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Cognitive and Behavioral Practice 19 (2012) 606-618

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1
Contains Video

Brief Acceptance and Commitment Therapy and Exposure for Panic Disorder:
A Pilot Study
Alicia E. Meuret, Southern Methodist University
Michael P. Twohig, Utah State University
David Rosenfield, Southern Methodist University
Steven C. Hayes, University of Nevada
Michelle G. Craske, University of California, Los Angeles

Cognitive and biobehavioral coping skills are central to psychosocial therapies and are taught to facilitate and improve exposure
therapy. While traditional coping skills are aimed at controlling maladaptive thoughts or dysregulations in physiology, newer
approaches that explore acceptance, defusion, and values-based direction have been gaining interest. Acceptance and Commitment
Therapy (ACT) involves creating an open, nonjudgmental stance toward whatever thoughts, feelings, and bodily sensations arise in a
given moment, experiencing them for what they are, and moving toward them while inner experiences such as anxiety are present. This
approach can be seen as consistent with exposure therapies and may be utilized to organize and facilitate engagement in exposure
exercises. This study examines the feasibility and efficacy for combining a brief ACT protocol with traditional exposure therapy. Eleven
patients with panic disorder with or without agoraphobia received 4 sessions of ACT followed by 6 sessions of exposure therapy, with
data collected on a weekly basis. Acquisition of ACT skills and their application during exposure was monitored using a novel
“think-aloud” technology. Treatment was associated with clinically significant improvements in panic symptom severity, willingness to
allow inner experiences to occur, and reductions in avoidant behavior. Although preliminary, results suggest that our brief training in
ACT only (as assessed prior to exposure exercises) and in combination with exposure therapy was acceptable to patients and offered
benefits on the order of large effect sizes. Clinical and research implications are discussed.

C and biobehavioral coping skills are central

OGNITIVE
to psychosocial therapies for anxiety disorders and
are taught to facilitate and improve exposure therapy.
These control-based coping skills typically aim to change
catastrophic appraisals or change somatic symptoms.
While traditional coping skills are aimed at controlling
maladaptive thoughts or dysregulations in physiology,
newer approaches that explore acceptance or willingness
to experience such states have been gaining interest. One
specific cognitive behavioral modality that is receiving
increased attention is Acceptance and Commitment
Therapy (ACT; Hayes, Strosahl, & Wilson, 2011). ACT is
part of the cognitive behavioral tradition, but it focuses
1
Video patients/clients are portrayed by actors.
Keywords: Acceptance and Commitment Therapy; exposure; behav-
ioral; panic; efficacy
1077-7229/12/606-618$1.00/0
© 2012 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
more heavily on acceptance and mindfulness processes as
ways of responding to internal experiences (i.e., thoughts,
feelings, bodily sensations) than more traditional CBT
protocols. To this end, ACT is more similar to other
acceptance- and mindfulness-based interventions, such as
Mindfulness-Based Cognitive Therapy (Segal, Williams, &
Teasdale, 2002), that focus on the function of internal
experiences rather than their form or content.
With the focus shifting away from the question of
whether “CBT works” to “why it works” (i.e., mediators)
and “for whom” (i.e., moderators), the examination of
novel approaches seems particularly vital (Kazdin, 2007;
McNally, 2007; Meuret, Wolitzky-Taylor, Twohig, &
Craske, 2012). While the combination of therapeutic
components that make up traditional CBT is generally
effective for patients suffering from an anxiety disorder
(Norton & Price, 2007; Westen & Morrison, 2001), there
is considerable room for improvement. This seems
particularly true for patients suffering from panic
disorder with or without agoraphobia (PD/A). Here,
effect sizes for CBT are the smallest among the anxiety
disorders (Andrews, Cuijpers, Craske, McEvoy, & Titov,
 Brief ACT and Exposure
2010; Hofmann & Smits, 2008; but not Norton & Price,
2007), attrition is high (Haby, Donnelly, Corry, & Vos,
2006), and a large percentage of completers do not reach
responder status after treatment (T. Brown & Barlow,
1995).
ACT involves the creation of an open, allowing attitude
and nonjudgmental curiosity toward whatever emotions
arise in a given moment, including panic-related ones,
and the ability to then mindfully turn attention toward
values-based actions (Hayes et al., 2011). It aims to help
clients notice panic-related inner experiences, see them
as simply events occurring within the body, allow them to
either occur or not, and continue a valued direction with
these experiences as aspects of life. While these pro-
cedures are not antithetical to traditional CBT pro-
cedures, ACT makes no attempts to eliminate the
content of inner experiences. In traditional CBT, clients
are encouraged to learn cognitive skills to control
negative thoughts or somatic skills to control dysregulated
physiology, which are then applied during exposure
to feared sensations or situations. In ACT training,
clients learn how to function with or without the presence
of panic-related inner experiences, rather than trying
to regulate or control them before changing behavior.
As such, there is little concern for the intensity or
frequency of panic-related thought, feelings, or bodily
sensations.
There is support for this conceptualization of PD/A
(e.g., Levitt et al., 2004; Levitt & Karekla, 2005; Orsillo,
Roemer, Block-Lerner, & Tull, 2004) and growing evidence
supporting the utility of ACT for anxiety disorders (as
reviewed in Codd, Twohig, Crosby, & Enno, 2011).
Correlational studies have shown that psychological in-
flexibility (the target process in ACT) predicts anxiety
and anxiety sensitivity across a range of patients (Hayes,
Luoma, Bond, Masuda, & Lillis, 2006). Randomized
controlled trials of ACT for anxiety disorders are emerging,
including ACT for test anxiety (L. Brown et al., 2011; Zettle,
2003), social anxiety disorder (Kocovski, Fleming, & Rector,
2009), generalized anxiety disorder (Roemer, Orsillo, &
Salters-Pedneault, 2008), and obsessive-compulsive disor-
der (Twohig et al., 2010). ACT protocols can be applied
across a variety of anxiety disorders. This has been
demonstrated in case studies (Codd et al., 2011), effective-
ness studies with samples of participants diagnosed with
anxiety disorders (Lappalainen et al., 2007), or studies with
clinically severe levels of anxiety and depression, albeit
undiagnosed (Forman, Herbert, Moitra, Yeomans, &
Geller, 2007).
While some of these studies purposefully exclude
exposure exercises for experimental reasons (Codd et al.,
2011; Twohig, Hayes, & Masuda, 2006; Twohig et al., 2010),
ACT is complementary to traditional exposure exercises.
From an ACT perspective, “The purpose of exposure is not
607
to reduce emotional arousal but to practice acceptance of
private experiences and the ability to function in a more
free, flexible, and values-based way in their presence”
(Hayes et al., 2011, p. 400; see also Hayes, 1987, p. 365). This
view is consistent with a current view of exposure put forth
by Craske and colleagues (2008) that exposure may work by
optimizing learning based on increasing tolerance for fear
and anxiety, rather than the traditional focus on fear
reduction. With empirical support for fear reduction
serving as a predictor of treatment outcome largely lacking
(Baker, Mystkowksi, Culver, Yi, Mortazavi, & Craske, 2010;
Craske et al., 2008; Culver, Stoyanova & Craske, 2012;
Kircanski et al., 2012; Meuret, Seidel, Rosenfield, Hofmann,
& Rosenfield, in press), the quest for identifying outcome
predictors is more pertinent than ever.
Hence, ACT may offer a potent alternative approach
that enhances the acceptability of and engagement in
exposure therapy/behavioral change by creation of
response flexibility and new learning that occurs while
exposing oneself to the feared stimuli. Preliminary
evidence for this thesis has been shown in recent
experimental studies in which brief training in emotional
acceptance lowered distress and increased tolerance for
experimentally induced anxiety symptoms in individuals
with PD/A (Campbell-Sills, Barlow, Brown, & Hofmann,
2006; Eifert & Heffner, 2003; including carbon-dioxide
inhalation challenges, Levitt et al., 2004). Similar results
have been shown for pain tolerance (e.g., Hayes, Bissett,
et al., 1999) and exposure to distressing International
Affective Picture System slides (Arch & Craske, 2006).
The current investigation aimed to assess the feasibility
and efficacy of a behaviorally based ACT treatment that
was systematically divided into a skill training phase and a
skills application phase. Patients in this pilot trial suffered
from a principal DSM-IV (American Psychiatric Associa-
tion, 1994) diagnosis of PD/A. They received 4 sessions of
ACT focusing on acceptance, defusion, and values-based
action, followed by 6 sessions of ACT combined with
exposure therapy. Panic symptom severity and willingness
to accept panic-related inner experiences were examined
after ACT only and after the combination of ACT with
exposure.
Methods
Patients and Procedure
Eleven patients (ages 20 to 55, average age=34.3)
participated in the open series of behaviorally based ACT
treatment. The study was conducted at two sites: the Stress,
Anxiety, and Chronic Disease Research Program at
Southern Methodist University, Dallas (SMU; N=5), and
the Anxiety Disorders Research Center at the University of
California, Los Angeles (UCLA; N=6). Patients were
recruited by regional postings, newspaper advertisements,
and by self-referrals to the anxiety clinics, and selected
608 Meuret et al.

based on the following inclusion and exclusion criteria:
(a) current principal diagnosis of PD/A (DSM-IV criteria),
(b) 18 years or older, (c) if medicated, on a stable dose of
psychotropic medication for at least 3 months before study
initiation and willingness to maintain on a stable dose
throughout treatment, (d) agreement not to initiate
additional therapy while participating in the study, and
(e) no indication of a history of bipolar disorder, psychotic
disorder, suicidal intention, current substance abuse or
dependence, or current organic mental disorder, serious
medical disease, respiratory illness, or seizures.
Patients who appeared eligible on the basis of an initial
telephone screen were invited for a diagnostic interview
using the Anxiety Disorders Interview Schedule for DSM–IV
(ADIS–IV–L; DiNardo, Brown, & Barlow, 1994) at UCLA or
the Structured Clinical Interview for DSM–IV, Patient
Edition (SCID; First, Spitzer, Gibbon, & Williams, 1995) at
SMU. Complete phone screens were available from 24
individuals. Several more expressed interest but were not
phone screened (never returned calls, numbers were not in
service) or terminated screen prematurely (largely due to
insufficient reimbursement). Of the 24 phone contacts, 11
were ineligible due to another DSM-IV diagnosis being
principal (social phobia [1], bipolar disorder [4], specific
phobia [1], psychosis [1], GAD [1], PTSD [1]) or not
endorsing panic attacks [2]). Of the remaining 13
participants, 2 were not eligible because they did not
meet criteria for a principal diagnosis of PD. The principal
diagnosis of PD/A and other psychiatric diagnoses were
established by consensus at a weekly staffing meeting.
The diagnostic interviews were followed by the clinician-
administered Panic Disorder Severity Scale (PDSS; Shear et
al., 1997), which was repeated at posttreatment. All inter-
views were conducted by clinicians trained and certified in
the respective instruments. Following the initial diagnostic
and clinical interviews, patients were enrolled to receive
four individual sessions of ACT followed by six sessions of
exposure therapy (interoceptive and in-vivo exposure).
All patients were female and the majority was married
(63.6%), well educated (14.4 years), and working
(54.5%). Most were Caucasian (72.7%), with the remainder
being Hispanic (27.3%). Eighty-one percent had at least
one additional current DSM-IV Axis I diagnosis (anxiety
disorder [n=9], anxiety and mood disorder [n=2]). Six
patients were on stable doses of psychotropic medication
(antidepressants [n=3], benzodiazepines [n=3]).
The average number of sessions utilized was 8.1
(ranging from 1 to 10). Of these, 8 patients completed
all 10 treatment sessions, 1 patient terminated treatment
after the 6th session because she no longer felt
symptomatic, and 2 patients dropped out early in
treatment (after Session 1 and 3) due to transportation
or scheduling difficulties. According to the PDSS (range
0–4), levels of severity were in a moderate range (PDSS=
2.08, SD=0.76) at pretreatment Table 1.
Intervention
Our protocol focused heavily on the acceptance
element of ACT but also addressed defusion and
values-based action for the first four sessions, and then
utilized these skills in the context of exposure exercises
for the following six sessions. Patients were trained in ACT
as a form of skill training to allow them to more effectively
“cope” with panic symptoms. In contrast to traditional
“coping” skills training of CBT, patients learned to accept,
notice, and be open to inner experiences that related to
panic without the attempt to eliminate or control them
(e.g., through corrections of thoughts or regulation of
physiology).

Table 1
Session-by-session EM Means (SD)
ACQ (0-56) ASI (0-64) FFMQ (15 - 75) PDSS (0-4)
Pre/Session 1 23.27 (3.72) 37.81 (4.45) 42.55 (2.23) 2.08 (0.20)
Session 2 18.68 (3.75) 33.39 (4.51) 41.23 (2.29)
Session 3 16.39 (3.77) 31.33 (4.54) 43.73 (2.31)
Session 4 17.48 (3.85) 31.42 (4.69) 46.21 (2.44)
Mid/Session 5 12.78 (3.85) 25.34 (4.66) 47.40 (2.41) 1.31 (0.21)
Session 6 14.70 (3.86) 22.23 (4.68) 47.34 (2.42)
Session 7 14.55 (3.91) 22.76 (4.77) 46.55 (2.50)
Session 8 9.58 (3.98) 19.32 (4.88) 50.54 (2.60)
Session 9 8.91 (3.95) 19.10 (4.81) 51.13 (2.54)
Session 10 8.54 (3.95) 17.02 (4.82) 52.39 (2.55)
Post treatment 7.66 (3.96) 15.03 (4.82) 53.40 (2.55) 0.54 (0.23)
Note. ACQ = Agoraphobia Cognition Questionnaire; ASI = Anxiety Sensitivity Index; FFMQ = Composite Non-Judging and Non-Reactivity
Scales of the Five Factor Mindfulness Questionnaire (FFMQ); PDSS = Panic Disorder Severity Scale.
 Brief ACT and Exposure
Sessions 1–4: ACT Skill Acquisition Training
Session 1. Session 1 began with basic descriptions of
the intervention and what is to be expected in
treatment (Video 1). ACT was presented as a means
to back away from and not get entangled with panic-
related inner experiences. This can be confusing for
many patients because it is usually assumed that
treatment focuses on reducing or regulating panic-
related inner experiences. The logic of the ACT
approach was introduced by leading the patient
through an exercise to demonstrate that the more
effort at regulating panic-related inner experiences,
the poorer the actual control over them. This was
ultimately highlighted with the “man in the hole” met-
aphor (Hayes, Strosahl, & Wilson, 1999, pp. 101-104)
in which the patient is in a hole (the panic-related
inner experiences) and digging (attempting to control
or regulate these internal events) does not get the
individual out of the hole, but enlarges it (Video 2).
Instead of trying to regulate the panic-related inner
experiences, it is suggested that the patient focus on
finding ways to step back from these events and
mindfully watch them occur. This is explained through
the “two scales” metaphor (Video 3; Hayes, Strosahl,
et al., 1999, pp. 133-134): the patient is asked to take
the focus off the first scale (the level or intensity of
panic-related inner experiences) and to shift that
focus and energy over to the second scale (the degree
of willingness to experience these events as they are in
the moment).
As part of our abbreviated ACT protocol, patients also
participated in a 15-minute audio exercise that involved
accepting, stepping back from thoughts, and mindfully
watching them. It began by remembering the most recent
Video 1. Treatment description and expectations (Session 1).
609
panic attack that occurred. After that was brought to mind,
the patient was asked to mindfully notice all inner
experiences that were occurring. This involved noticing
all bodily experiences, such as the feeling of sitting in a
chair, the tightness of one's jaw, and other sensations
related to panic attacks. It was suggested to the patient,
“When you feel yourself getting sucked into the emotions—
like we sometimes do with very intriguing television
shows—pull yourself back and continue to watch it.”
The patient was asked to shift attention to any emotions that
were experienced. Specifically, the patient was asked to
notice all aspects of that emotion with curiosity instead of
judgment or evaluation. This was done more formally in a
mindfulness exercise that involved watching thoughts pass
by without grabbing onto or pushing any thoughts away.
Finally, it was suggested that when inner experiences are
noticed from a mindful and nonjudgmental stance, they
are easier to experience. It was suggested that the patient
take this position to other inner experiences in life.
ACT-based between-session exercises. At the end of the first
training session, patients received detailed instructions on
the rationale and practice of two, 15-minute, daily
between-session exercises. The first was called “Practicing
Awareness of Your Experience.” Homework in our ACT
protocol was structured and closely monitored with the
aid of modern technology. The specific exercise was the
15-minute audio-script previously described. The second
was a self-guided exercise in which patients recorded
themselves practicing awareness of breathing, panic-
related symptoms, and any other internal stimuli. At
specific intervals during the exercise (minute: 3, 7, 11),
patients were prompted to verbalize their thinking using a
digital voice recorder (see Measures section). At each
weekly session during the ACT skills acquisition training,
Video 2. Illustrating ill-fated attempts to control anxiety using the
“Man in the Hole” metaphor (Session 1).
610 Meuret et al.
Video 3. Stepping back from controlling anxiety using the “Two
Scales” metaphor (Session 1).
therapists reviewed reports of between-session exercises to
better assist in identifying examples of successful accep-
tance and cognitive defusion and support further
improving of skills. The aim of this close monitoring,
otherwise atypical for ACT protocols, was two-fold: first, to
assess the feasibility of structured exercises using audio-
scripts, and second, to better assess the degree and quality
of skill training in a home-based setting.
Session 2. Session 2 focused on the counterproductive
effects of attempting to control or regulate panic-related
inner experiences (Video 4). The process of attempting
to control events that are negatively evaluated was
normalized, but it was highlighted that this process is
much more successful when applied to events outside of
our bodies (e.g., the difference between controlling an
Video 4. Demonstrating the counterproductive effects of controlling/
regulating panic-related inner experiences (Session 2).
inner experience and controlling things in our outside
environments). The counterproductive result of attempt-
ing to control inner experiences was compared to attempt-
ing to not get anxious when connected to a polygraph
machine. Allowing the inner experiences to occur was
compared to a Chinese finger trap, a child's toy in which
trying to get out paradoxically traps the child (Hayes,
Strosahl, et al., 1999, pp. 104-105). Generally, the focus of
the session was to increase the patient's willingness to
experience panic-related inner experiences and cease
attempts to regulate them.
Session 3. Largely focused on defusion from the literal
meaning of panic-related cognitions, this session began
with a relatively simple exercise that helped the patient to
view having verbal abilities as a blessing and a curse. The
patient was asked to look around the room for anything
she could not name. Similarly, she was asked to see if she
could find anything about which she had no opinion—
that she could not evaluate. Most patients can name
everything and can evaluate just about everything. It was
noted that this process is very useful, but it can become
problematic when applied to our own inner experiences.
For example, when anxiety occurs it is usually named and
evaluated negatively. The same applies to many other
panic-related inner experiences. It was also noted that this
process cannot be stopped; everyone with cognitive
abilities does this (Video 5). Next, a series of defusion
exercises were covered that aimed to give patients the
ability to experience inner events as just events and less
tied to their cognitive meanings and evaluations. Exer-
cises included “Milk, Milk, Milk” (Hayes, Strosahl, et al.,
1999, pp. 154-156) and “Passengers on the Bus” (Video 6;
Hayes, Strosahl, et al., pp. 157-158). Both exercises focus
on seeing cognitive activity as an ongoing process that one
Video 5. Experiencing “language” for what it is (Session 3).
 Brief ACT and Exposure
Video 6. Exploring the “Passenger on the Bus” metaphor as an
example for recognizing thinking as an ongoing process (Session 3).
chooses to respond to; it is highlighted that cognitions are
not real and do not cause behavior. Again, it was noted
that if the patient could view panic-related inner
experiences as just bodily sensations, thoughts, and
emotions, that they would be easier to experience.
Session 4. The last ACT session focused on setting up
the exposure therapy sessions. Session 4 began with a brief
values-based discussion, where larger life goals were tied
into the therapy. It was highlighted that treatment is not
just about reducing panic attacks, but finding ways to
bring important, meaningful aspects of life back into
focus. The pursuit of one's values was compared to
moving through a muddy swamp where the things that
are important are at the other end of the swamp—moving
through the swamp is in the service of the patient's values
Video 7. Examining life goals by using the “Moving Through a Muddy
Swamp” metaphor (Session 4).
611
Video 8. Introduction to exposure therapy in the context of ACT
(Session 5).
(Video 7; Hayes, Strosahl, et al., 1999, pp. 247-248).
Acceptance and defusion, and how they can support
pursuing ones values, was also briefly covered in this
session.
Sessions 5–10: Exposure-Based Skill Application Training
Following the ACT sessions, patients received 6
individual sessions of exposure therapy. These exposure
sessions were very similar to what occurs in CBT exposure
therapy for panic disorder, except that the rationale and
focus of all exposures were to facilitate the ACT processes
that patients learned during the first phase of treatment.
Thus, instead of performing the exposures under contexts
of fear reduction, challenging of cognitive distortions, or
reappraising the danger of sensations, the focus was to
provide opportunities to practice and become more skilled
at applying ACT skills in the presence of panic-related inner
experiences (Video 8). The exposure phase included:
(a) educating patients about the mechanisms and benefits
of exposure, (b) creating a fear and avoidance hierarchy,
(c) therapist-guided preparation for in-session exposure,
(d) in-session interoceptive and in-vivo exposures, initially
therapist-guided, (e) therapist debriefing following in-
session exposure, and (f) instructing patients in between-
session exercises (i.e., interoceptive or in-vivo exposures),
albeit unmonitored. Patients were instructed to apply their
ACT skills throughout the entire exposure session.
In general, the exposures were an opportunity to
behave with one's panic-related thoughts, feelings, and
bodily sensations. This supported ACT and response
flexibility skills with the intent to ultimately realize that
one can drive for and reach life goals, even in the
presence of unpleasant inner experiences. To that end, it
was explicitly stated that the level of anxiety or fear was
not the determining factor. Rather, it was explained that
612 Meuret et al.
“Willingness can do surprising things to one's inner
experiences. If one is willing to experience anxiety it may
or may not show up. Thus, we are not going to judge the
success of these exposures on how high the anxiety gets, but
instead in how open you are to what might show up.” To
effectively plan for interoceptive (i.e., eliciting panic
sensations such as a racing heart or shortness of breath)
and in-vivo exposures (i.e., seeking places and situations that
were previously avoided because of the fear of panic
sensations), a hierarchy of least to most anxiety-provoking
items was created. Movement up the hierarchy was not based
on reductions in anxiety at the preceding step but high
willingness to experience panic-related inner experiences.
Supervision
Weekly group supervision meetings were held. The
group consisted of the respective site investigators (AEM at
SMU, MGC at UCLA), ACT expert supervisors (MT, SH),
one Ph.D. and four-senior level Ph.D. graduate students
who conducted the therapy (AEM, ARM, DCS, BD, KW).
The supervision served to ensure the treatment feasibility
and integrity of the delivery following ACT and exposure
principles. Additionally, both the ACT and exposure phases
followed treatment protocols developed for this pilot study.
Measures
All questionnaires were assessed prior to each treat-
ment session (Weeks 0–9) and posttreatment (Week 10),
with the exception of the PDSS, which was assessed at pre-,
mid-, and posttreatment (Weeks 0, 4, 10).
Panic Disorder Severity Scale (PDSS; Shear et al., 1997)
The PDSS is a semistructured 7-item interview rating
scale to assess overall PD severity on a 5-point Likert scale
ranging from 0 (none) to 4 (extreme). It includes ratings for
panic severity and intensity, anticipatory anxiety, avoid-
ance of sensations and situations, and impairment in work
and social functioning. The instrument has excellent
interrater reliability (Shear et al.).
Anxiety Sensitivity Index (ASI; Reiss, Peterson, Gursky, &
McNally, 1986)
The ASI assesses degree of concern about the possible
negative consequences of anxiety symptoms. Respondents
rate each of the 16 items, ranging from 0 (very little) to 4
(very much). The ASI has high levels of internal
consistency and good test-retest reliability and is sensitive
to treatment for PD/A (Reiss et al., 1986).
Agoraphobia Cognition Questionnaire (ACQ; Chambless, Caputo,
Bright, & Gallagher, 1984)
The ACQ measures the occurrence of 14 frightening
or maladaptive thoughts about catastrophic conse-
quences of anxiety and panic. A 5-point Likert-type scale
(0–4) is used to indicate how often a specific thought
occurred. Test-retest reliability is .86 and Cronbach's
alpha is .80 (Chambless et al., 1984).
Five Factor Mindfulness Questionnaire (FFMQ; Baer, Smith,
Hopkins, Krietemeyer, & Toney, 2006)
The original 39-item FFMQ, which is based on a factor
analysis of five mindfulness scales, assesses five compo-
nents of mindfulness, including observing, describing,
acting with awareness, accepting without judgment, and
nonreactivity to inner experience. Items are rated on a
5-point scale, ranging from 1 (never or very rarely true) to 5
(very often or always true). Because this investigation
focused on promoting nonjudging/reactivity and less on
the other aspects of mindfulness, only the accepting
without judgment and nonreactivity scales were utilized.
The composite score of the two scales are referred to as
mindfulness for the purposes of this study because they
reflect key aspects of mindfulness from an ACT perspec-
tive (Fletcher & Hayes, 2005). The FFMQ has good
psychometric properties (Baer et al., 2006; K. Brown &
Ryan, 2003) and scores have been shown to increase
following mindfulness-based training (K. Brown & Ryan).
The alpha coefficients for the nonjudging and nonreac-
tivity subscales were .87 and .75, respectively (Baer et al.).
Credibility/Expectancy Questionnaire (CEQ; Devilly & Borkovec,
2000)
The CEQ contains a total of 6 items; 4 measure
expectancy and 2 measure credibility of treatment.
Patients are asked to rate items on a scale of 1 to 9 (1=
not at all logical, 5=somewhat logical, and 9=very logical). The
scale has shown good internal consistency and test-retest
reliability (Devilly & Borkovec).
Recording and Evaluation of On-Line Thought Processes:
Think-Aloud Paradigm
A modified and extended version of the think-aloud
paradigm (Davison, Vogel, & Coffman, 1997; Davison,
Williams, Nezami, Bice, & DeQuattro, 1991; Williams,
Kinney, Harap, & Liebmann, 1997) was used to assess
concurrent, situation-specific and patient representative
thoughts. This on-line method of recording verbalizations
provides a sample of thinking that differs from the
constraints of forced-choice formats and retrospective
judgments (e.g., questionnaires), and appears to be less
susceptible to responder biases inherent in retrospective
judgments. Such think-aloud methodologies have been
used to evaluate thoughts during exposure to feared
situations (Williams et al., 1997) and are considered valid
indicators of covert verbalizations when derived from
instructions to “say in a continuous stream whatever one is
saying to oneself at that moment” (vs. report upon what
one thinks one has been saying over a past interval) and
limited to brief snippets of time (30 seconds; Hayes,
 Brief ACT and Exposure
White, & Bissett, 1998). The think-aloud samples,
collected both during the daily ACT between-session
exercises as well as during the exposures, served as
measures of the extent to which ACT skills were acquired
and applied during exposure.
During the between-session acceptance-skill training,
patients recorded their internal dialogue at prompted
(minute: 3, 7, 11), 30-second intervals during the
15-minute exercise period using a digital voice recorder
for recording. Recordings, with a date and time stamp,
were downloaded via a USB port to a PC.
Clinical Outcome and Data Illustration
Treatment Fidelity, Competence, Credibility, and Compliance
All sessions were audio- or videotaped and discussed in
weekly supervision meetings by expert clinicians to ensure
that therapists adhered to the treatment protocol. A
random sample of 10% of all recorded treatment sessions
was evaluated blindly for protocol adherence by an
independent, experienced master's-level clinicians who
scored videos on previous ACT trials (Twohig et al., 2010).
Therapist adherence and competence were rated against
an adherence/competence checklist that was created to
assess adherence in the study by Twohig et al. It contains
items pertaining to how well the therapist covered
elements central to ACT and therapist competence
rated on a 5-point Likert scale (1=not at all and 5=
extremely). Adherence and competence were rated high
(adherence: M=4, SD=0 competence: M=4.75, SD=0.5).
Treatment credibility ratings were completed after the
educational session (Session 1). Patients’ ratings for
expectancy and credibility were high. Mean (SD) ratings
for expectancy 7.0 (SD: 1.44) and 6.09 (SD: 1.55) for
credibility. Homework compliance (out of 13 ACT
exercises per week [assessed via electronic time/date
stamp] also was high: Week 1: 6.4 (SD: 5.7); Week 2: 8.7
(SD: 3.3); Week 3: 6.8 (SD: 4.7); Week 4: 7.0 (SD: 4.9).
Reduction in panic symptom severity and increased mind-
fulness. We analyzed the data using mixed-effects
regression models (MRM; also referred to as multilevel
models, random-coefficient models, etc.). MRM allows
inclusion of all participants, regardless of missing data,
and can be used in samples as small as 10 participants
(Maas & Hox, 2005; Snijders & Bosker, 1993) by using
regression coefficients (slopes) rather than Level 2
variances. Further, MRM focuses on slopes of improve-
ment over time, which take into account all the data for
each participant, thus yielding results that are more
reliable than analyses focusing on single end-point data
(e.g., ANCOVA). As a result, MRM is the method of
choice for analyzing longitudinal psychiatric data (Hamer
& Simpson, 2009).
613
For the outcomes that were measured each week (ASI,
ACQ, and mindfulness), we modeled the growth curve of
symptoms over time as discontinuous (Singer & Willett,
2003), allowing the slope of improvement to change
between the training and exposure phases of the study
(see Figure 1). Time was coded as weeks and ranged from
0–10 (0=baseline, 4=midtreatment, 10=posttreatment;
0–4=ACT skills training, 4–9=exposure). Because the
repeated measures over time were correlated, we mod-
eled the error covariance matrix of the repeated measures
as auto-regressive. The effect size of each slope during
each phase (ES) was estimated as the percent of the Level
1 error variance (σ 2) which was accounted for by that
slope (Singer & Willett).
Results indicated that the slopes of improvement were
significant during both phases of the study for all three
outcomes. In particular, ASI decreased significantly during
the ACT phase and the exposure phases of the study, b=-3.11,
t(59)=-3.49, p=.001, ES=26.4% and b=-1.61, t(46)=-2.41,
pb.05, ES=15.4%. Similarly, ACQ decreased significantly
during both phases, b=-2.09, t(47)=-4.76, pb.001, ES=46.0% ,
and b=-1.01, t(39)=-3.24, pb.005, ES=27.9%. Also, mindful-
ness increased significantly during each phase of the study,
b=1.13, t(54)=2.38, pb.05, ES=38.3% and b=1.16, t(43)=
3.39, pb.005, ES=22.7%, respectively. For all outcomes, the
slopes were not significantly different between the two phases
of the study (ps=.27, .11, and .95 for ASI, ACQ, and
mindfulness, respectively).
PDSS was measured at baseline, after ACT skills
training, and after exposure sessions. Thus, the growth
curve was modeled as a single linear slope over time
(5 data points are needed for a discontinuous slope),
and time was coded 0, 1, 2 for the three assessments of
PDSS (0 = pretreatment, 1 = midtreatment, 2 = posttreat-
ment). Results indicated that PDSS decreased signifi-
cantly over time, b = -.73, t(24) = 8.26, p b.001, ES = 73.3%
(see Figure 1).
All treatment completers (n=8 of the 11 participants)
were “treatment responders” (i.e., PDSS score reduction
of at least 30% as defined by Shear, Clark, & Feske, 1998)
(range=67–100% reduction).
Illustration of think-aloud snippets. We obtained data
from a total of 550 vocalizations. To illustrate feasibility,
adherence to homework instructions, and treatment
progress, we present the complete transcripts of first
and last week of ACT training on the example of two
participants (total of 165 snippets; 30% of the total
sample; Figure 2). Overall, patients were very receptive to
and compliant with the recording devices for measuring
their verbalizations.
As described earlier, patients were prompted to say in a
continuous stream whatever came to their mind at the
very moment of prompting. These repeated 30-second
614 Meuret et al.

4 64

40
PDSS (0-4)

ASI (0-64)
2

20
1

0 0
0 2 4 6 8 10 0 2 4 6 8 10

56 75

FFMQ Non-Judge plus Non-react (15-75)

60
40
ACQ (0-56)

45

20

30

0 15
0 2 4 6 8 10 0 2 4 6 8 10
Weeks Weeks

Figure 1. Individual slopes for weekly measures of ASI, ACQ, and Mindfulness during Phase 1 (pretreatment [Week 0], through end of AC
phase [Week 4]) and for Phase 2 (Weeks 4 through end of exposure [Week 9]), and posttreatment [Week 10]). PDSS scores were collected
only at pre-, mid-, and posttreatment and thus raw scores are graphed. The 5 missing PDSS scores (out of 33) were interpolated from
individual slopes taken from the overall HLM analysis. Patterns of dashes for each participant are the same in the four sections of the figure.

snippets were recorded on digital recorders with a time,
duration, and date stamp. Data of this type offer much
needed insight into the acquisition and application of
coping skills. We selected extracts to indicate the variety
that we observed in terms of the verbalizations. Patient
1004 offered some dialogue of increased willingness to
experience panic sensations and interest in practicing
acceptance while having a panic attack. Patient 1002
showed a greater grasp of acceptance, thus exemplifying
that the skills learned in the initial four sessions can
transfer to practices outside of therapy. It should be noted
that the transcripts from our selected patients may not be
representative of all patients included in the study.
Further studies will be needed to construct a coding
scheme like the one by Williams and colleagues (1997) to
examine the degree to which skill acquisition and
subsequent application (e.g., during exposure) mediate
treatment outcome.
Discussion and Clinical Implications
The results of our pilot study indicate that a brief ACT
protocol, focusing heavily on acceptance as well as
defusion and values-based action, alone and in combina-
tion with exposure therapy, is a feasible and likely
effective intervention. Large reductions in panic symptom
severity were observed during ACT skills training, and
continued improvements were observed during the
exposure phase of treatment. The observed reduction in
panic symptom severity compared well to traditional CBT
trials. For instance, in the study by Barlow and colleagues
 Brief ACT and Exposure 615

(2000), intent-to-treat PDSS decreased from 1.82 (0.55) at
pretreatment to 1.14 (0.74) at posttreatment for patients
receiving 13 sessions of CBT only. Comparably, PDSS
levels in our study were 2.08 (0.20) at pretreatment, 1.31
(0.21) after ACT training, and 0.54 (0.23) at posttreat-
ment. Significant reductions were also seen on measures
of anxiety sensitivity and cognitive misappraisals, whereas
increases occurred on measures of mindfulness. Further-
more, the think-aloud recordings demonstrated the
feasibility, and partial success, of measuring the acquisi-
tion of ACT skills. Transcripts of the verbalizations, as
depicted in Figure 2, support patients’ ability to accept,
step back from, and mindfully watch their anxious
thoughts and sensations. For instance, Patient 1002
verbalized her desire to move through the swamp to get
to the other side, to things that she really wanted to do,
but has not done due to panic and anxiety. Such “on-line”
information provides invaluable insight into patients’
progress toward acquiring skills outside the therapist's
office. Recordings can be easily played back during the
session with the patient, providing a unique opportunity
to refine skills and discuss obstacles.
While this is not the first investigation into the effects
of ACT for anxiety disorders (see L. Brown et al., 2011;
Dalrymple & Herbert, 2007; Kocovski et al., 2009; Roemer
et al., 2008; Twohig et al., 2010; Wetherell et al., 2011;
Zettle, 2003), it is the first to use ACT as a model for
exposure to feared stimuli. Prior studies have either
excluded exposure from ACT methods for analytic
reasons (Codd et al., 2011; Twohig et al., 2006; Twohig

Figure 2. Complete transcripts from the “Think-Aloud” recordings for Patient 0102 and Patient 0104 for their first and last week of
acceptance skill training.
616 Meuret et al.
Figure 2 (continued ).
et al., 2010), or included exposure exercises within the
general ACT protocol as a natural extension of the
underlying model (e.g., Dalrymple & Herbert). In the
current study, we systematically examined the effects of
ACT training without exposure, followed by ACT skills
combined with exposure. A brief and limited ACT
protocol led to significant reductions in panic symptoms
and improvements in mindfulness, and significant addi-
tional benefits were observed during the phase in which
ACT skills were implemented in exposure. However, due
to the lack of an exposure-only control condition, the
degree to which ACT augments exposure remains to be
tested. While these findings are preliminary, they suggest
that ACT offers a viable option for working with anxious
clients. ACT may be particularly suitable when traditional
CBT approaches fail, especially for reasons such as poor
motivation to participate or difficulties tolerating panic-
related inner experiences. For instance, emerging re-
search on moderators indicates that individuals with
higher levels of catastrophic cognitions fail to respond
well to cognitive restructuring techniques and CBT
(Meuret, Hofmann, & Rosenfield, 2010; Wolitzky-Taylor,
Arch, Rosenfield, & Craske, under review). Conceivably,
theoretical arguments against beliefs of catastrophic
 Brief ACT and Exposure
outcome may be overturned by deeply entrenched,
enduring negative attributions, thus leading to minimal
improvement. Techniques that focus on acceptance of
thoughts and sensations, as opposed to their correction,
may be more beneficial for individuals with highly
elevated catastrophic misappraisals.
Even though the findings from this study possess a high
degree of internal validity (e.g., use of standardized
assessments throughout, use of a structured treatment
protocol, supervision of the independent variable by
experts), without a control condition it is impossible to
know to what extent the findings were the result of
nonspecific treatment factors. Furthermore, the durabil-
ity of the results remain unknown due to the absence of
long-term follow-up data, as well as posttreatment
diagnostic assessments. Nonetheless, the results of the
pilot data suggest that training in ACT skills and their
incorporation into exposure is a powerful novel interven-
tion that is worthy of further investigation.
Appendix A. Supplementary data
Supplementary data to this article can be found online
at http://dx.doi.org/10.1016/j.cbpra.2012.05.004.
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The pilot study was funded in part by the generous support of the
Beth and Russell Siegelman Foundation (Meuret). We wish to thank
the study therapists, Anne R. Miller, Deborah Corbitt-Schindler,
Barbara Depreeuw, Kathryn Williams, and our therapy adherence
rater, Kate Morrison.
Address correspondence to Alicia E. Meuret, Ph.D., Department of
Psychology, Southern Methodist University, Dallas, TX, 72505 (e-mail:
ameuret@smu.edu) or Michael P. Twohig, Ph.D., Department of Psychol-
ogy, Utah State University, Logan, UT (e-mail: michael.twohig@usu.edu).
Received: October 12, 2011
Accepted: May 8, 2012
Available online 30 June 2012