Key Constructs in Classical and New Wave Cognitive Behavioral

Psychotherapies: Relationships Among Each Other

and With Emotional Distress
Ioana A. Cristea,1,2 Guy H. Montgomery,3 Stefan Szamoskozi,1 and Daniel David1,3
1

Babes-Bolyai University, Cluj-Napoca

University of Pisa
3
Mount Sinai School of Medicine
2

Objective:

We aimed to relate key constructs from three forms of cognitive behavioral therapy that are often placed in competition: rational emotive behavior therapy, cognitive therapy, and
acceptance and commitment therapy. The key constructs of the underlying theories (i.e., irrational
beliefs/unconditional self-acceptance, dysfunctional cognitions, experiential avoidance/psychological
inflexibility) of these therapies have not been explicitly studied in their relationships to each other and
with emotional distress. Method:
We used a cross-sectional design. The variables were selected
to indicate key constructs of the three major forms of therapy considered. Study 1 used a sample of
152 students, who were assessed during a stressful period of their semester (mean age = 21.71;
118 females), while Study 2 used a clinical sample of 28 patients with generalized anxiety disorder
(mean age = 26.67; 26 females). Results:
Results showed that these constructs, central in the
therapies considered, had medium to high associations to each other and to distress. Experiential
avoidance was found to mediate the relationship between the other, schema-type cognitive constructs
and emotional distress. Moreover, multiple mediation analysis in Study 2 seemed to indicate that the
influence of the more general constructs on distress was mediated by experiential avoidance, whose
effect seemed to be carried on further by automatic thoughts that were the most proximal to distress.
Conclusions: Although each of the cognitive constructs considered comes with its underlying
theory, the relationships between them can no longer be ignored and cognitive behavioral therapy
C 2013
theoretical models reliably accounting for these relationships should be proposed and tested. 
Wiley Periodicals, Inc. J. Clin. Psychol. 00:116, 2013.
Keywords: cognitive behavioral psychotherapy; rational-emotive behavioral therapy; cognitive therapy;
acceptance and commitment therapy; mediation

Cognitive behavioral therapy (CBT) is one of the fastest developing fields in psychotherapy.
Emerging from the classical CBT paradigm (e.g., Beck, 1976; Ellis, 1962), new forms of CBT,
sometimes called the third wave or the new wave, have been developed (Hayes, 2004). Their
shift relates to changing the way we look at the very basis of CBT, namely, the status of cognitive
change.
Clark (1995), in common with other leading cognitive therapists asserts that a fundamental
postulate of the cognitive model of psychopathology is that cognitive change is central to treating
psychological disorders, stating that all therapies work by altering dysfunctional cognitions,
either directly or indirectly (p. 158). While they still view cognitions as highly relevant to
psychopathology, third wave CBTs consider change in cognitive content as nonessential in

We thank Dr. Aurora Szentagotai Tatar and Dr. Florin Alin Sava for valuable consultation regarding the
adaptation of the AAQ-II, Dr. Krisztina Szabo for providing the study database for the Romanian adaptation
of the AAQ-II, as well as Dr. Andrew Hayes and Dr. Kristopher Preacher for important advice on mediation
procedures.
Please address correspondence to: Ioana A. Cristea, Babes-Bolyai University, Department of Clinical Psychology and Psychotherapy, No.37, Republicii St., 400015, Cluj-Napoca, Romania. E-mail:
ioana.alina.cristea@gmail.com
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 00(00), 116 (2013)
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).


C 2013 Wiley Periodicals, Inc.
DOI: 10.1002/jclp.21976

Journal Of Clinical Psychology, xxx 2012

producing therapeutic change. More precisely, from this perspective, while thoughts are still
essential in causing and maintaining emotional disorders, the objective of therapy is not to alter
the actual content of dysfunctional thoughts, but to transform their function in determining
psychopathology, by modifying the individuals relationship to these thoughts. As such, these
third wave CBTs choose to focus on different processes (e.g., psychological flexibility, acceptance,
defusion) that employ a more experiential approach to the clients beliefs.
The classical and the third wave CBT perspectives seem to each be working on their own,
diverging theories as part of the same broad paradigm. Classical CBT focuses on measuring
cognitive change (i.e., changes in measures of cognitive constructs, such as dysfunctional
beliefs) and relating it to changes in therapeutically relevant outcomes, such as distress or
measures of specific psychopathology. Third wave CBTs focus on measuring processes other
than cognitive change (e.g., experiential avoidance), deemed as etiologically relevant in causing
psychopathology, and relating these processes to very similar outcomes.

The Classic Wave in Cognitive Behavioral Psychotherapy

Rational emotive behavior therapy (REBT). The first form of CBT, REBTs model
states that it is not the event itself causing our emotional states, but our beliefs related to
that event. Regarding beliefs, it distinguishes between two key evaluation/appraisal styles:
irrational and rational. The irrational evaluations are not logical, do not have factual support
in reality, and/or hinder the person from achieving his/her goals, while the rational ones are
logical, have empirical support, and/or help the person achieve his/her goals. The REBT
therapeutic stance involves changing the patients dysfunctional emotions and behaviors by
means of changing the irrational beliefs into rational ones and by promoting the patients
unconditional self-acceptance (David, Montgomery, Macavei, & Bovbjerg, 2005). Studies have
linked irrationality to state anxiety, anger, guilt (David, Schnur, & Belloiu, 2002), state anger
(Martin & Dahlen, 2004), and exam-related distress (Montgomery, David, DiLorenzo, & Schnur,
2007). Irrationality was also linked to psychopathology, such as depressive symptoms (Chang,
1997), major depressive disorder (Solomon, Arnow, Gotlib, & Wind, 2003), and clinical anxiety
(Muran & Motta, 1993).
Cognitive therapy (CT). The basic difference between the REBT and the CT (Beck, 1976)
therapeutic stances lies in their chief focus on one category of thoughtshot versus cold
cognitions (David, Miclea, & Opre, 2004). Becks CT focuses primarily on cold cognitions,
mental representations of relevant circumstances (Lazarus, 1991), in the forms of dysfunctional
descriptions and inferences. The difference between these two is that, whereas descriptions
merely present an observed fact (e.g., Its 10 oclock and my wife is not home), inferences
extend further from the perceived fact (e.g., The fact that she is not home at this hour shows
she is having an affairjumping to conclusion dysfunctional belief). In contrast, therapies
such as REBT focus mainly on hot cognitions in the form of evaluations (appraisals), which
refer to the ways in which cold cognitions/representations are processed in terms of their
relevance for personal well-being (Lazarus, 1991; e.g., The fact that she is having an affair is
catastrophic for meawfulizing irrational belief). Studies have linked dysfunctional attitudes
to distress, such as depression, anxiety, and hostility (Whittal & Dobson, 1991) and depressed
mood (Henriques & Leitenberg, 2002). They have also been related to psychopathology, such as
depression (de Graaf, Roelofs & Huibers, 2009), hypomania (Lex, Hautzinger & Meyer, 2011),
and bipolar disorders (Perich, Manicavasagar, Mitchell, & Ball, 2011).
The New Wave in Cognitive Behavior Psychotherapy
Acceptance and commitment therapy (ACT). ACT is one of the most visible new wave
CBTs, especially regarding the investigation of its proposed theory. New wave CBTs downplay
the importance of explicit cognitive restructuring/challenging of the content of thoughts in
favor of methods that attempt to alter the function of the thoughts and not their content. More
specifically, they aim to change the individuals relationship to dysfunctional beliefs (i.e., the

Key Constructs in Cognitive Behavioral Therapies

significance of having these beliefs), a process through which cognitions are thought to become
neutralized and the distress related to them is reduced or accepted.
Therapeutic change is considered to be brought about through the modification of key processes postulated to be at the root of psychopathology. One such process is experiential avoidance/psychological inflexibility. Experiential avoidance (EA) refers to excessive negative evaluations of unwanted thoughts, feelings, bodily sensations, memories, or behavioral predispositions,
as well as an unwillingness to experience these private events, and deliberate efforts to control
them or be rid of them (Hayes et al., 1999). EA is proposed to represent a stronger contributor
to psychopathology than the content (e.g., intensity, frequency, negative valence) of private psychological and emotional experiences (Hayes et al., 1999). In clinical and nonclinical samples,
it was found to be strongly correlated with measures of general psychopathology (Hayes et al.,
2004) and specific measures of anxiety and depression (Forsyth, Parker, & Finlay, 2003; Marx
& Sloan, 2005; Roemer, Salters, Raffa, & Orsillo, 2005).

Objectives of the Studies

The aim of the present research is to clarify the interrelationships among key theoretical processes
of three forms of CBT (REBT, CT, and ACT) in regard to their relative contributions to distress.
For REBT, we considered irrational beliefs and unconditional self-acceptance as they are the core
cognitive processes in REBT (see David, Lynn, & Ellis, 2009). For CT we chose dysfunctional
attitudes (cognitive distortions) as they are at the heart of cognitive therapy (Beck, 1995). Finally,
for ACT, the key process considered was experiential avoidance/psychological inflexibility, since
it is at the heart of ACT and one of the most investigated ACT components (Hayes et al., 2004). To
our knowledge, associations between irrational beliefs/unconditional self-acceptance (REBT),
dysfunctional cognitions (CT), experiential avoidance/psychological inflexibility (ACT), and
emotional distress have not been examined within a single study.
Our other objective involved determining the relative contributions of the constructs to
psychological distress. We set to explore the possible mediational models using these concepts,
using distress as an outcome, to test whether the effect of classical CBT constructs on distress
was mediated by the third wave construct of experiential avoidance or vice versa.

General Method
Overview
We investigated these relations in two types of samples: a healthy one nonetheless vulnerable to
experiencing distress (Study 1) and a clinical sample (Study 2). The study design, as well as the
procedure and the instruments used, were consistent across studies.

Measures
Clinical diagnosis. We used the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) Axis I Disorders,
Patient Edition (SCID-I/P; First, Spitzer, Gibbon, & Williams, 2002). In Study 1 we applied
only the screening questionnaire to exclude participants with a suspicion of psychopathology,
while in Study 2 we used the entire SCID to assess clinical diagnostic status.
Irrational and rational beliefs. The Attitudes and Beliefs Scale 2 (ABS 2; DiGiuseppe,
Robin, Leaf, & Gormon, 1989) was devised as a measure of the central constructs in REBT.
It comprised 72 items representing assertions with which the person is asked to rate his/her
agreement on a 5-point Likert scale, ranging from 0 (strongly disagree) to 4 (strongly agree). The
items denote beliefs an individual might hold about particular situations and are formulated in
either irrational or rational terms. We computed both irrationality and rationality scores. The
ABS 2 was adapted and validated on the Romanian population (Macavei, 2002). Reliability was
assessed on a sample of 340 individuals and indicated good internal consistency (Cronbachs

Journal Of Clinical Psychology, xxx 2012

alpha of 0.88 for the total scale). Factor analysis on the Romanian ABS 2 supported the presence
of two distinct factors, corresponding to irrationality and rationality (Fulop, 2007).

Unconditional self-acceptance. The Unconditional Self-Acceptance Questionnaire

(USAQ; Chamberlain & Haaga, 2001) was developed based on Albert Elliss theory of unconditional self acceptance, a central concept of REBT. The person has to evaluate the degree
of agreement with 20 assertions on a 7-point Likert scale. Higher scores indicate higher unconditional self-acceptance. The USAQ was adapted on the Romanian population (Macavei,
2007). Reliability analysis on a sample of 437 individuals indicated good internal consistency
(Cronbachs alpha = 0.73). Validity analysis showed positive associations between unconditional
self-acceptance and rational beliefs, and negative ones between unconditional self-acceptance
and different types of dysfunctional beliefs, as well as distress.
Dysfunctional attitudes. The Dysfunctional Attitudes Scale A (DAS-A; Weissman &
Beck, 1978) offers information regarding the persons dysfunctional attitudes, which function as
schemata through which the individual builds his/her view of reality. It comprises 40 items formulated as assertions to be rated on a 7-point Likert scale, ranging from total agreement to total
disagreement. Even though this scale was initially developed to measure cognitions relevant to
depression, subsequent studies showed it measured more general cognitive vulnerabilities (Dyck,
1992). The DAS-A was adapted for the Romanian population (Macavei, 2006). Reliability analysis on a sample of 701 individuals indicated a value of Cronbachs alpha of 0.86. Validity analysis
showed that the scale correlated positively with other measures of dysfunctional thinking, as
well as with negative emotions. Moreover, the DAS-A was able to discriminate between subjects
with high and low levels of negative emotions.
Experiential avoidance/psychological inflexibility. The Acceptance and Action Questionnaire (AAQ-II; Bond et al., 2011) is a revised form of the AAQ (Hayes et al., 2004), which was
originally developed to provide an internally consistent measure of the ACT treatment model
and behavioral effectiveness. The instrument comprises seven items, representing statements
that the person evaluates in terms of how true they are for him/her on a 7-point Likert scale.
High scores indicate high experiential avoidance (or high psychological inflexibility). Factorial
analysis showed the AAQ-II is a one-dimensional measure that assesses the key ACT construct
referred to, variously, as experiential avoidance or psychological inflexibility. Confirmatory factor analysis indicated that it did so in a comparable manner across very different samples. The
AAQ-II was translated into Romanian for the purpose of this study (details of the procedure are
available upon request). It presented very good internal consistency (Cronbachs alpha = 0.88
for the sample in Study 1 and 0.90 for the clinical sample in Study 2).
Emotional distress. The Profile of Emotional Distress/Profile of Affective Distress
(PED/PAD; Opris & Macavei, 2005) is an instrument designed to evaluate distress. It comprises 39 items that are adjectives describing emotions, both negative and positive. The subject
is asked to rate the suitability of each item in assessing how he/she has felt during the last
2 weeks, on a 5-point Likert scale. The global negative emotions score was used in the current
studies as an index of distress. The scale was validated on the Romanian population (Opris &
Macavei, 2007). The reliability analysis on a sample of 745 healthy volunteers indicated very
good internal consistency for the negative emotions scale (Cronbachs Alpha = 0.94). Validity
analysis revealed a two-factor structure, with a general distress factor accounting for around
60% of the variance, and a second factor, named functional distress, for around 28% of the
variance.
Procedure
Participants were asked for consent and then given the scales. They were told the data would
be used for study purposes and they could receive a personalized interpretation of the results
should they wish to.

Key Constructs in Cognitive Behavioral Therapies

Data Analysis
We applied correlational and mediational analysis. For mediational analysis, we used the bootstrapping procedure for assessing indirect effects (Preacher & Hayes, 2008). We used the Preacher
and Hayes (2008) mediation script for SPSS for calculations.
We calculated effect sizes for the mediational models following the procedure recommended
by Preacher and Kelley (2011), using the MBESS package (Kelley & Lai, 2010). Given the
inherent difficulties of estimating effect sizes for mediation procedures, the authors recommend
a standardized index called kappa-squared (i.e., 2 ), which represents the magnitude of the
indirect effect relative to the maximum possible indirect effect, given the design of the study and
the distributional particularities of the variables considered.

Study 1
Research demonstrates that the period before an exam (Malouff et al., 1992) is often a stressful
one, which may negatively affect emotional health. In Study 1 we explored the relationships
between the constructs in a nonclinical sample in such a period, before moving to a clinical
sample in Study 2.

Method
One hundred and fifty-two student participants took part in the study. The gender distribution
was 22.4% males (n = 34) and 77.6% females (n = 118). Ages ranged from 17 to 25 years, with
a mean age of 21.71 (standard deviation [SD] = 1.33). None of the subjects had had any prior
experience with any of the forms of therapy taken into account. Absence of psychopathology was
assessed with the screening questionnaire of the SCID-I/P (First, Spitzer, Gibbon, & Williams,
2002). One hundred seventy subjects were screened, 18 of which were not included in the study
due to suspicion of psychopathology. Subjects were tested right before their exam period.

Results and Discussions

Descriptive data. Descriptive data for the main variables are presented in Table 1. The
mean score for distress, reported on the PED/PAD, qualifies the sample as having a high level of
negative emotions, according to comparisons with Romanian norms (Opris & Macavei, 2007).
Correlational analysis. The association between the cognitive variables from each therapy
approach considered and their associations with distress are presented in Table 2.
The results from the correlational analysis showed a significant and high positive correlation between irrational beliefs and dysfunctional attitudes, as well as a significant and medium

Table 1
Means, Standard Deviations (SD), Minimum (Min) and Maximum (Max) Values for the Main
Variables in Study 1

USAQ Unconditional self-acceptance

AAQ-II Experiential avoidance
DAS-A Dysfunctional attitudes
ABS 2 Global Irrationality
ABS 2 Rationality
PED/PAD Distress

Min

Max

Mean

SD

151
152
149
152
152
150

42
7
44
4
36
32

120
46
214
216
163
127

80.08
21.21
124.01
99.14
102.05
61.93

13.27
8.51
29.65
42.83
22.38
22.73

Note. USAQ = Unconditional Self-Acceptance Questionnaire; AAQ-II = Acceptance and Action Questionnaire II; DAS-A = Dysfunctional Attitudes Scale A; ABS 2 = The Attitudes and Beliefs Scale 2; PED/
PAD = Profile of Emotional Distress/Profile of Affective Distress.

Journal Of Clinical Psychology, xxx 2012

Table 2
Correlations Between the Cognitive and Subjective/Emotional Variables in Study 1
Cognitive variables
1. USAQ Unconditional self-acceptance
2. AAQ-II Experiential avoidance
3. DAS-A Dysfunctional attitudes
4. ABS 2 Global Irrationality
5. ABS 2 Rationality
Subjective-emotional variables
6. PED/PAD Distress

.55
.61
.38
.19

.53
.40
.21

.60
.40

.88

.42

.60

.32

.24

.14

Note. USAQ = Unconditional Self-Acceptance Questionnaire; AAQ-II = Acceptance and Action Questionnaire; DAS-A = Dysfunctional Attitudes Scale A; ABS 2 = The Attitudes and Beliefs Scale 2; PED/
PAD = Profile of Emotional Distress/Profile of Affective Distress.
p < .003 Bonferroni corrected for multiple comparisons.

negative correlation between irrational beliefs and unconditional self-acceptance. Irrational beliefs and dysfunctional attitudes are both core beliefs, organized as evaluative and, respectively,
descriptive/inferential schemas, and thus strongly related to each other. One theoretical possibility is that the core irrational beliefs prime the generation of dysfunctional cognitions in
negative situations and then both generate more specific evaluative and descriptive/inferential
beliefs in the form of automatic thoughts (David et al., 2009).
The small correlation between rational beliefs and unconditional self-acceptance may indicate
they represent different aspects of adaptive thinking. Unconditional self-acceptance denotes the
notion that the individual fully and unconditionally accepts himself whether or not he behaves intelligently, correctly, or competently and whether or not other people approve, respect,
or love him (Ellis, 1977, p. 101). As such, it may represent a different thinking process than
other types of rational/functional beliefs, aiming at more radical, profound modifications of
an individuals life philosophy (Ellis, 1994). Experiential avoidance/psychological inflexibility
displayed medium to high positive correlations with cognitive constructs related to dysfunctional thinking (irrationality, dysfunctional attitudes), pointing to the existence of a degree of
overlap.
Also experiential avoidance had a medium to high negative correlation (r = 0.55) with
unconditional self-acceptance, which again could imply they deal with related, yet distinct,
approaches to acceptance. The REBT concept of unconditional self-acceptance might be related
to the ACT concept of acceptance (the opposite of experiential avoidance, see Bond et al.,
2011). In this sense we could speculate that the unconditional regard for oneself promoted by
REBT might also incorporate an acceptance of self-critical cognitions or of painful experiences,
promoted by ACT. An intriguing association was the negative, but small and nonsignificant,
correlation between experiential avoidance and rational beliefs, supporting the idea the two
represent distinct constructs.
The associations between these constructs and distress were consistent with the underlying
theories. Irrationality had medium positive correlation with distress (see David et al., 2005).
Dysfunctional attitudes also had medium positive correlations to distress (see de Graaf et
al., 2009). As expected from the ACT literature (e.g., Hayes et al., 2004), experiential avoidance/psychological inflexibility bore high positive associations with distress.

Mediation analysis. We used bootstrapping tests with 5,000 re-samples and reported
a bias corrected and accelerated confidence interval (Preacher & Hayes, 2008). Mediation is
considered to have taken place when the confidence interval for the estimation of the indirect
effect does not contain 0. We alternatively tested all possible meditational models, using distress
as the outcome (experiential avoidance as a mediator and the classic CBT constructs as respective
predictors; experiential avoidance as predictor and each of the other, classic CBT constructs as
potential mediators).

Key Constructs in Cognitive Behavioral Therapies

Figure 1. Simple mediation diagrams for Study 1. Values are path coefficients representing standardized
regression weights and standard errors (in parentheses). The c path coefficient refers to the total effect of the
independent variable (IV) on the dependent variable (DV). The c-prime path coefficient refers to the direct
effect of the IV on the DV.

The results indicated that experiential avoidance/psychological inflexibility acted as a mediator in the relationship between global irrationality and emotional distress, indirect effect = .13,
standard error (SE) = .03, 95% confidence interval (CI; bias corrected and accelerated) = .08 to
.20. Experiential avoidance/psychological inflexibility also mediated the relationship between
unconditional self-acceptance and emotional distress, indirect effect = .52, SE = .10, 95%
CI (bias corrected and accelerated) = .74 to .34, and between dysfunctional attitudes and
emotional distress, indirect effect = .25, SE = .05, 95% CI (bias corrected and accelerated) =
.17 to .36. For each of the alternative models, the confidence intervals of the indirect effects
contained zero, indicating the absence of mediation. Figure 1 depicts the significant mediation
models.
Effect sizes were calculated for all significant mediation models. In the first one, with experiential avoidance mediating the relationship between global irrationality and emotional distress, 2

Journal Of Clinical Psychology, xxx 2012

took the value of .25, 95% CI (bias corrected) = .14 to .35. In the second model, where experiential avoidance mediated the relationship between unconditional self-acceptance and emotional
distress, 2 was .28, 95% CI (bias corrected) = .19 to .37. In the case of experiential avoidance
mediating the relationship between dysfunctional attitudes and emotional distress, 2 was .31,
95% CI (bias corrected) = .22 to .40.
We underscore that irrational beliefs and dysfunctional cognitions are conceptualized as core
beliefs, vulnerability factors, coded as underlying schemata (Beck, 1995; Ellis, 1994); hence, they
are more general and not easily experienced directly. Moreover, by interaction with specific
activating events, they generate automatic thoughts that are experienced consciously and are
associated with dysfunctional feelings and behaviors. According to ACT theory, experiential
avoidance might include the lack of willingness to experience (i.e., rather than alter the content
or frequency of) these automatic thoughts (i.e., unwanted private events in ACT terms; Hayes
et al., 1999). Thus, if these constructs are related to each other, the effect of irrational beliefs and
dysfunctional cognitions on distress could be mediated on one hand by experiential avoidance,
and on the other hand by automatic thoughts. Regarding experiential avoidance, our study
provides support for this prediction. Other studies sustain the mediating role of automatic
thoughts in the relationship between deeper level cognitive constructs (e.g., irrational beliefs)
and distress (Szentagotai & Freeman, 2007). However, there are no studies investigating all of
these constructs in the same research design.
Consequentially, some interesting conjectures emerged after Study 1, regarding the relationship between experiential avoidance and automatic thoughts as mediators between more
general, deeper, schema-type constructs and distress. One theoretical possibility would be that
irrational beliefs and/or dysfunctional cognitions represent underlying cognitive vulnerabilities
that in negative situations generate automatic thoughts (specific cognitions, evaluative and/or
descriptive/inferential, related to the activating events), which are then experientially avoided,
generating distress. The other would be that irrational beliefs and/or dysfunctional cognitions,
as underlying cognitive vulnerability factors, prompt the response of experiential avoidance,
which in turn activates automatic thoughts by a mechanism similar to the paradoxical rebound
effect of suppression (i.e., the white bear effectWegner, Schneider, Carter, & White, 1987).

Study 2
In Study 2, we aimed to see whether the mediation models supported in Study 1 were valid in
the case of a clinical sample. We used the same measures of beliefs and distress so as to make
the results comparable to the ones for the healthy sample. We also wanted to check which of
the two theoretical predictions regarding the potential role of automatic thoughts, advanced
consequently to Study 1, better described the relationships between the constructs considered.
Thus, we also measured automatic thoughts as a potential mediator in the relationship between
more profound cognitive structures (e.g., irrational beliefs), experiential avoidance and distress.

Method
Twenty-eight participants (26 females, 2 males) diagnosed with generalized anxiety disorder
(GAD) took part in this study. Ages ranged from 21 to 50 years, with a mean age of 26.67
(SD = 6.29). None of the subjects had had any prior experience with any of the forms of
therapy taken into account. Subjects were recruited from an ongoing randomized clinical trial
comparing various forms of CBT for GAD. All participants were diagnosed with GAD after
having been evaluated with SCID-I/P module for anxiety disorders (First, Spitzer, Gibbon, &
Williams, 2002). The procedure used was the same as in Study 1, with the addition of a measure
of automatic thoughts. Questionnaires were completed at baseline before the participants were
randomized in any of the treatment groups.
Automatic thoughts were measured with the Automatic Thoughts Questionnaire (ATQ; Hollon & Kendall, 1980). This instrument comprises 15 statements that represent dysfunctional
self-related automatic thoughts. The subject has to rate them in terms of frequency of occurrence
on a 5-point Likert scale, ranging from 1 (never) to 5 (almost always). The ATQ was adapted on

Key Constructs in Cognitive Behavioral Therapies

the Romanian population (Moldovan, 2007), on a sample of 240 individuals, showing excellent
reliability (Cronbachs alpha = .92). Validity analysis indicated the scale correlated positively
with other measures of dysfunctional thinking (irrational beliefs, dysfunctional attitudes) and
negatively with unconditional self-acceptance and self-esteem.
We employed the same data analysis procedure as in Study 1 (correlational and mediation
analysis), but additionally we tested multiple step mediation. We applied the Hayes, Preacher,
and Myers (2011) multiple step multiple mediation procedure in which mediators are allowed
to influence each other, implemented in the MEDTHREE script for SPSS. We reported bias
corrected and accelerated confidence intervals for 5000 bootstrap samples.

Results and Discussions

Descriptive data. Means and standard deviations, as well as minimum and maximum
values for the main variables included in the study, are presented in Table 3. Predictably, the
clinical sample scored high on measures of emotional distress, both compared with the normative
values of the PED/PAD scale (Opris & Macavei, 2007), as well as to the sample from Study 1.
Correlational analysis. The association among variables from each therapy approach
considered (REBT, CT, ACT) and their associations with distress are presented in Table 4.

Table 3
Means, Standard Deviations (SD), Minimum (Min) and Maximum (Max) Values for the Main
Variables in Study 2

USAQ Unconditional self-acceptance

AAQ-II Experiential avoidance
DAS-A Dysfunctional attitudes
ABS 2 Global Irrationality
ABS 2 Rationality
PED/PAD Distress

Min

Max

Mean

SD

28
28
27
28
28
28

45
13
106
29
34
26

109
47
231
234
130
132

70.14
33.25
151.67
121.75
90.91
86.57

16.97
8.81
31.17
52.81
25.79
28.31

Note. USAQ = Unconditional Self-Acceptance Questionnaire; AAQ-II = Acceptance and Action Questionnaire II; DAS-A = Dysfunctional Attitudes Scale A; ABS 2 = The Attitudes and Beliefs Scale 2; PED/
PAD = Profile of Emotional Distress/Profile of Affective Distress.

Table 4
Correlations Between the Cognitive and Subjective/Emotional Variables in Study 2
Cognitive variables
1. USAQ Unconditional self-acceptance
2. AAQ-II Experiential avoidance
3. DAS-A Dysfunctional attitudes
4. ABS 2 Global Irrationality
5. ABS 2 Rationality
6. ATQ Automatic thoughts
Subjective-emotional variables
7. PED/PAD Distress

.62
.67
.77
.69
.38

.47
.61
.48
.74*

.80
.74
.57

.95
.58

56

.59

.75

.58

.75

.70

.79

Note. USAQ = Unconditional Self-Acceptance Questionnaire; AAQ-II = Acceptance and Action Questionnaire; DAS-A = Dysfunctional Attitudes Scale A; ABS 2 = The Attitudes and Beliefs Scale 2; ATQAutomatic Thoughts Questionnaire; PED/PAD = Profile of Emotional Distress/Profile of Affective Distress.
p < .05 Holm-Bonferroni corrected for multiple comparisons.

10

Journal Of Clinical Psychology, xxx 2012

The correlation pattern was similar to the one obtained in Study 1. However the correlations
were higher than those for the sample in Study 1. Functional, protective constructs such as
rationality or unconditional self-acceptance had medium to high degrees of correlation,
higher than in Study 1. Their associations with the ACT construct of experiential avoidance/psychological inflexibility were also medium to high (albeit not significant for rationality).
Automatic thoughts were, as expected from the literature, highly correlated with distress. They
displayed medium correlations with the more broad, core cognitive constructs (irrationality, dysfunctional attitudes), indicating they represent different, but related constructs. We also noted
there was a high positive correlation with experiential avoidance.
We believe these results might suggest that vulnerability factors such as irrational beliefs,
dysfunctional schema, automatic thoughts, and experiential avoidance are more influential and
effective in generating emotional distress in the case of a clinical sample.

Simple mediation analysis. The results indicated experiential avoidance/psychological

inflexibility acted as a mediator in the relationship between global irrationality and emotional
distress, indirect effect = .15, SE = .06, 95% CI (bias corrected and accelerated) = .06 to
.30. Experiential avoidance/psychological inflexibility also mediated the relationship between
unconditional self-acceptance and emotional distress, indirect effect = .65, SE = .23, 95% CI
(bias corrected and accelerated) = 1.21 to .30, as well as between dysfunctional attitudes
and emotional distress, indirect effect = .26, SE = .11, 95% CI (bias corrected and accelerated)
= .09 to .53. The converse models were again nonsignificant (the confidence interval of the
indirect effect contained zero). A graphic representation of the mediation models is presented in
Figure 2.
Effect sizes were calculated for all three mediation models. In the first one, with experiential
avoidance mediating the relationship between global irrationality and emotional distress, 2
took the value of .34, 95% CI (bias corrected) = .16 to .53. In the second model, where experiential avoidance mediated the relationship between unconditional self-acceptance and emotional
distress, 2 was .39, 95% CI (bias corrected) = .17 to .59. In the case of experiential avoidance
mediating the relationship between dysfunctional attitudes and emotional distress, 2 = .32, 95%
CI (bias corrected) = .10 to .51.
The results were therefore consistent with those of Study 1, indicating that the effects of
more general, schema-like cognitive variables (irrationality, unconditional self-acceptance, dysfunctional attitudes) on emotional distress were carried out through the mediation of the more
circumscribed construct of experiential avoidance.
Multiple step mediation analysis. We also tested two alternative multiple mediation
models, corresponding to the two possible paths we anticipated theoretically: with automatic
thoughts as mediator 1 and experiential avoidance as mediator 2, and, respectively, with experiential avoidance as mediator 1 and automatic thoughts as mediator 2. As predictors we
consecutively used each of the schema-type constructs, while as outcome we used distress.
Our results showed significant mediation in the cases in which experiential avoidance played
the role of mediator 1 and automatic thoughts the role of mediator 2: with irrationality as the
predictor, indirect effect = .08, SE = .05, 95% CI (bias corrected and accelerated) = .01 to .22;
with unconditional self-acceptance as a predictor, indirect effect = .40, SE = .25, 95% CI (bias
corrected and accelerated) = 1.08 to .09; and with dysfunctional attitudes as the predictor,
indirect effect = .11, SE = .08, 95% CI (bias corrected and accelerated) = .002 to .31. For
each of the alternative models (automatic thoughts as mediator 1 and experiential avoidance as
mediator 2), the confidence intervals of the indirect effect contained zero, indicating the absence
of mediation. A graphic representation of these models is presented in Figure 3.
Summary and Concluding Discussion
The first major conclusion of our research was that these core constructs, central for each of
the therapies considered, shared a degree of overlap. Their associations were medium to high,
which could mean they measure similar, related, but still distinct, processes. REBT unconditional

Key Constructs in Cognitive Behavioral Therapies

11

Figure 2. Simple mediation diagrams for Study 2. Values are path coefficients representing standardized
regression weights and standard errors (in parentheses). The c path coefficient refers to the total effect of the
independent variable (IV) on the dependent variable (DV). The c-prime path coefficient refers to the direct
effect of the IV on the DV.

self-acceptance shared significant variance with ACT acceptance (understood as the opposite
process of experiential avoidance; see Bond et al., 2011 for details), but each maintained a
standalone, distinct part. Future studies could further clarify the nature of these associations.
For instance, one might speculate that REBT acceptance of the person as a whole also includes
ACT acceptance of unwanted thoughts or experiences. REBTs preferential, rational formulation
of desires or goals (e.g., I would like to get a good result and do my best to get it, but I accept
that it might not happen no matter how hard I try) might intersect with core acceptance
components developed in ACT. Schema-type constructs like irrational beliefs and dysfunctional
attitudes were significantly associated with experiential avoidance, but a non-negligible part of
each of them remained distinct. The observed overlap may be because of the characteristics of
rigidity and inflexibility expressed by all three constructs.
The second major conclusion was that experiential avoidance/psychological inflexibility mediated the relationship between the cognitive constructs (e.g., irrationality, unconditional selfacceptance, dysfunctional attitudes) and distress. The effect held for both the student sample

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Journal Of Clinical Psychology, xxx 2012

Figure 3. Multiple step mediation diagrams for Study 2. Values are path coefficients representing standardized regression weights and standard errors (in parentheses). The c path coefficient refers to the total
effect of the independent variable (IV) on the dependent variable (DV). The c-prime path coefficient refers
to the direct effect of the IV on the DV.

in Study 1, as well as for the clinical sample in Study 2. Our results are consistent with the
mediation analyses conducted by Kashdan, Barrios, Forsyth, and Steger (2006), in which rigid,
inflexible coping mechanisms affected distress and adaptation via experiential avoidance. While
we looked at dysfunctional thinking patterns and not coping or emotion regulation strategies,
it is possible that the rigid, inflexible character of these different variables is responsible for
triggering avoidant response tendencies that in turn are responsible for sustaining distress.

Key Constructs in Cognitive Behavioral Therapies

13

An interesting key result, which emerged in the multiple step mediation analysis of Study 2,
was that the effect of the more general, schema-type constructs on distress was carried out by
acting upon experiential avoidance, which in turn primed automatic thoughts that were the most
proximal to distress. In an integrated CBT theory we can argue that during an activating event
deeper, schema type constructs activate experiential avoidance which in turn primes automatic
thoughts presumably by a mechanism similar to Wegner et al. (1987) white bear effect (i.e.,
avoided thoughts return with more frequency). However, because of our limited sample size, we
recommend the testing of these multiple mediation models on larger samples.
We used a robust method for testing mediationbootstrappingwhich has the advantage of
being independent from sample sizes and not assuming a normal distribution of the indirect
effects (Preacher & Hayes, 2008). The values for our effect sizes (around .30) indicated we
managed to show a consistent part of the maximum indirect effect that could have been attained
given the design and distribution characteristics. Preacher and Kelley (2011) also gave some
tentative benchmark values for kappa-squared, warning they are to be interpreted cautiously.
The values proposed are same ones as for Cohens r2 small, medium and large effect sizes
correspond to values of 0.01, 0.09, and 0.25, respectively (Cohen, 1988, pp. 7981). In our
case, all of the confidence intervals for the effect sizes included 0.25, indicating large effect
sizes.
Theoretically, from a classical CBT standpoint, these results seem to reinforce the notion
that irrational beliefs and/or dysfunctional cognitions are underlying cognitive vulnerability
factors that in negative situations activate experiential avoidance, which in turn primes automatic
thoughts, possibly by a mechanism similar to Wegner et al.s (1987) white bear effect (i.e., avoided
thoughts return with more frequency, generating distress). However, our results can also be
integrated in a third wave CBT (i.e., ACT) perspective. It could be that irrational beliefs and
dysfunctional cognitions, by being rigid and inflexible, represent barriers in the pursuit of valued
goals and, thus, foster experiential avoidance/psychological inflexibility.
The cross-sectional nature of our study does not warrant us to draw conclusions about
the effects that changes in these constructs may have on changes in distress. An interesting
conjecture could be that a change only in experiential avoidance and/or automatic thoughts
might momentarily reduce distress, but leave the client with deeper, schema-type latent cognitive
vulnerabilities (e.g., irrational beliefs, dysfunctional cognitions), which might become activated
in future situations and foster the cycle all over again. Future randomized controlled trials with
follow-up analyses could test this hypothesis. In this direction, a recent study (Kuyken et al.,
2010) showed that for participants with recurrent depression who received mindfulness-based
cognitive therapy (MBCT), cognitive reactivity posttreatment was not related with depressive
symptoms at 15 months follow-up, but that the relationship was present in the medication group.
While this result seems to indicate that MBCT did indeed change the very relationship between
dysfunctional thoughts and the emotional outcomes, we note that another study (Manicavasagar,
Perich, & Parker, 2012) looking at cognitive predictors of change (rumination) did not report
differences between MBCT and a classical CBT intervention.
Our research has several limitations. The most important is the very nature of the study,
which used a cross-sectional design. Cross-sectional studies have previously been used to test
relationships between constructs in psychotherapeutic models, both in general and for specific
disorders. Nonetheless, because all measures were taken at the same time point, we cannot
conclude that the proposed mediators do indeed account for changes in the dependent variable
(distress). Future studies should address this limitation by measuring hypothesized mediators
prior to assessing outcome.
Another limitation is that while classical CBT was represented by more core constructs,
measuring different aspects on dysfunctional thinking, third wave CBT was represented by just
one. Future studies could include more processes coming from ACT and third wave approaches
in relationship to more classical CBT constructs and with distress to test for complex mediation
models. Last, procedural limitations should also be noted. While the measures for constructs
in classical CBT are among the most widely used and psychometrically sound (Bridges &
Harnish, 2010) and have been adapted on the Romanian population, the measure for experiential
avoidance/psychological inflexibility (AAQ-II) had not been previously used. However we did

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Journal Of Clinical Psychology, xxx 2012

report good psychometric properties on both samples used in our studies. Also it is possible that
the screening questionnaire of the SCID used to rule out participants with psychopathology in
Study 1 might have had some false negatives.
The study should be replicated on other samples of participants, especially on various clinical
samples. Moreover, research efforts should be devoted to formulating a CBT paradigm that
would explain and integrate these findings.

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