to their traumatizing association with the accident; trying to

escape the space inside, Jack devoted himself to his work, keeping distance from his loved ones;

this avoidance and social withdrawal brought him relief from his distressing memories.

However, a person with PTSD cannot expect to run away from his problems forever: a chance

encounter with internal and external cues, which symbolize the problem, will always lead him to

significant distress (embodied in Jack’s anxiety attacks).

The point is that, following Rothschild (2000), a traumatizing event results in an

increased adrenaline response, creating neurological patterns in the person’s brain, which makes

him hyper-responsive to future fearful events. The amygdalocentric model of PTSD links its

symptoms to the impairments in brain mechanisms of experience and emotion regulation: high

levels of stress suppress the activity of the hippocampus (which is supposed to place our

memories in the correct space-time context), which results in flashbacks when a person with

PTSD undergoes a similar stimulus; however, due to hyper-activation of the amygdala

(responsible for our perception of the threatening stimuli) and the inability of the medial

prefrontal cortex to control its arousal, a person, being exposed to a similar stimuli has to relive

his traumatizing experience again and again. PTSD is also associated with the impaired balance

of neurotransmitters, being characterized by higher levels of norepinephrine, catecholamine, and

corticotropin-releasing factor. This also leads one to an idea that the neurophysiological

abnormalities induced by PTSD affect the hypothalamic-pituitary-adrenal axis (Raddley et al.,

2011). Moreover, PTSD symptoms are also associated with low serotonin levels. This
 8

contributes to the patients’ anxious states, irritability, aggression, and impulsivity (Olszewski &

Varrasse, 2005). In this sense, Bisson (B. et al., 2015) mentions that the combination of

pharmacological and psychotherapeutic treatment is significantly more beneficial than their

separate use.

Interventions

Following McLean and Folette (2017), it is essential to help the patient suffering from

PTSD understand that we are used to label some feelings as bad and others – as good. Trying to

extend our pleasures, we are prone to escape our painful feelings. However, even if our

avoidance of negative cognitions and states may appear beneficial in the short term, typically,

avoidance does not work well in the long run. ACT theorists assume that since that emotional

pain is also a part of our lives, painful feelings, like anger, sadness, and anxiety, cannot be

escaped. In this sense, ACT emphasizes the way people respond to their arising emotions,

whereas a person’s attempt to avoid painful cognitions can only lead one to more suffering and

psychological disorders. Woidneck (W., Morrison, & Twohig, 2014) provides the following

example: a person with PTSD, being constantly flooded by memories of his trauma and

associated anxiety and fear, may try to escape his cognitions with the help of alcohol, drugs, or,

as in Jack’s case, by plunging into his work. However, the pain is likely to worsen, leading to

numerous impairments in his social and occupational life. Thus, ACT is based on the idea that it

is not our painful emotion that leads us into suffering, but instead, our pain increases

dramatically with our attempts to avoid it. Therefore, in general, the main goal of ACT is to help

people stay open to their feelings, focusing their attention on the events of their inner life without

any attempt to escape them, living a meaningful life.

 9

In particular, ACT’s treatment of PTSD can be broken down into five goals: firstly, a

person should develop creative hopelessness, which means his ability to understand that avoiding

emotional pain will never work; secondly, he is supposed to accept the idea that his controlling

attempts may only worsen his state; thirdly, similar to mindfulness techniques, a person should

learn to step back from his thoughts to the state of observational self, not buying into them as

truth; fourthly, a person should stop the inner struggle with his cognitions; finally, identifying

meaningful areas in his life, a person is encouraged to act in accordance with his values, not

succumbing to the arising emotions.

Following Orsillo and Batten (2005), one of the most effective interventions used by

ACT therapists in the context of PTSD is exposure. A person is asked to go into details and

describe his painful experience in a safe environment several times to reduce the significance of

his cognitive and emotional experiences, associated with trauma. An ACT therapist is supposed

to guide a person into his painful memories, comforting his painful feelings and teaching him to

sit with them. In case the person is overwhelmed with his anxiety, grounding techniques (which

help one focus on his current sensations instead of traumatic memories of his past) may be used

to alleviate his stress (Thompson, Luoma, & LeJeune, 2013). In the context of the patient’s

exposure to his traumatic memories, it a therapist needs to help his client develop a set of skills

related to the decentralizing of trauma and broadening of the self-concept. It is also essential to

assist the client in clarifying his values to help him achieve a better understanding of self-as-

context (Pohar & Argaez, 2017).

Orsillo and Batten (2005) also emphasize the role of a therapeutic relationship in the

context of ACT due to the fact of its process’s often being emotionally intense. A strong
 10

therapeutic relationship contributes to the client’s feelings of safety, encouraging him to

verbalize and re-experience his traumatic memories.

Finally, considering the number of similarities between ACT and mindfulness practices,

an essential part of the therapeutic work may include the client’s psychoeducation (in the context

of the meditational practices). This will help him achieve a better understanding of the difference

between self-as-content and self-as-context.

Present Status

ACT provides an empirically-based scientific apparatus to evaluate the client’s progress

(in the context of his growing psychological flexibility) during the treatment. The first measuring

tool, proposed by Hayes (H. et al., 2004), is the Acceptance and Action Questionnaire (AAQ)

which is supposed to measure experiential avoidance, avoidant coping, and self-deceptive

positivity. However, since the fact that the AAQ was later found to have several severe

limitations in its ability to measure experiential avoidance, the Acceptance and Action

Questionnaire II was developed in order to improve the faults found in AAQ.

Following Boulanger (B., Hayes, & Lillis, 2009), the ACT interventions, aiming to

improve one’s psychological flexibility, address six core processes: acceptance, cognitive

defusion, self-as-context, being present, values, and committed action. Acceptance means Jack’s

ability to embrace his emotions, instead of attempting to get rid of them: having survived a plane

crash and having his history of social withdrawal, Jack may experience enormous scope of

problematic emotions (including anger, guilt, depression, anxiety, etc.), which can be difficult for

him to process. Cognitive defusion may be the most intricate of these processes, teaching one not

to take his cognitions as literal. If Jack has recurrent thoughts that he “is going to die,” he should
 11

be able to restructure them into “I am having a thought that I am going to die.” Cognitive

defusion is supposed to help Jack develop his self-as-context, making it possible for him to stay

aware of his problematic cognitions without being attached to them. That is, Jack should be able

to distinguish between his self-as-content (containing the flow of his inner experiences) and his

self-as-context (the background of this flow). The process of recognizing values should help Jack

clarify the meaningful aspects of his life: since Jack has declared his strong attachment to his

loved ones and his occupational life, the therapist should encourage him to distinguish these

values from his current painful emotions. Finally, committed action teaches the patients to

change their emotionally-induced behaviors to valuable ones. With the therapist’s assistance,

Jack is supposed to understand his psychological barriers, which prevent him from meaningful

activities.

Considering the potential intensity of Jack’s therapeutic process, it is essential to

understand that the success of ACT depends on the strong therapeutic relationship and, in

particular, on the therapist’s ability to comfort Jack’s emotions and help him examine them. If

Jack happens to have any difficulties with the establishment of a trusting relationship with his

therapist which is common in those suffering from PTSD (or in case Jack has any difficulties

with the process of ACT, being unable to observe his cognitions without any judgment) his

therapy may be accompanied with pharmacological treatment. The combination of

psychotherapy and pharmacological treatment was found to be more effective than their separate

use (Bisson et al., 2015).

Following Abdallah (A. et al., 2019), the FDA has approved sertraline and paroxetine, as

antidepressants of the selective serotonin reuptake inhibitors class (SSRIs), in the context of

PTSD treatment. These types of antidepressants are considered more effective and safe than
 12

tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). APA Practice

Guidelines state that SSRIs have proven their efficacy in the context of PTSD and related

symptoms and conditions treatment (Ursano et al., 2004).

Moreover, in case of Jack’s persisting nightmares, he may use an Apple Watch app

“NightWare”, which makes the watch vibrate when it detects an arising nightmare, based on the

patient’s heart rate and body movement.

Ethical Issues

In the case of PTSD treatment, a therapist needs to understand that trauma survivors

show different scores of resilience and posttraumatic growth. In this sense, specific ethical

considerations must be incorporated in the context of this kind of therapeutic work. Following

Frankel (2017), the client’s traumatic experiences may be overwhelming for both the client and

the therapist, thus, endangering professional and ethical boundaries.

There are several domains of ethical considerations that should be followed during the

therapist’s work with those who faced some traumatic event: informed consent, risk

management, establishment (and maintenance) of a strong therapeutic alliance, transference and

countertransference, and traumatic bonding (Frankel, 2017).

Informed consent ensures that Jack has an clear understanding of his diagnosis, planned

therapeutic techniques and interventions, expected time of treatment, and possible consequences

in the context of specific therapeutic tasks and goals (especially in the context of exposure

techniques). Moreover, some studies also suggest (Dusharme, 2017) that the clients with a

history of trauma are prone to violate the therapist’s boundaries, in particular, missing the
 13

appointments, bringing gifts, calling him during non-office hours, etc. In this sense, it is vital to

set proper personal boundaries with Jack during the first sessions.

Another important ethical consideration in treating those with PTSD is their inclination to

suicidal ideation and engagement in self-harming behaviors (Ellis et al, 2017): the therapist

needs to continuously monitor Jack’s possible suicidal thoughts to prioritize his safety, especially

following intense sessions.

Ellis (E. et al, 2017) also points out that patients with a history of trauma may have

difficulties in establishing close and trusting relationship. Moreover, during the therapeutic

process, a client may discuss terrifying and disturbing experiences, resulting in the therapist’s

strong negative reactions which can lead to his emotional distancing and detachment from the

client. Obviously, such behavior, as performed by the therapist, can reinforce the client’s

negative self-image. The therapist also needs to consider that his excessive curiosity about the

details of the client’s traumatic experience may also be recognized as a lack of empathy. Thus,

striving to benefit Jack and making efforts not to harm him, a therapist must be flexible and

sensitive in the context of establishing a strong therapeutic alliance.

Considering the possible threats of transference and counter-transference in the course of

the therapy of those with PTSD, several studies (Dalenberg, Tauber, & Palesh, 2001) emphasize

the therapist inclination to experience “an a priori counter-transference.” In other words,

understanding that Jack has gone through a traumatic event, the therapist may develop some

thoughts, feelings, and prejudices before their meeting in person. These personal attitudes may

interfere with the therapist’s ability to do his job adequately. In this sense, having faced such

experiences, the therapist should receive increased levels of personal therapy.

 14

Finally, since ACT treatment of PTSD is associated with the client’s re-experiencing his

traumatic memories, accompanied by powerful emotions, Jack may form an intense bond with

his therapist. This may lead the latter to act in an overprotective manner or, on the contrary, to

his distancing from Jack (Dutton & Painter, 1993). Recognizing trauma bonding, the therapist

should also have increased levels of personal therapy.

Relevant Research

To understand the theoretical rationale for Jack’s treatment it is essential to have a clear

view of his current psychological state and mental struggles. Having survived the plane crash

heroically, Jack has developed PTSD symptoms that touch upon his socioemotional life:

avoiding his traumatizing memories, Jack, either consciously or subconsciously, withdraws

himself from meaningful relationships which are associated with his trauma. Moreover, Jack’s

anxiety prevents him from performing his occupational duties. This puts at risk his career as a

coach of a university football team since it has become emotionally difficult for him to travel by

plane.

Indeed, Jack’s traumatizing experience has resulted in numerous impairments to his

ability to process his emotions, which can be considered the cornerstone of his current mental

problems. Cognitive-behavioral therapy (CBT) is strongly recommended by the American

Psychological Association in the context of treatment of PTSD (especially as combined with

exposure therapy since it is considered significant and helpful for those with PTSD symptoms to

be able to relive their traumatic experience). There is strong evidence that CBT can reduce PTSD

depressive symptoms and even result in a loss of PTSD diagnosis (Forman-Hoffman et al.,

2018). Moreover, trauma-focused cognitive behavioral therapy has also demonstrated its

effectiveness and is recommended as a first-line treatment for PTSD by the American Psychiatric
 15

Association, the National Institute of Clinical Excellence, Australian Centre for Posttraumatic

Mental Health, and the Australian Psychological Society (Forman-Hoffman et al, 2018).

Considering the present evidence of CBT’s effectiveness in the context of PTSD treatment, it is

essential to provide a thoughtful argumentation in favor of ACT as a primary (yet, not excluding

some techniques, proposed by the similar therapeutic perspectives) theoretical approach in the

context of treatment of Jack’s mental condition.

CBT’s theoretical understanding of the process of treatment can be boiled down to

challenging and changing cognitive distortions, subsequent improvement of the patient’s

emotional regulation, and development of his adaptive coping strategies (Beck, 2011). Following

CBT’s understanding of neurosis and neurotic states, psychological disorders develop from one’s

thought distortions and maladaptive behaviors. CBT has its philosophical roots in Stoic tradition

which supposes that our destructive emotions develop from our problematic understanding and

false beliefs about reality and ourselves.

In this sense, CBT encourages its clients to challenge their cognitive distortions (such as

overgeneralization and catastrophizing) and replace them with more adaptive ones. CBT

therapists state that it is not a stimulus itself that leads one to problematic emotions and

maladaptive behaviors, but it is the patient’s distorted understanding of them (and himself) which

results in his neurotic experiences. Thus, CBT teaches its clients to critically observe the content

of their cognition and develop a rational understanding of the reality and their place in this

reality.

However, the neurological studies of PTSD have demonstrated (Etkin & Wager, 2007)

that the development of PTSD symptoms is associated with hyper-activation of the amygdala

(responsible for one’s appraisal of a current stimulus as threatening) at the cost of diminished
 16

activity in the prefrontal cortex (responsible for one’s rational thinking abilities). Therefore, a

person with PTSD is initially in a no-win situation. His hyper-activated amygdala prevents him

from rational decision-making which disrupts his chances to critically evaluate his thinking

processes (which is considered the main goal of the CBT process).

Moreover, despite the findings of CBT’s effectiveness and its being proposed as first-line

treatment by various influential psychological organizations, a 2015 meta-analysis has revealed

its declining efficacy since 1977 (Johnsen & Friborg, 2015). Among the possible causes for this

decline, the authors list inadequate training of the therapists and their lack of experience, and the

patient’s hopes and expectations associated with the method. Possibly the growing popularity of

CBT and its Stoic philosophical foundations, resulting in numerous self-help techniques

available for the mass audience, have turned their innovativeness into something familiar, thus,

diminishing their therapeutic effect.

Thus, instead of challenging Jack’s false beliefs associated with his triggers, ACT

proposes a different idea. Whereas the classic CBT approach emphasizes the patient’s ability to

think rationally, ACT has no inclination to underestimate the power of the person’s emotions and

their inevitable impact on his maladaptive behaviors. The critical component of the ACT

therapeutic process is to help the client accept his problematic emotions and cognitions, instead

of trying to control them rationally.

The idea to sit calmly with the patient’s emotions, being in the position of a neutral

observer of his inner events, may seem counter-intuitive to the Western culture, which

emphasizes the problem-focused coping strategies. However, ACT finds its theoretical

foundations in the Eastern practices of mindfulness. These practices incorporated into the

process of therapy help one to dissociate himself from his problematic cognitions, being in the
 17

role of their neutral observer. That is, contrary to CBT’s inclination to understand a person as an

algorithm, which structure is predetermined by the rational content of his cognition, ACT

proposes an idea that an individual can accept his problematic mental state without any intention

to change it, still having an opportunity to act in accordance with his values.

However, to establish ACT as a proper treatment for Jack’s PTSD symptoms, this

approach and proposed techniques should have their empirical basis. In this sense, Ruiz (2010)

mentions that ACT is considered one of the most representative therapies in the context of the

third wave of behavior therapy. He also emphasizes the main idea of ACT: it does not recognize

the client’s thoughts as being either correct or incorrect, but instead as being either useful of not

in the context of the client’s values. The first studies focused on the empirical effectiveness of

ACT demonstrated its being less effective than CBT in treating mental disorders (Ost, 2008).

The subsequent evaluation of ACT’s effectiveness was carried out in the context of its

comparison with CBT: ACT has demonstrated lower scores than CBT (Chambless & Ollendick,

2001). However, Gaudiano (2009) attempted to re-evaluate the results of this research, having

found out that it was conducted over different disorders (with the more difficult ones to be

treated by ACT). Moreover, the study has also demonstrated that CBT studies mentioned above

were 4.5 more times funded than those of ACT.

Next, Levin and Hayes (2009) have conducted a meta-analytical review of ACT’s

effectiveness as compared to established treatment strategies, which has demonstrated that ACT

was better than established treatments.

The subsequent empirical evidence for ACT touches upon correlational, experimental

psychology and component, outcome, and case studies. Correlational studies attempted to
 18

understand the correlation scores among experiential avoidance and psychological symptoms and

other psychological constructs. Experiential avoidance is a central idea of ACT which can be

defined as the occurrence of a person’s deliberate efforts to escape from aversive cognitions

which leads to psychological inflexibility and the person’s subsequent need to avoid his

problematic cognitions to perform valuable behavior Most of the correlational studies of ACT

have used the AAQ, as a general measurement tool of experiential avoidance. Hayes (2006) has

found that experiential avoidance is positively related to a large number of psychological

symptoms (in particular, with anxiety and depression symptoms) and negatively related with

quality of life and general health measurements. The role of experiential avoidance has been

analyzed in the context of other symptoms and psychological constructs, as chronic pain: Kratz,

Davis, and Zautra (2007) have found that the acceptance of pain predicts posterior positive

effect. Several studies (Esteve, Ramirez Maestre, & Lopez Martinez, 2007; McCracken &

Vowles, 2007; Wicksell, Renofalt, Olsson, Bond, & Melin, 2008) have also found that the

construct of pain acceptance has correlations with functional status and functional disability,

predicting pain severity, its interference with one’s everyday life, and person’s physical state and

mental well-being. Moreover, pain acceptance was also found to be capable of mediating the

psychological effects of catastrophizing thoughts, and anxiety and depression symptoms.

McCracken, Vowles, and Gaurlett-Gilbert (2007) have demonstrated that acceptance and

persistence in activity are positively related to better long-term functioning, being negatively

related to distress and disability. Bond are Flaxmann (2006) have also found that experiential

avoidance can predict a person’s working performance, whereas Farach, Mennin, Smith, and

Mandelbaum (2006) stated that experiential avoidance was a mediator between 9/11 terrorist

attacks and anxiety, between maladaptive perfectionism and worry (Santanello & Gardner,
 19

2006), anxiety sensitivity and Borderline Personality Disorder (Gratz, Tull, & Gunderson, 2008),

social anxiety and posttraumatic stress in quality of life (Kashdan, Morina, Priebe, 2008).

Finally, Tull, Jakupack, Paulson, and Gratz (2007) state that experiential avoidance can predict a

person’s aggressive behavior.

On the other hand, several studies attempted to shed some light on the predictive power

of experiential avoidance in participants’ performance of different experimental tasks. In this

sense, Zettle (Z. et al., 2005) has found that those with higher scores in AAQ (which reflects

their higher levels of experiential avoidance) had lower tolerance. They managed to keep their

hands in the cold water for less time than those with lower AAQ scores and lower levels of

experiential avoidance. Feldner, Zvolensky, Eifert, and Spira (2003) have demonstrated that,

during a carbon dioxide-enriched air challenge, participants with higher levels of AAQ

demonstrated significantly higher levels of anxiety and emotional discomfort. Moreover,

participants with higher experiential avoidance levels were found (Karekla, Forsyth, & Kelly,

2004) were more prone to show their panic-related symptoms. The participants with higher

experiential avoidance levels were also found to show higher emotional experiences and higher

heart rate while being demonstrated unpleasant films (Salters-Pedneault, Gentes, & Roemer,

2007).

Interestingly, in the context of the controversial question of the efficacy of CBT

techniques, as compared to the efficacy of ACT’s approach, Marcks and Woods (2005) have

found that the participants, who were instructed to perform acceptance coping strategies, tended

to experience minor discomfort from their intrusive thoughts. At the same time, suppression and

challenging attempts were found to increase their anxiety. Moreover, Takahashi, Muto, Tada,

and Sugiyama (2002) that those participants who had received the acceptance-defusion rationale
 20

increased their pain tolerance (keeping their hands in the cold water) more significantly than

those who were provided the classic CBT instructions.

In the context of the outcome studies in clinical psychology, with the respect to anxiety

disorders, ACT has demonstrated (Twohig, Hayes, & Masuda, 2006) more positive results in

patients with obsessive-compulsive disorder, as compared to Progressive Relaxation Treatment.

ACT was also found to have better results in patients with social anxiety in the context of their

public speaking abilities (Dalrymple & Herbert, 2007). The effects of the ACT instructions

received by the patients with generalized anxiety disorder are also significant (Roemer, Orsillo,

Salters-Pedneault, 2008).

Moreover, several studies (Branstetter, Wilson, Hildenbrandt, & Mutch, 2004;

Montesinos & Luciano, 2005) compared the levels of distress of the participants with some form

of cancer, in the context of ACT versus CBT treatment strategies. The researchers have found

out that those who received ACT treatment demonstrated lower levels of distress.

Finally, the idea of ACT’s efficacy was also approved in the context of case studies of

generalized anxiety disorder (Huerta, Gomez, Molina, & Luciano, 1998), anxiety (Ferro, 2000),

panic disorder (Eifert, Forsyth, Arch, Espejo, & Langer, 2009), and PSTD (Batten, & Hayes,

2005; Orsillo, & Batten, 2005; Twohig, 2009).

Thus, ACT has demonstrated its efficacy in a wide range of problems that share a

common pattern of experiential avoidance (as one of the main focuses of attention of ACT

therapists). Ruiz (2010) also states that the effect of ACT is even better at follow-up, whereas the

interventions proposed by ACT are, typically, relatively short, showing relevant results. Despite

that it is difficult to unequivocally state the effectiveness of ACT, as compared to CBT, the
 21

existing empirical evidence is promising for ACT. Some studies point out the similar effects of

these approaches, whereas other studies have demonstrated better results for ACT.

Since Jack’s proposed treatment in the context of ACT also touches upon his mindfulness

skills, it is essential to shed some light on the empirical validation of the effectiveness of these

skills in participants with relevant mental conditions.

Mindfulness-based treatments of PTSD are considered present-centered since they

encourage their clients’ nonjudgment and acceptance of the present cognitions. Following Boyd

(B., Lanius, & McKinnon, 2018), mindfulness meditation was found to result in activation of the

prefrontal cortex with the decreased activation of the amygdala, associated with the production

of negative emotions. Mindfulness-based treatments (including mindfulness-based stress

reduction and mindfulness-based cognitive therapy) have proved their efficacy in the context of

reducing symptoms of PTSD: in particular, being addressed with mindfulness meditation

techniques, such symptoms as re-experiencing, avoidance, numbing, and hyper-arousal have

demonstrated significant reductions.

Considering that Jack’s proposed treatment also implies a possible prescription of SSRIs

(in the case of Jack’s being unresponsive to the methods of treatment mentioned above), it is

essential to notice that this group of antidepressants has also proved its effectiveness in reducing

the symptoms of PTSD. Approved by the FDA, SSRIs are considered the first-line treatment of

PTSD. However, in case of their ineffectiveness for Jack’s symptoms, he may also be prescribed

with the SNRI venlafaxine which is also considered a beneficial treatment for those with PTSD

(Alexander, 2012).
 22

Finally, the NightWare app, proposed as an additional and innovative treatment, has also

demonstrated its effectiveness during a 30-day randomized, sham-controlled trial of 70 patients:

the participants who wore AppleWatch with this software showed significant improvement on

the sleep scales (U.S. Food and Drug Administration, 2020).

 23

References

Abdallah CG, Averill LA, Akiki TJ, Raza M, Averill CL, Gomaa H, et al. (2019). "The

Neurobiology and Pharmacotherapy of Posttraumatic Stress Disorder." Annual Review of

Pharmacology and Toxicology. 59 (1): 171–189. doi:10.1146/annurev-pharmtox-010818-

021701. PMC 6326888. PMID 30216745

Alexander W. (2012). Pharmacotherapy for Post-traumatic Stress Disorder In Combat Veterans:

Focus on Antidepressants and Atypical Antipsychotic Agents. P & T : a peer-reviewed

journal for formulary management, 37(1), 32–38.

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental

Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

American Psychological Association. (2010). Ethical principles of psychologists and code of

conduct.

A-Tjak, JG; Davis, ML; Morina, N; Powers, MB; Smits, JA; Emmelkamp, PM (2015). "A meta-

analysis of the efficacy of acceptance and commitment therapy for clinically relevant

mental and physical health problems" (PDF). Psychotherapy and Psychosomatics. 84 (1):

30–6. doi:10.1159/000365764. PMID 25547522. S2CID 215537860

Beck JS (2011), Cognitive behavior therapy: Basics and beyond (2nd ed.), New York, NY: The

Guilford Press

Bisson JI, Cosgrove S, Lewis C, Robert NP (2015). "Post-traumatic stress disorder." BMJ. 351:

h6161. doi:10.1136/bmj.h6161. PMC 4663500. PMID 26611143.

Boulanger, Jennifer L.; Hayes, Steven C.; Lillis, Jason (2009). "Acceptance and Commitment

Therapy." In Fisher, Gary L.; Roget, Nancy A. (eds.). Encyclopedia of Substance Abuse

 24

Prevention, Treatment, & Recovery. 1. Thousand Oaks, CA: SAGE Publications. pp. 4–

7. ISBN 9781412950848.

Boyd, J. E., Lanius, R. A., & McKinnon, M. C. (2018). Mindfulness-based treatments for

posttraumatic stress disorder: a review of the treatment literature and neurobiological

evidence. Journal of psychiatry & neuroscience : JPN, 43(1), 7–25.

https://doi.org/10.1503/jpn.170021

Branstetter AD, Wilson, KG, Hildebrandt M, & Mutch D (2004). Improving psychological

adjustment among cancer patients: ACT and CBT. Paper presented at the Association for

Advancement of Behavior Therapy, New Orleans

Dalenberg, Constance; Tauber, Yvonne; Palesh, Oxana (2001). "Recovered memory and a priori

countertransference in the context of ongoing risk." doi:10.1037/e609242012-147

Dalrymple KL & Herbert JD (2007). Acceptance and Commitment Therapy for Generalized

Social Anxiety Disorder. Behavior Modification, 31, 543-568.

Ducharme, Elaine L. (2017-09-01). "Best practices in working with complex trauma and

dissociative identity disorder". Practice Innovations. 2 (3): 150–

161. doi:10.1037/pri0000050. ISSN 2377-8903

Dutton, Donald G.; Painter, Susan (January 1993). "Emotional Attachments in Abusive

Relationships: A Test of Traumatic Bonding Theory." Violence and Victims. 8 (2): 105–

120. doi:10.1891/0886-6708.8.2.105. ISSN 0886-6708.

Eifert GH, Forsyth JP, Arch J, Espejo E, & Langer D (2009). Acceptance and Commitment

Therapy for anxiety disorders: Three case studies exemplifying a unified treatment

protocol. Cognitive and Behavioral Practice, 16, 368-385.

 25

Ellis, Amy E.; Simiola, Vanessa; Brown, Laura; Courtois, Christine; Cook, Joan M. (2017-06-

29). "The role of evidence-based therapy relationships on treatment outcome for adults

with trauma: A systematic review." Journal of Trauma & Dissociation. 19 (2): 185–

213. doi:10.1080/15299732.2017.1329771. ISSN 1529-9732. PMID 28509624.

Esteve R, Ramirez-Maestre C, & Lopez-Martinez AE (2007). Adjustment to chronic pain: The

role of pain acceptance, coping strategies, and pain-related cognitions. Annals of

Behavioral Medicine, 33, 179-188.

Etkin A, Wager TD (2007). "Functional neuroimaging of anxiety: a meta-analysis of emotional

processing in PTSD, social anxiety disorder, and specific phobia." The American Journal

of Psychiatry. 164 (10): 1476–

88. doi:10.1176/appi.ajp.2007.07030504. PMC 3318959. PMID 17898336

Farach FJ, Mennin, DS, Smith RL, & Mandelbaum M (2008). The impact of pretrauma analogue

GAD and posttraumatic emotional reactivity following exposure to the september 11

terrorist attacks: A longitudinal study. Behavior Therapy, 39, 262–276.

FDA. (2020). FDA Permits Marketing of New Device Designed to Reduce Sleep Disturbance

Related to Nightmares in Certain Adults. U.S. Food and Drug Administration.

https://www.fda.gov/news-events/press-announcements/fda-permits-marketing-new-

device-designed-reduce-sleep-disturbance-related-nightmares-certain-adults.

Feldner MT, Zvolensky MJ, Eifert GH, & Spira AP (2003). Emotional avoidance: An

experimental tests of individual differences and response suppression during biological

challenge. Behaviour Research and Therapy, 41, 403-411.

 26

Ferro R (2000). Aplicación de la terapia de aceptación y compromiso en un ejemplo de evitación

experiencial. Psicothema, 12, 445-450.

Forman-Hoffman V, Middleton JC, Feltner C, Gaynes BN, Weber RP, Bann C, et al.

(2018). "Psychological and Pharmacological Treatments for Adults With Posttraumatic

Stress Disorder: A Systematic Review Update." AHRQ Comparative Effectiveness

Review. Rockville (MD): Agency for Healthcare Research and Quality

(US). doi:10.23970/ahrqepccer207. PMID 30204376

Gaudiano BA & Herbert JD (2006). Believability of hallucinations as a potential mediator of

their frequency and associated distress in psychotic inpatients. Behavioural and Cognitive

Psychotherapy, 34, 497-502.

Gratz KL, Tull MT, & Gunderson JG (2008). Preliminary data on the relationship between

anxiety sensitivity and borderline personality disorder: The role of experiential

avoidance. Journal of Psychiatric Research, 42, 550-559.

Giller EL (1990). Biological Assessment and Treatment of Posttraumatic Stress Disorder.

Washington DC: American Psychiatric Press, Inc

Harris, Russ (2006). "Embracing your demons: an overview of Acceptance and Commitment

Therapy" (PDF). Psychotherapy in Australia. 12 (4): 2–8.

Hayes, Steven; Kirk Strosahl; Kelly Wilson; Richard Bissett; Jacqueline Pistorello; Dosheen

Toarmino; Melissa Polusny; Thane Dykstra; Sonja Batten; John Bergan; Sherry Stewart;

Michael Zvolensky; Georg Eifert; Frank Bond; John Forsyth; Maria Karekla; Susan

McCurry (2004). "Measuring Experiential Avoidance: A Preliminary Test of a Working

Model." The Psychological Record. 54 (4): 553–578. doi:10.1007/BF03395492

 27

Hayes, S. C., & Smith, S. (2005). Get Out of Your Mind and into Your Life: The New Acceptance

and Commitment Therapy. Santa Rosa, CA: New Harbinger Publications.

Hayes, Steven C.; Strosahl, Kirk D.; Wilson, Kelly G. (2012). Acceptance and Commitment

Therapy: The Process and Practice of Mindful Change (2 ed.). New York: Guilford

Press. p. 240. ISBN 978-1-60918-962-4.

Johnsen TJ, Friborg O (2015). "The effects of cognitive behavioral therapy as an anti-depressive

treatment is falling: A meta-analysis." Psychological Bulletin. 141 (4): 747–

68. doi:10.1037/bul0000015. PMID 25961373. S2CID 27777178

Kratz AL, Davis MC, & Zautra AJ (2007). Pain acceptance moderates the relation between pain

and negative affect in female osteoarthritis and fibromyalgia patients. Annals of

Behavioral Medicine, 33, 291–301.

Leahy, R. L. (2004). Contemporary cognitive therapy: Theory, research, and practice. New

York, NY: Guilford Press.

Levin, Michael E.; Hildebrandt, Mikaela J.; Lillis, Jason; Hayes, Steven C. (2012). "The Impact

of Treatment Components Suggested by the Psychological Flexibility Model: A Meta-

Analysis of Laboratory-Based Component Studies." Behavior Therapy. 43 (4): 741–

56. doi:10.1016/j.beth.2012.05.003. PMID 23046777.

McCracken LM & Vowles KE (2007). Psychological flexibility and traditional pain management

strategies in relation to patient functioning with chronic pain: An examination of a

revised instrument. Journal of Pain, 8, 339-349.

McLean, C., & Follette, V. M. (2016). Acceptance and commitment therapy as a

nonpathologizing intervention approach for survivors of trauma. Journal of trauma &

 28

dissociation : the official journal of the International Society for the Study of

Dissociation (ISSD), 17(2), 138–150. https://doi.org/10.1080/15299732.2016.1103111

Olszewski TM, Varrasse JF (2005). "The neurobiology of PTSD: implications for

nurses." Journal of Psychosocial Nursing and Mental Health Services. 43 (6): 40–

7. doi:10.3928/02793695-20050601-09. PMID 16018133

Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment therapy in the treatment of

posttraumatic stress disorder. Behavior Modification, 29(1), 95–129.

Öst, Lars-Göran (2008). "Efficacy of the third wave of behavioral therapies: A systematic review

and meta-analysis." Behaviour Research and Therapy. 46 (3): 296–

321. doi:10.1016/j.brat.2007.12.005. PMID 18258216

Panagioti M, Gooding PA, Triantafyllou K, Tarrier N (2015). "Suicidality and posttraumatic

stress disorder (PTSD) in adolescents: a systematic review and meta-analysis." Social

Psychiatry and Psychiatric Epidemiology. 50 (4): 525–37. doi:10.1007/s00127-014-

0978-x. PMID 25398198. S2CID 23314414

Pohar, R., & Argáez, C. (2017). Acceptance and Commitment Therapy for Post-Traumatic Stress

Disorder, Anxiety, and Depression: A Review of Clinical Effectiveness. Canadian Agency

for Drugs and Technologies in Health.

Radley JJ, Kabbaj M, Jacobson L, Heydendael W, Yehuda R, Herman JP (2011). "Stress risk

factors and stress-related pathology: neuroplasticity, epigenetics and

endophenotypes." Stress. 14 (5): 481–

97. doi:10.3109/10253890.2011.604751. PMC 3641164. PMID 21848436.

Reisman M. (2016). PTSD Treatment for Veterans: What's Working, What's New, and What's

Next. P & T : a peer-reviewed journal for formulary management, 41(10), 623–634.

 29

Rothschild B (2000). The Body Remembers: The Psychophysiology of Trauma and Trauma

Treatment. New York: W.W. Norton & Company. ISBN 978-0-393-70327-6

Ruiz, F. (2010). A review of Acceptance and Commitment Therapy (ACT) empirical evidence:

Correlational, experimental psychopathology, component and outcome studies.

International Journal of Psychology and Psychological Therapy. 10. 125-162.

Salters-Pedneault K, Gentes E, & Roemer L (2007). The role of fear of emotion in distress,

arousal, and cognitive interference following an emotional stimulus. Cognitive Behaviour

Therapy 36, 12–22.

Takahashi M, Muto T, Tada M, & Sugiyama M (2002). Acceptance rationale and increasing pain

tolerance: Acceptance-based and FEAR-based practice. Japanese Journal of Behavior

Therapy, 28, 35-46.

Thompson, B. L., Luoma, J. B., & LeJeune, J. T. (2013). Using acceptance and commitment

therapy to guide exposure-based interventions for posttraumatic stress disorder. Journal

of Contemporary Psychotherapy, 43(3), 133–140.

Ursano RJ, Bell C, Eth S, Friedman M, Norwood A, Pfefferbaum B, et al. (2004). "Practice

guideline for the treatment of patients with acute stress disorder and posttraumatic stress

disorder." The American Journal of Psychiatry. 161 (11 Suppl): 3–

31. doi:10.1176/appi.books.9780890423363.52257. ISBN 0-89042-336-9. PMID 156175

11

Woidneck, M. R., Morrison, K. L., & Twohig, M. P. (2014). Acceptance and Commitment

Therapy for the Treatment of Posttraumatic Stress Among Adolescents. Behavior

modification, 38(4), 451–476. https://doi.org/10.1177/0145445513510527

 30

Zettle RD (2003). Acceptance and Commitment Therapy (ACT) versus systematic

desensitization in treatment of mathematic anxiety. The Psychological Record, 53, 197-

215.