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The Evolution of a Contextual Approach to Therapy: From Comprehensive Distancing to ACT Robert D. Zettle Wichita State U
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International Journal of Behavioral Consultation and Therapy
Volume 1, No. 2, Spring, 2005
The Evolution of a Contextual Approach to Therapy: From Comprehensive Distancing to ACT Robert D. Zettle Wichita State University Abstract This paper traces the developmental history of acceptance and commitment therapy (ACT) from its beginning as comprehensive distancing to its current form and status. It is maintained that technical differences between the two approaches are overshadowed by ones of conceptualization. Comprehensive distancing emerged from efforts to extend Skinner’s work on verbal behavior and rule-governance to clinical phenomena, while relational frame theory as a post-Skinnerian account of human language has served as the conceptual foundation for ACT. Possible research strategies to further clarify conceptual differences between the two approaches are discussed. Key Words: Acceptance and commitment therapy, relational frame theory, rule-governance, verbal behavior, language, clinical phenomena, functional contextualism, private events.
During the past decade and a half, a series of interventions have ascended within behavior therapy that have been viewed collectively as constituting a “third wave” (Hayes, 2004). Included are such seemingly disparate interventions as functional analytic psychotherapy (Kohlenberg & Tsai, 1991), dialectical behavior therapy (Linehan, 1993), integrative behavioral couples therapy (Jacobson & Christensen, 1996) and mindfulness-based cognitive therapy (Segal, Williams, & Teasdale, 2002) that, nevertheless, are united in emphasizing a contextualistic approach to psychological phenomena such as private events and interpersonal relationships over direct attempts to modify or control them. Within the “third wave” of behavior therapies, the approach that has perhaps received the most increased visibility as of late is acceptance and commitment therapy (ACT). Recent books have detailed the basic approach (Hayes, Strosahl, & Wilson, 1999) as well as providing practical guidelines for its implementation with various types of presenting problems and populations (Hayes & Strosahl, 2004). In addition, an entire special issue of Behavior Therapy (Haaga, 2004) was recently devoted to ACT. It is not the purpose of this paper to provide an overview of ACT nor a review of its empirical support. The interested reader is advised to consult the above references for more on these issues. It is perhaps understandable for many both inside and outside the behavior therapeutic community to regard ACT as ostensibly a “Johnny-come-lately” intervention that is simply the most recent to ride the crest largely created by other “third wave” approaches already mentioned that preceded it. The purpose of this paper is to address this possible misperception by tracing the historical and conceptual developments occurring over the last quarter of a century that provided the context for the evolution of ACT from its earliest beginnings as “comprehensive distancing” to its current form. Before doing so, it seems appropriate to explicitly acknowledge some of the caveats inherent in such an endeavor. A history of necessity is constrained by the verbal behavior
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of the historian and this verbal behavior may be under multiple sources of control. While I believe my verbal behavior here to be under reasonably tight stimulus control of the actual events being discussed (particularly those that I witnessed and/or participated in during the first time period discussed below in the evolution of ACT), it should be recognized that it cannot be other than “personal” in nature and others may have differing stories to tell (particularly those who may have been more prominent participants in events occurring during the second time period to be discussed). As just alluded to and for purposes of discussion, it seems useful to divide the history of ACT’s development into three temporal phases: (1) an initial formative period in the late 1970s and early 1980s that provided a conceptual foundation for an early version of ACT by emphasizing an extension of basic behavior analytic approaches to verbal (Skinner, 1957) and rule-governed behavior (Skinner, 1969) to clinical phenomena; (2) a transitional period beginning from the late to mid 1980s through much of the next decade during which time relational frame theory (RFT) was developed as a post-Skinnerian account of language, verbal control, and especially rule-governance (Hayes, Barnes-Holmes, & Roche, 2001); and (3) most recently, a phase in which ACT has been increasingly disseminated and investigated as a fully integrated functional contextualistic approach to psychotherapy grounded in RFT The Initial Formative Period and Comprehensive Distancing (Late 1970s -1985) The earliest work that in retrospect appears to have contributed substantially to the development of ACT occurred while I was doctoral student under the mentorship of Steve Hayes at the University of North Carolina at Greensboro beginning in 1976. Steve has just been hired as an assistant professor and I was to be his first doctoral student. The two of us shared the sense that an understanding of the role that verbal behavior and language played in the initiation, maintenance, and treatment of abnormal human behavior was of critical importance in developing a behavioral approach to clinical psychology. We also agreed that the answers to the questions we sought would not be found in mainstream cognitive and mechanistic accounts popular at the time (e.g., Bandura, 1976, 1977; Mahoney, 1974). Instead, we looked to apply Skinner’s (1957, 1969) basic conceptual work in verbal and rule-governed behavior to clinical phenomena and issues (Zettle, 1980b). For the most part, these efforts at first essentially involved reinterpreting nonbehavioral clinical approaches such as those emphasizing the process of insight (Zettle, 1980a) and the use of coping self-statements (Zettle & Hayes, 1983) by extending a Skinnerian perspective on verbal control and rulegovernance. In particular in doing so, thinking, believing, and related cognitive phenomena were regarded as mere behavior that was not accorded any causal status because of its private nature. Moreover, because initiating causes from a radical behavioral perspective are reserved for directly manipulable environmental events that can both predict and control behavior (Hayes & Brownstein, 1986), any influence that thinking might have on other behavior could not be regarded as being causal in nature. However, consistent with Skinner’s (1953) account of selfcontrol, thinking as behavior was not viewed as being precluded from entering into a controlling behavior-behavior relationship with other actions provided the necessary environmental supports were in place. 78
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When “cognitive control” was reconceptualized as a possible behavior-behavior relation, the question of “What role do thoughts play in controlling human behavior?” became transformed into one of “What type of contingencies would lead one behavior, namely thinking, to occur and influence another behavior?” Not only was it necessary to specify the contingencies that give rise to each member of the behavior-behavior relation, but, even more importantly, also the contingencies that support such a controlling relation itself. To the extent that the contingencies that support “cognitive control” are of an arbitrary and verbal-social nature, it appeared possible to create a special verbal community within the context of therapy to weaken any dysfunctional control by thinking and other private events. In particular, the verbal behavior of reason-giving, especially reasons offered by clients that make reference to private events in support of dysfunctional behavior (e.g., “I didn’t go to work today because I was too depressed to get out of bed’), was regarded as problematic. While these basic points about dysfunctional verbal-cognitive control were expanded upon in subsequent publications (Hayes, 1987; Zettle, 1990), they were initially developed several years earlier (Zettle & Hayes, 1982) in a chapter that reinterpreted and critiqued the cognitive therapeutic approaches of Ellis (1962, 1973) and Beck (Beck, Rush, Shaw, & Emery, 1979) from the perspective of rule-governance. This chapter in hindsight appears noteworthy for several reasons. For one, it clearly departed from the mere extension of Skinner’s (1966, 1969) depiction of rule-governed behavior as under the control of “contingency-specifying stimuli” by proposing functional units of rule-following (pliance, tracking, and augmenting) and redefining rule-governed behavior as being “in contact with two sets of contingencies, one of which includes a verbal antecedent” (p. 78). Secondly, it also paved the way a few years later for a series of basic studies contrasting rule-governed versus schedule control of human operant performance (Hayes, Brownstein, Haas, & Greenway, 1986; Hayes, Brownstein, Zettle, Rosenfarb, & Korn, 1986) that further explored distinctions among functional units of rulefollowing. Of perhaps greatest importance, distinguishing rules as verbal antecedents from discriminative stimuli more generally, as will be seen, proved to be instrumental in the later development of relational frame theory and a reconceptualization of rule-governance within it. The 1982 chapter is also noteworthy as it was written around the same time Hayes (1981) compiled the first treatment manual for what became to be known as comprehensive distancing and work began on the first comparative outcome study to evaluate its efficacy. How and why a treatment approach derived from a radical behavioral view of cognitive phenomena came to be known as comprehensive distancing requires some elaboration. Our critique and reconceptualization of Beck’s cognitive therapy identified “distancing” as a component within his approach that most closely addressed (albeit in an attenuated fashion) some of the same processes our still unnamed intervention also targeted:
. . . Beck has emphasized the necessity of clients being able to “distance” themselves from their beliefs, or stated somewhat differently, being able to observe their own verbal behavior from the perspective of a listener. Over time, self-rules are often not viewed critically by the person formulating them. The usual listener behaviors in a 79
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public interaction (e.g., examining the credibility of the statement and the speaker; recognizing that reality and descriptions of it may not always be in harmony; and so on) may be gradually suspended for self-rules. This has several destructive effects. For example, augmenting functions may occur automatically – in a sense, the person-aslistener may become needlessly emotionally invested in a particular view of things. Similarly, obvious impure tacts or intraverbals may be seen as tacts in a way they never would be for others’ rules. Distancing allows self-rules to be viewed as behavior of an organism – not as literal reality or as the organism itself. (Zettle & Hayes, 1982, p. 107) Readers familiar with ACT will recognize references to mindfulness, defusion, and deliteralization in the above passage. Because we viewed the intervention being developed as at least in part extending and expanding upon “distancing” within cognitive therapy, it came to be known as “comprehensive distancing.” An initial evaluation of comprehensive distancing found it to compare favorably with cognitive therapy in treatment of outpatient depression (Zettle, 1984), but to apparently operate through different processes (Zettle & Hayes, 1986). An inspection of the treatment manual used in the dissertation reveals several similarities, but also differences between comprehensive distancing and ACT as it is currently presented and practiced. Comprehensive distancing can be conceptualized as consisting of components that addressed deliteralization and defusion by inclusion of exercises (e,g., physicalizing) and metaphors (e.g., polygraph and the chessboard) still integral to ACT. However, the observer exercise was not included to create awareness of self-as-perspective (Hayes et al., 1999, p. 188) and engendering a state of creative hopelessness was not given the prominence it currently receives within ACT. Parenthetically, it seems relevant to note that the observer exercise was not incorporated into comprehensive distancing untilaround 1985 at the suggestion of Terry Olson, a graduate student in the Hayes’ lab at the time (S. C. Hayes, personal communication, March 28, 2005). While the exercise itself was adopted from Assagioli (1971), the conceptual and therapeutic rationale for enhancing a transcendent sense of self had been presented by Hayes (1984) at least a year earlier in a paper entitled, “Making Sense of Spirituality.” Although it included no explicit mention of deictic framing, the paper clearly described the “behavior of seeing seeing from a perspective” (p. 103) as a basis of spirituality, and, consequently in hindsight, can be viewed as providing a key initial link in the developing relationship between ACT and RFT. One final technical difference between comprehensive distancing and present day ACT concerns behavioral homework. While behavioral homework was included within comprehensive distancing, the clarification and identification of client values were not. Consequently, homework was not value-directed, but instead appeared to be more similar to behavioral activation (Jacobson et al, 1996; Jacobson, Martell, & Dimidjian, 2001) as it was “designed to provide subjects with experience in activities in the presence of private events which otherwise might undermine such commitments” (Zettle, 1984, p. 55). The Transitional Period and RFT (1985 -1999) This second phase in the evolution of ACT begins when the previous one ends around 1985-1986 and continues until the publication of the first ACT book (Hayes et al.) in 1999. 80
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Several historically important events appeared around the start of this phase. First and perhaps most importantly, Hayes and Brownstein (1985) presented the first detailed overview of RFT in an invited address at the Association for Behavior Analysis (ABA) convention. Around the same time, Hayes left UNC-Greensboro to accept at faculty position at the University of Nevada, Reno. What began as an initial attempt to provide an alternative explication of equivalence class formation by appealing to synonymic relational framing subsequently would be developed over the next decade and a half by Hayes and his lab in collaboration with Dermot Barnes-Holmes, Bryan Roche and their Irish colleagues into a comprehensive post-Skinnerian account of human language and cognitive phenomena (Hayes et al., 2001). While it is beyond the scope of this paper to provide an overview of RFT [the interested reader is referred to Hayes et al (2001) for this purpose], some discussion of how rulegovernance, that had served as the backdrop for the development of comprehensive distancing, came to be replaced and subsumed within RFT as the existing conceptual foundation for ACT appears warranted. As discussed previously, Zettle and Hayes (1982) had earlier argued that Skinner’s definition of rule-governed behavior should be modified to explicitly incorporate control by a verbal antecedent rather than a “contingency-specifying stimulus.” Hayes and Brownstein (1985) moved even further from Skinner’s position towards RFT by proposing that “a verbal stimulus has its discriminative, eliciting, establishing, or reinforcing effects because of its participation in relational frames established by the verbal community for the purpose of producing such effects” (p. 19). An important intermediate contribution between the initial efforts of Hayes and Brownstein (1985) to subsume rule-governance within RFT and the culmination of this process with the publication of the RFT book (Hayes et al, 2001) and, in particular, its chapter on selfdirected rules (Barnes-Holmes, Hayes, & Dymond, 2001) was an edited volume devoted exclusively to issues involving rule-governed behavior (Hayes, 1989). Of special significance was a chapter by Hayes and Hayes (1989) with the stated purpose “to apply a relational perspective to the issue of rule-governance” (p. 177). In doing so, relational responding was conceptualized as a functional unit of behavior entailing both “speaking with meaning and listening with understanding.” Readers familiar with the RFT book will recognize these perspectives on speaking and listening. Parenthetically, it should be noted that there is some lack of clarity when and where speaking and listening as verbal behavior were first explicitly defined in this manner. Hayes in the prologue to the RFT book claims (p. viii) that it first occurred in his 1985 paper with Brownstein. While there are clear allusions to such a definition (“verbal behavior is speaking and listening”), I have been unable to locate any passages [unlike in the Hayes and Hayes (1989) chapter] in the document that explicitly provides it. Another historical fact that appears somewhat unclear is when and where “ACT” was first used instead of “comprehensive distancing”. What is documented is that within a few years after the name “comprehensive distancing” was first coined, efforts were underway to replace it with a designation that avoided the dissociative connotations associated with the term and to more clearly distinguish it from cognitive therapy. For example, terms such as “a contextual 81
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approach to psychotherapy” (Zettle & Hayes, 1986), “a contextual approach to therapeutic change” (Hayes, 1987), and simply “contextual therapy’ (Zettle & Rains, 1989) were used as synonyms for “comprehensive distancing.” As I can best determine, the first documented use of the term “acceptance and commitment therapy” in the title of a paper occurred in May, 1991 at ABA in a presentation by Hayes and members of his lab (Wilson, Khorakiwala, & Hayes, 1991). By contrast, 6 months earlier, several papers were presented at the Association for Advancement of Behavior Therapy (AABT) convention that still included “comprehensive distancing” in their titles (Follette, 1990: Hayes, 1990; Hayes, Wilson, Afari, & McCurry, 1990). It thus seems fairly clear that the transition in the use of terms occurred from late 1990 to early 1991. In November of 1991, the first paper I am aware of that contained “ACT” in its title was presented at AABT (Wilson & Taylor, 1991). However, as far as I can verify, the first use of “acceptance and commitment therapy” in a publication’s title did not occur for another 3 years (Hayes & Wilson, 1994). The Hayes (1987) chapter mentioned earlier warrants some further attention as the first publication to present an in-depth treatment of the therapeutic approach and to suggest modifications to it based upon newly emerging research in relational responding. Mention is made of the Skinnerian framework of rule-governance that provided the initial conceptual foundation for comprehensive distancing (“the control exerted by rules may involve alteration of the contingencies surrounding verbal control, without having to change the rules themselves”). But more importantly, Hayes also hints at further refinements to come that proved to be instrumental in the transformation of comprehensive distancing to ACT: Furthermore, it (a modification of the control exerted by rules) might involve alternation of the nature of the relational classes in which the rule participates, again without actually changing the form of the rule itself. While a skeptical reader might claim that the special nature of verbal control to which I am pointing is exactly what the cognitive theorists have held all along, the occurrence of this analysis in a behavioral context gives rise to fundamentally different conclusions and techniques. (p. 336) In effect, two ways of weakening dysfunctional verbal control are being proposed. One is management from a straightforward Skinnerian operant perspective of verbal-social contingencies that support a controlling relationship between verbal and other forms of behavior. The other emphasizes defusion and deliteralization procedures and techniques derived from RFT. With the further development of RFT, ACT, relative to comprehensive distancing, would come to place differing emphasis on the two change strategies proposed by Hayes (1987). Simply put, I believe a case can be made in hindsight that comprehensive distancing placed relatively more emphasis on what might be termed contingency management than it did upon defusion and deliteralization in attempting to weaken dysfunctional verbal control. The emphases in ACT as it is currently presented and practiced appear to have been reversed (what). Another important development occurring during the time period under discussion in the evolution of ACT from comprehensive distancing that further embeds it within RFT involves its inclusion of values identification and clarification. Within ACT values are defined as “verbally 82
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construed global life consequences” (Hayes et al., 1999, p. 206). Verbal control and rulegovernance over other behavior can have both dysfunctional and functional consequences. While comprehensive distancing clearly sought to reduce self-destructive forms of verbal control, unlike ACT, it did not provide an equivalent emphasis on strengthening constructive forms of rule-following. In particular, although comprehensive distancing stressed changes in overt behavior through making and keeping commitments, such behavioral changes were not explicitly guided by values identification and clarification as is the case in ACT. Unfortunately, the immediate contingencies surrounding behavior often support dysfunctional actions (e.g., substance abuse). However, through participation in temporal relational frames (e.g. “if . . . then,” “ before . . . after”), values as verbal constructions may come to control more functional behavioral changes (e.g, “I can be a better parent to my children if I stop drinking.”) ( see Barnes-Holmes, O’Hora, Roche, Hayes, Bissett. & Lyddy, 2001, pp. 113-114). In essence, embedding ACT within RFT increased the likelihood that any instigated changes in overt behavior would participate in a value-driven process. The Coming-of-Age Dissemination Period (2000 - Present) Although exactly when ACT “came of age” is perhaps debatable, there can be no dispute that the last 5 years have seen an explosive growth in basic (Feldner, Zvolensky, Eifert, & Spira, 2003; Karekla, Forsyth, & Kelly, 2004; Zettle et al., in press), outcome (Hayes, Masuda, Bissett, Luoma, & Guerrero 2004), and process research (Hayes, Bissett et al, 2004; Gifford et al, 2004) related to ACT. The reader especially interested in a review of the latest outcome research on ACT is encouraged to consult Hayes, Masuda et al, (2004). A good deal of the growth in ACT apparently can be attributed to its dissemination internationally. Recent publications, for example, have reported applications of ACT conducted in England (Bond & Bunce, 2000), Spain (Gutierrez, Luciano, Rodriguez, & Fink, 2004), and Sweden (Dahl, Wilson, & Nilsson, 2004). On a related note, not to be overlooked are the seminal contributions of Dermont Barnes-Holmes and his colleagues and students at the National University of Ireland to the development of RFT. Summary and Conclusions Aristotle wrote, “If you would understand anything, observe its beginning and its development.” In this respect, it is my hope that this paper may further contribute not only to our understanding of ACT as it currently exists and is practiced, but also of how it evolved from comprehensive distancing. It might be argued that the name change from comprehensive distancing to ACT was, and still is, a mere matter of semantics. From a relational frame perspective, though, words do make a difference. As has been pointed out, comprehensive distancing and ACT shared the common goal of undermining dysfunctional control by private events but differed from each other in some of their treatment techniques and procedures. However, it seems more useful to view both interventions as integrated approaches rather than as mere “toolboxes” that may or may not contain some of the same treatment procedures. From this perspective, any critical and meaningful difference between comprehensive distancing and ACT seems more conceptual than technical. I believe history shows that the primary conceptual foundation for comprehensive distancing was Skinner’s radical behavioral accounts of controlling relationships, verbal 83
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behavior, and rule-governance. However, as limitations and cracks in this conceptual foundation became more obvious, efforts to address them ultimately resulted in the transformation of comprehensive distancing into ACT and its grounding in RFT as a post-Skinnerian account of human language and cognition Conceptual differences, of course, also often give rise to technological differences (Hayes, 1978) and it may be that a closer analysis of some of the technical dissimilarities between comprehensive distancing and ACT may loop back to improve our conceptual understanding of ACT. One possible strategy towards this end would be to subject ACT to a component analysis. A dismantling strategy akin to what Jacobson and his colleagues (Jacobson et al, 1996, 2001) conducted with cognitive therapy might be considered. For example, one approach that exclusively emphasizes procedures and techniques commonly employed in ACT in the service of mindfulness, defusion, and deliteralization could be compared against another that focuses solely on making and maintaining changes in value-driven overt behavior. A variant on the latter approach could still emphasize behavioral commitment (ala behavioral activation) but exclude any explicit linkage to values and thus, technically at least, approximate comprehensive distancing. While there is perhaps something to be said for such a dismantling strategy in strengthening our conceptual understanding of ACT, there would appear to be even stronger reasons instead to continue to recommend any alternative approach. ACT has emerged from an inductive approach in which new techniques have either been added or existing ones validated through evaluating the impact of specific therapeutic components and related processes with both nonclinical (e.g., Gutierrez et al., 2004; Hayes, Bissett, Korn, Zettle, Rosenfarb, Cooper, & Grundt, 1999; Masuda, Hayes, Sackett, & Twohig, 2004) and clinical populations (e.g., Heffner, Eifert, Parker, Hernandez, & Sperry, 2003; Levitt, Brown, Orsillo, & Barlow, 2004). At some point in the future, a component analysis of ACT may prove to be useful. However, for the time being it seems premature to dismantle an approach; that in spite of its recent coming-of age and differentiation from its ancestor, comprehensive distancing; continues to grow and, in large measure, is still being built.
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for depression: A new approach to preventing relapse. New York: Guilford. Skinner, B. F. (1953). Science and human behavior. New York: Free Press. Skinner, B. F. (1957). Verbal behavior. New York: Appleton. Skinner, B. F. (1966). An operant analysis of problem solving. In B. Kleinmuntz (Ed.), ProblemSkinner, B. F. (1969). Contingencies of reinforcement: A theoretical analysis. New York: Appleton. Wilson, K. G., Khorakiwala, D., & Hayes, S. C. (1991, May). Change in acceptance and commitment therapy. In K. G. Wilson (Chair), Radical behavioral psychotherapy process research. Symposium conducted at the meeting of the Association for Behavior Analysis Atlanta. Wilson, K. G., & Taylor, N. (1991, November). Why the “acceptance” in acceptance and commitment therapy (ACT)? In S. C. Hayes (Chair), Acceptance as change: Acceptance as a strategy of clinical intervention. Symposium conducted at the meeting of the Association for Advancement of Behavior Therapy, New York. Zettle, R. D. (1980a, November). Insight: Rules and revelations. In S. C. Hayes (Chair), The baby and the bathwater: Radical behavioral interpretations of traditional clinical phenomena. Symposium conducted at the meeting of the Association for Advancement of Behavior Therapy, New York. Zettle, R. D. (1980b). The role of rule-governed behavior in clinical phenomena. Unpublished manuscript, University of North Carolina at Greensboro. Zettle, R. D. (1984). Cognitive therapy of depression: A conceptual and empirical analysis of component and process issues. Unpublished doctoral dissertation, University of North Carolina at Greensboro. Zettle, R. D. (1990). Rule-governed behavior: A radical behavioral answer to the cognitive challenge. The Psychological Record, 40, 41-49. Zettle, R. D., & Hayes, S. C. (1982). Rule-governed behavior: A potential theoretical framework for cognitive-behavioral therapy. In P. C. Kendall (Ed.), Advances in cognitive-behavioral research and therapy (Vol. 1, pp. 73-118). New York: Academic Press. Zettle, R. D., & Hayes, S. C. (1983). Effect of social context on the impact of coping selfstatements. Psychological Reports, 52, 391-401. Zettle, R. D., & Hayes, S. C. (1986). Dysfunctional control by client verbal behavior: The context of reason-giving. The Analysis of Verbal Behavior, 4, 30-38. Zettle, R. D., Hocker, T. R., Mick, K. A., Scofield, B. E., Petersen, C. L., Song, H., & Sudarijanto, R. P. (in press). Differential strategies in coping with pain as a function of level of experiential avoidance. The Psychological Record.
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solving:
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Zettle, R. D., & Rains, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45, 436-445.
Author Contact Information: Robert D. Zettle, Ph.D. Department of Psychology Wichita State University Wichita, KS 67208 Phone: (316) 978-3081 E-mail: [email protected]
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