Journal of Contextual Behavioral Science ()

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Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

Comparing paths to quality of life: Contributions of ACT and cognitive

therapy intervention targets in two highly anxious samples
Christopher R. Berghoff n, John P. Forsyth, Timothy R. Ritzert, Sean C. Sheppard
University at Albany, State University of New York, 1400 Washington Ave., Albany, NY 12222, USA

art ic l e i nf o

a b s t r a c t

Article history:
Received 19 February 2013
Received in revised form
11 March 2014
Accepted 7 April 2014

Anxiety disorders are associated with numerous costs and poor quality of life (QOL), and yet are highly
treatable. The present study evaluated the relations between putative change processes, anxiety
symptom severity, and QOL by employing path analysis to compare two theoretically-derived models
of anxious psychopathology in an examination of pre-intervention data from two self-help effectiveness
studies. Consistent with expectation, symptom severity predicted QOL in a model derived from cognitive
therapy principles, though the model did not provide a good t to the data. A model derived from
Acceptance and Commitment Therapy principles suggested that the impact of experiential avoidance
(EA) on QOL was independent of symptom severity and provided a better t to the data. In fact, the path
from anxious symptomatology to QOL became non-signicant when EA was allowed to relate to QOL
directly. Cognitive fusion strongly predicted anxiety sensitivity which, in turn, signicantly predicted
symptoms. Theoretical and practical implications of the ndings are discussed in the context of
improving available treatments for anxiety-related disorders.
& 2014 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.

Keywords:
Acceptance and commitment therapy
Cognitive therapy
Experiential avoidance
Cognitive fusion
Anxiety
Fear

1. Introduction
Anxiety disorders are common, chronic, debilitating, and associated with a range of functional impairments and poor quality of
life (QOL; i.e., the subjective well-being of an individual across
multiple domains of life; Frisch, Cornell, Villaneuva, & Relatzaff,
1992; Mendlowicz & Stein, 2000). Yet, anxiety disorders respond
well to traditional Cognitive Behavioral Therapies (tCBT), including
cognitive therapy (CT), that employ a range of evidence-based
intervention strategies (see Olatunji, Cisler, & Deacon, 2010 for a
recent meta-analytic review). Generally, cognitive-based interventions aim to ameliorate anxious suffering by directly altering
problematic psychological and emotional content (i.e., symptomatology) as a means to reduce functional impairments and increase
QOL (Hofmannn & Asmundson, 2008). This line of work has
yielded an impressive array of time-limited and efcacious interventions for a broad range of problems (e.g., anxiety disorders, see
Clark et al., 2003; mood disorders, see DeRubeis et al., 2005; and
psychosis, see Drury, Birchwood, Cochrane, & Macmillan, 1996).
Though behavior-change techniques are utilized in tCBT, the
central aim of CT is to identify, challenge, and correct negative or
distorted cognitions, maladaptive beliefs, and assumptions (Beck,
n
Correspondence to: University at Albany, State University of New York,
Department of Psychology, Social Sciences 399, 1400 Washington Ave., Albany,
NY 12222, USA. Tel.: 1 518 442 4820; fax: 1 518 442 4867.
E-mail address: cberghoff@albany.edu (C.R. Berghoff).

1995; Clark, 1995; Dobson & Dozois, 2010; Hofmann, Asmundson,

& Beck, 2013; Leahy, 2003; McGinn & Sanderson, 2001). For
instance, cognitive constructs such as anxiety sensitivity (AS; i.e.,
fear of fear; Reiss, Peterson, Gursky, & McNally, 1986) emphasize
catastrophic misappraisals and beliefs and, in turn, have been
proposed to explain why some individuals develop anxiety disorders while others do not (e.g., Bentez et al., 2009; McNally,
2002; Naragon-Gainey, 2010). Based upon the premise that cognitions play a causal role in moderating and inuencing the
behavior-outcome (i.e., psychological symptoms) relations
(Hofmannn & Asmundson, 2008), treatment manuals detail how
to identify automatic thoughts, challenge distorted thinking patterns, and alter dysfunctional schemas (e.g., Beck, 1995; Clark &
Beck, 2010). Thus, a primary goal of effective treatment is modication of dysfunctional cognitions that are causally related to
symptom interpretation and related psychological distress
(Hofmannn & Asmundson, 2008, p. 7). In other words, CT postulates that altering the content (i.e., the form or frequency) of
cognitions is a means to reduce symptomology.
In line with this approach, virtually all CT efcacy trials utilize
measures of symptom severity or frequency as primary outcome
variables (e.g., panic disorder, see Arntz, 2002; generalized anxiety
disorder, see Hanrahan, Field, Jones, & Davey, 2013; social anxiety
disorder, see Stangier, Schramm, Heidenreich, Berger, & Clark,
2011; obsessive-compulsive disorder, see Wilhelm et al., 2009).
Yet, evidence is mixed in supporting the view that change in the
content of cognitions is a causal mechanism responsible for

http://dx.doi.org/10.1016/j.jcbs.2014.04.001
2212-1447/& 2014 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.

Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i

C.R. Berghoff et al. / Journal of Contextual Behavioral Science ()

symptom change. While evidence suggests that some cognitive

constructs mediate outcomes in specic studies that target anxiety
disorders (e.g., catastrophic cognitions: Hofmann et al., 2007;
perceived control: Meuret, Roseneld, Seidel, Bhaskara, &
Hofmannn, 2010; negative evaluations and views of the self:
Rapee, Gaston, & Abbott, 2009), a recent review suggests that
little evidence supports cognitive change as a mediator of symptom improvement (Longmore & Worrell, 2007).
Moreover, virtually all forms of CT are guided by the view that
symptom reduction leads to enhanced life satisfaction, of which
QOL is a part (Hofmann & Asmundson, 2008). Indeed, QOL is now
routinely evaluated as one possible treatment outcome in tCBT and
CT research (e.g. Bechdolf et al., 2010; Costa, Cheniaux, Rang,
Versiani, & Nardi, 2012; Diefenbach, Abramowitz, Norberg, & Tolin,
2007; Mo
rtberg, Clark, Sundin, & Wistedt, 2007). This work
suggests that individuals suffering with anxiety are at risk for
signicantly lower QOL than non-anxiety control groups (Olatunji,
Cisler, & Tolin, 2007) and that tCBT can have a signicant positive
impact on QOL (e.g., Mendlowicz & Stein, 2000; Mo
rtberg et al.,
2007). Yet, to the best of our knowledge, no studies have identied
signicant relations between putative change mechanisms in CT
on QOL. Thus, it remains unclear as to whether cognitive change is
related to symptom reduction, and whether such relations
impact QOL.
Other recent developments within behavior therapy suggest
that targeting symptoms directly, including the content or frequency of cognitions, is neither necessary nor sufcient to improve
broader indices of functioning, of which QOL is a part. For instance,
Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, &
Wilson, 2012), which shares several fundamental, intellectual, and
practical commitments with tCBTs generally (e.g., evidence-based
practice, direct behavior change technologies, foundation in basic
learning principles; Hayes, 2004, 2008), departs from CT in several
important ways. Most notably, ACT offers a functional, processoriented account of human suffering and its alleviation that builds
upon a behavioral account of human language and cognition (see
Eifert & Forsyth, 2005; Hayes, 2004; Hayes, Levin, PlumbVilardaga, Villatte, & Pistorello, 2013; Hayes et al., 2012). As an
alternative to cognitive-content change and symptom reduction,
ACT suggests that altering contexts that support several unhealthy
processes, preeminently experiential avoidance (EA) and cognitive
fusion, is critical to more effective action and improved QOL
(Hayes et al., 2012).
EA is dened as rigid and inexible efforts to change the form
or frequency of unwanted internal experiences, and the inability to
effectively alter behavioral patterns that impede value-directed
living (Hayes et al., 2004, 2012). EA appears to be a toxic process in
the development and maintenance of anxiety disorders. For
example, EA is associated with anxiety-related distress and other
forms of psychopathology (Hayes, Luoma, Bond, Masuda, & Lillis,
2006) and appears to mediate meaning in life, personal growth,
and general QOL outcomes following exposure to traumatic events
(Kashdan & Kane, 2010; Kashdan, Morina, & Priebe, 2008). Moreover, in non-clinical samples, EA is related to social anxiety
symptoms (Kashdan, Breen, Afram, & Terhar, 2010), worry
(Santanello & Gardner, 2007), and panic attacks (Tull & Roemer,
2008). This evidence suggests that the behavioral reaction to
unpleasant thoughts and feelings, and not necessarily the presence
or specic content of such private events, may be important when
accounting for QOL.
Likewise, the theoretically related construct cognitive fusion
(i.e., the tendency for cognitive language processes, such as reason
giving, problem-solving, and evaluating, to regulate behavior
beyond the inuence of other contextual variables) can become
problematic when it serves to organize behavior in unhelpful ways
(Eifert & Forsyth, 2005; Forsyth, Eifert, & Barrios, 2006; Hayes

et al., 2012, 2013). When fusion controls behavior, individuals buy

into aversive cognitive content (e.g., the thought I can't handle
my panic) and believe the content as a literal truth. This often
leads to EA and various forms of avoidant behavior in an effort to
change the form or frequency of private experiences. When fused,
panic-inducing contexts may be avoided, substances may be used
as an escape from internal content, and an individual may become
insensitive to immediate, environmental contextual cues (Eifert &
Forsyth, 2005). Collectively, research suggests that cognitive fusion
is an important psychological process in the conceptualization and
treatment of various anxiety problems (e.g., Arch, Eifert et al.,
2012; math anxiety: Zettle, 2003; OCD: Twohig, Hayes, & Masuda,
2006; Twohig et al., 2010; PTSD: Twohig, 2009; and social anxiety:
Dalrymple & Herbert, 2007).
Moreover, ACT processes demonstrate relations with traditional symptom measures in expected directions (see Hayes
et al., 2006; Ruiz, 2010, for recent reviews) and consistently
mediate outcomes in clinical trials for a number of mental health
problems spanning syndromal diagnostic categories (Hayes et al.,
2006), including anxiety disorders (e.g., Arch, Wolitzky-Taylor,
Eifert, & Craske, 2012; Dalrymple & Herbert, 2007; Forman,
Herbert, Moitra, Yeomans, & Geller, 2007; Twohig et al., 2010).
Although not principally targeted, improvements in psychological
and emotional distress can and often do accompany effective ACT
treatment for individuals suffering with anxiety (e.g., see Twohig,
2009; Twohig et al., 2010). Such outcomes suggest that directly
addressing the content of private experiences by identifying,
challenging, and restructuring cognitions may be unnecessary if
the aim is to positively affect psychological health, behavioral
functioning, or QOL (e.g., Arch, Eifert et al., 2012). Indeed, the focus
of ACT is on altering the way one relates to aversive cognitions
(i.e., increasing defusion by fostering awareness of the process of
thinking) in the service of increasing exible and less avoidant
behaviors (i.e., fostering increased experiential acceptance and
psychological exibility) in response to aversive content (Hayes
et al., 2013).
Research suggests that both CT and ACT impact symptoms of
anxiety pathology, distress, and QOL, although they do so using
different models of psychopathology and intervention approaches.
Thus, each leads to testable predictions regarding how putative
change processes and symptomatology may be related to QOL. CT
principles suggest that behavioral processes should be mediated
by cognitive constructs that are directly related to anxious symptomatology, and consequently QOL (Hofmann & Asmundson,
2008). By contrast, ACT principles suggest that behavioral processes such as EA and cognitive fusion ought to be directly related
to QOL, while also possibly affecting other predispositions and
symptomology more generally (e.g., Arch, Eifert et al., 2012; Eifert
& Forsyth, 2005). Path analysis is well suited to evaluate hypotheses arising from both models, and was used herein to examine
pre-intervention data from two randomized clinical trials investigating the effectiveness of ACT and tCBT self-help books in
international community samples of anxiety sufferers. Specically,
we investigated if behavioral processes proposed by ACT (EA and
cognitive fusion) have a direct relation to QOL, or if such processes
are statistically mediated by cognitive processes (i.e., AS), thereby
affecting anxious symptom severity and QOL indirectly.
1.1. Study 1
Data utilized in Study 1 was collected as part of the pretreatment assessment battery of a randomized wait-list controlled
trial evaluating the effectiveness of an ACT-based self-help workbook titled The mindfulness & acceptance workbook for anxiety:
A guide to breaking free from anxiety, phobias, and worry using
Acceptance and Commitment Therapy (MAWA; Forsyth & Eifert,

Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i

C.R. Berghoff et al. / Journal of Contextual Behavioral Science ()

2008b). Participants were recruited through posts to a variety of

Internet-based forums, including electronic mailing lists and
anxiety disorder-support and social-networking sites. All assessments, including informed consent and eligibility, were administered in English at www.SurveyMonkey.com. Eligible participants
self-reported being at least 18 years of age, uent in English at the
8th grade level, having regular access to a computer with Internet
service, and no prior exposure to the MAWA. Additionally, eligible
participants endorsed at least one item suggesting they struggled
with worry, fear, and anxiety, along with the item Do you believe
that you have a problem with anxiety, or may suffer from an anxiety
disorder? A workbook was mailed to eligible participants after the
completion of a pre-treatment assessment battery and randomization to a 12-week condition (workbook or wait-list). As incentives, participants received a free copy of the workbook and a 1 in
50 chance of winning a $25 Amazon.com gift certicate. All
procedures were approved by the local IRB.

2. Method
2.1. Participants
All study candidates who entered the online portal consented
to participate, and 616 were deemed eligible for the treatment
study following eligibility screening. One hundred thirteen (18.3%)
eligible participants did not respond to our invitation to complete
the pre-intervention assessment. Analyses indicated that these
individuals reported having heard of ACT less frequently (18.3
versus 33.0%; 2(1) 9.033, p o.01) and reported lower rates of
seeing a mental health professional (35.7 versus 46.3%; 2(1)
4.161, p o.05), than did completers. The nal sample consisted of
503 participants from the United States and abroad (females 394,
Mage 38.05 years, age range: 1872). The geographic distribution
of participants was diverse, and included residents of the United
States (n339), United Kingdom (n54), Canada (n43), Australia
and New Zealand (n 41), Ireland (n 7), and various other
European, Asian, and North American countries (n 18). The selfidentied ethnic/racial distribution of the sample was predominately White (n 435), followed by Other (n 20), Asian (n 16),
Hispanic (n 16), Multiracial (n 9), African-American (n 4), and
Native American (n 3). More than 60% of participants reported
being in a committed relationship (n 316). Participants were
generally highly educated (166 individuals had obtained a college
degree; 145 completed at least some graduate education), yet
reported a high rate of unemployment (14.12%). Moreover, 46.7%
of participants reported currently seeing a mental health professional for psychological difculties, 49.7% reported current medication use, 82% had been given a psychiatric diagnosis at some
point in their lives, and 56% reported receiving an anxiety disorder
diagnosis.
2.2. Materials
Anxiety sensitivity index (ASI). The ASI (Peterson & Reiss, 1992;
Reiss et al., 1986) is a widely used (e.g., Arch, Eifert et al., 2012)
self-report measure that assesses fear of aversive anxiety symptoms (e.g., shortness of breath), a key component of anxiety
disorders (Craske et al. 2009). Agreement with 16 items (e.g.,
It scares me when I am nervous) is rated on a 5-point Likert-type
scale (0 very little to 4 very much). Higher total scores
(range064) represent greater levels of catastrophic fear and
negative evaluations of anxiety symptoms (i.e., fear of fear).
The ASI has demonstrated good internal consistency in both
clinical (.88; Zinbarg, Barlow, & Brown, 1997) and non-clinical
samples (.86; Schmidt & Joiner, 2002), in addition to good

2-week (r .75; Reiss et al., 1986) and 3-year (r .71; Maller &
Reiss, 1992) testretest reliability. Internal consistency was excellent in the present study (.91).
2.2.1. Acceptance and action questionnaire 16 (AAQ)
The AAQ (Hayes et al., 2004) is a self-report scale designed to
measure EA. The present study utilized the 16-item version that
includes items assessing behavioral (a) avoidance of private
experiences (e.g. I try hard to avoid feeling depressed or
anxious), (b) control of private experiences (e.g., I rarely worry
about getting my anxieties, worries, and feelings under control,
reverse scored), and (c) action in the presence of unwanted private
experiences (e.g., When I feel depressed or anxious, I am unable
to take care of my responsibilities). Items are rated on a 7-point
Likert-type scale (1 never true to 7 always true), with higher
total scores (range16112) indicating greater levels of EA.
The AAQ has acceptable to good internal consistency (.78.86;
Arch, Eifert et al., 2012), and had good internal consistency in the
present study (.80).
2.2.2. Believability of anxious feelings and thoughts questionnaire
(BAFT)
Consistent with prior research (Masuda et al., 2009), the BAFT
(Forsyth & Eifert, 2008a; Herzberg et al., 2012) is designed to
assess the believability of thoughts and feelings, and specically
the extent to which one's relation with unpleasant private events
is fused or defused. Respondents rate 16 self-report items (e.g.,
My happiness and success depends on how good I feel) on a
7-point Likert-type scale (1 not at all believable to 7 completely
believable). Higher total scores (range16112) represent more
fusion with private content. The BAFT has demonstrated excellent
internal consistency in healthy undergraduate (.90) and highly
anxious community samples (.91). In addition, the BAFT has
good testretest reliability (r .77), strong construct validity, and is
sensitive to an ACT self-help treatment (Herzberg et al., 2012).
Internal consistency in the present study was excellent ( .90).
2.2.3. Beck anxiety inventory (BAI)
The BAI (Beck, Epstein, Brown, & Steer, 1988) is a self-report
assessment of anxiety symptom severity. Respondents rate 21
common anxiety symptoms (e.g., unable to relax and face
ushed) on a 4-point Likert-type scale (0 not at all to 3 severely
 I could barely stand it) indicating the degree to which the
symptoms bothered them over the past week. Scores range from
0 to 63, with scores below 7 suggestive of minimal anxiety and 26
or greater suggestive of severe anxiety. The BAI has excellent
internal consistency (a .92), good testretest reliability (r .75),
good convergent and discriminant validity, and distinguishes
between individuals diagnosed with an anxiety disorder and those
who are not (Beck et al., 1988). Internal consistency was excellent
in the present study ( .93).
2.2.4. Quality of life inventory (QOLI)
The QOLI (Frisch, 1994; Frisch et al., 1992) is a 32-item selfreport measure of general life satisfaction. Sixteen life domains
(e.g., work, friends, and family) are rated for both importance
(0 not at all important to 2 extremely important) and satisfaction
( 3 very dissatised to 3 very satised) using Likert-type scales.
Total QOL (range  6 to 6) is calculated as the average of the
domain composite scores (Importance  Satisfaction) following
removal of domains rated as not at all important, with higher
scores representing greater QOL. The QOLI has acceptable to good
internal consistency ( .77.89), strong testretest reliability
(r .80.91), and good discriminant and convergent validity

Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i

C.R. Berghoff et al. / Journal of Contextual Behavioral Science ()

(Frisch et al., 1992). Internal consistency was good in the present

study ( .80).
2.3. Data analytic approach
Path analysis affords investigation of a priori, specied, theoretically-based structural models by examining the t of hypothesized causal pathways to observed data, and is particularly
useful when existing empirical and theoretical support are strong
(Kelloway, 1998; Shadish, Cook, & Campbell, 2002). Therefore,
path analysis is an appropriate technique to employ given the
well-developed literature regarding both CT and ACT models of
putative variables that contribute to QOL.
Two hierarchal nested path models, based on the covariance
matrix and employing maximum likelihood estimation, were
tested to examine differential pathways to QOL hypothesized by
CT and ACT. For the model representing ACT-relevant predictors,
behavioral processes (EA and cognitive fusion) were allowed to
relate to both AS and QOL directly (e.g., Eifert & Forsyth, 2005;
Hayes et al., 2012, 2013). AS was entered as a mediator of
behavioral processes on anxiety symptom severity, and symptom
severity was allowed to relate to reported QOL directly. Finally, EA
and cognitive fusion were allowed to co-vary, given their close
relation within ACT theory. Overall, the model allowed behavioral
process measures to relate to QOL directly and indirectly.
The nested model, representing CT theory (e.g., Hofmann &
Asmundson, 2008; Hofmann et al., 2013), constrained the direct
paths from EA and cognitive fusion to QOL to equal 0. All other
paths of the ACT relevant model were left in place. This change
removed the direct relations of behavioral processes to QOL and
forced statistical mediation of such effects by both cognitive
processes and anxiety symptom severity. Thus, behavioral process
variables were allowed to affect QOL only indirectly.
Path analyses were conducted in LISREL 8.8. Three common t
indices (goodness of t index [GFI], comparative t index [CFI],
and nonnormed t index [NNFI]), and a chi-square difference test
were used to evaluate model-t (Hu & Bentler, 1999). Conventional
cutoff values of .90 for the GFI and NNFI (Kelloway, 1998) and
values approaching .95 for the CFI (Hu & Bentler, 1999) were used.

3. Results and discussion

Two participants failed to complete the full assessment battery
and were excluded from the analyses.1 Two cases were identied
as multivariate outliers through Mahalanobis distance at p o.001
and removed from the analyses, resulting in 499 total cases.
Descriptive statistics (see Table 1) suggested the sample was
highly anxious. Average BAI scores (M 31.30) exceeded the
normative cutoff for severe anxiety, and ASI scores (M 36.00) fell
within the range suggestive of panic disorder or agoraphobia
(Peterson & Reiss, 1992). QOLI scores were quite low and comparable to those observed in inpatient Veteran populations (Frisch
et al., 1992). Consistent with this pattern, the sample yielded elevated
scores on both EA (AAQ) and cognitive fusion (BAFT), suggesting
signicant struggle with anxiety related behaviors and symptoms.
All variables were signicantly correlated at po.01 (see Table 1).
Fig. 1 displays the path analysis model, 2, the 2 difference test,
and t statistics for both models evaluated. Non-signicant paths
have been removed from the gure for ease of interpretation, though
the gure is derived from the full model. Overall, the chi-square
difference test indicated that the paths from EA and cognitive fusion
1
The two participants neglected to complete entire scales used in the analyses,
preventing use of data imputation techniques.

to QOL signicantly improved the t of the model to the observed

data, above and beyond that of the CT-representative model, 2(2)
107.64, po.001. While anxiety symptom severity initially appeared
to account for QOL in the CT-representative model, all t statistics
converged in suggesting a poor t of the model. This is in comparison
to the statistical model representative of ACT components, where
both the CFI and GFI suggested a good t of the model and the NNFI
indicated an acceptable t to the data.
Table 2 provides a decomposition of the effects for both
statistical models. Each model accounted for 49% of the variance
in ASI scores and 52% of the variance in BAI scores. However, the
ACT-representative model accounted for approximately three
times the variance (i.e., 34%) in QOLI scores compared to the
CT-representative model (i.e., 12% of the variance). Overall, EA
emerged as the direct and primary contributor to QOL outcomes.
Within the ACT-representative model, only EA was a signicant
predictor of QOL scores ( .57, p o.01). Anxiety symptom
severity became a non-signicant predictor when EA was allowed
to directly relate to QOL. This nding suggests that treatments
targeting EA may provide an efcient method of affecting an
individual's QOL. As expected, both EA (.13, p o.01) and
cognitive fusion (.60, p o.01) emerged as predictors of AS,
providing an explanation as to how altering ACT processes may
affect cognitive constructs and anxious symptomology. Finally, AS
emerged as a signicant predictor of anxiety symptom severity
(.72, p o.01), providing support for the CT postulate that
changes in cognitive constructs should lead to changes in anxiety
symptomology (e.g., Hofmann & Asmundson, 2008).
3.1. Study 2
Study 2 made use of data collected during the initial assessment of a comparative clinical effectiveness trial of two self-help
workbooks, one based on ACT (MAWA; Forsyth & Eifert, 2008b)
and the other on tCBT principles (The Cognitive Behavioral Workbook for Anxiety; Knaus, 2008). Recruitment, informed consent,
and eligibility criteria were identical to Study 1, including prior
exposure to, or use of, either of the two workbooks. Eligible
participants were randomly assigned to a treatment condition
and a copy of the appropriate workbook was mailed to each
participant. As incentives, participants received a free copy of one
of the workbooks and a chance of winning one $25 Amazon.com
gift certicate. All procedures were approved by the local IRB.
3.2. Method
3.2.1. Participants
All potential participants who entered the online portal consented to participate, and 258 were deemed eligible following
eligibility screening. Fifty-two (20.2%) participants did not respond
to our invitation to complete the pre-intervention assessment.
These individuals reported having adequate social support less
frequently than completers (44.2 versus 61.2%; 2(1) 4.880,
po .05), though no other signicant differences emerged. The
nal sample was composed of 208 international participants
(157 females; Mage 37.45, age range: 1871). The sample was less
geographically diverse than Study 1. Most participants reported
residing in the USA (n 158), followed by the United Kingdom
(n 17), Canada (n 12), Australia (n 12), Ireland (n 3), and
various other European and Asian countries (n 6). Most participants were White (n 176), followed by Other (n 12), Multiracial
(n 9), Asian (n 6), Hispanic (n 3), and African American (n 2).
Overall, 93 individuals reported being married while 86 indicated
they were single. The unemployment rate (19.71%; n 41)
appeared high given that 85.1% (n 177) of the sample completed
at least some college (59 individuals held a graduate degree).

Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i

C.R. Berghoff et al. / Journal of Contextual Behavioral Science ()

Table 1
Descriptive statistics and correlation matrix for variables tested in Study 1.
Scale

SD

ASI

BAI

AAQ

BAFT

ASI
BAI
AAQ
BAFT
QOLI

36.00
31.30
78.30
82.56
 .16

14.10
14.12
12.95
18.17
1.85

.718
.564
.695
 .361

.542
.651
 .343

.725
 .582

 .428

Note. N 499; ASI Anxiety Sensitivity Index; BAIBeck Anxiety Inventory;

AAQ Acceptance and Action Questionnaire (16-item version); BAFTBelievability
of Anxious Thoughts and Feelings Scale; QOLI Quality of Life Inventory.
All correlations p o .01.

CT Model
Fusion
.72

.60

ANX Sensitivity

.13

.48
.72

ANX Symptoms
-.34

.51
Quality of Life

Avoidance

.88
ACT Model
.51
Fusion

.60

ANX Sensitivity

.48
.72

Table 2
Decomposition of effects from the path analyses of Study 1.
Effect

Parameter
estimate

ACT model
On anxiety sensitivity
Of experiential
avoidance
Of cognitive fusion
On anxiety symptom
severity
Of anxiety sensitivity
On quality of life
Of experiential
avoidance
Of cognitive fusion
Of anxiety symptom
severity
tCBT model
On anxiety sensitivity
Of experiential
avoidance
Of cognitive fusion
On anxiety symptom
severity
Of anxiety sensitivity
On quality of life
Of anxiety symptom
severity

Standardized
estimate

R2

.49
.14

.13

2.73n

.47

.60

12.97n
.52

.72

.72

22.98n

 .08

 .57

 10.67n

.00
 .01

 .01
 .04

.19
 1.02

.14

.13

2.73n

.47

.60

12.97n

.34

.49

.52
.72

.72

22.98n

 .05

 .34

 8.13n

.12

ANX Symptoms
Note: Estimates are of path coefcients.

.72

.13

-.57

Avoidance

p o .01.

Quality of Life
.66

2(df)

GFI
CFI
NNFI
CT Model
157.66(5)
0.89
0.88
0.77
ACT
50.02(3)
0.96
0.97
0.90
2(2) = 107.64, p < .001

Fig. 1. Path models and t statistics for Study 1. All variables are observed. Path
coefcients are standardized (). Non-signicant paths are not displayed, though
the models are derived from the full analysis, not a reduced form. Statistically
signicant differences between the models are emphasized in bold print.
ANX Anxiety. Avoidance Experiential Avoidance, as assessed by the Acceptance
and Action Questionnaire, 16-item version. Fusion Cognitive Fusion, as assessed
by the Believability of Anxious Feelings and Thoughts Scale. ANX Sensitivity
assessed by the Anxiety Sensitivity Index. ANX Symptoms assessed by the Beck
Anxiety Inventory. Quality of Life assessed by the Quality of Life Inventory. All
displayed paths are signicant at p o.01.

Table 3
Descriptive statistics and correlation matrix for variables tested in Study 2.
Scale

SD

ASI

BAI

AAQ

BAFT

ASI
BAI
AAQ
BAFT
QOLI

37.97
33.05
80.18
86.48
 .24

13.05
13.15
10.95
13.83
1.86

.700
.515
.662
 .308

.424
.594
 .339

.570
 .574

 .363

Note. N 205; ASI Anxiety Sensitivity Index; BAIBeck Anxiety Inventory;

AAQAcceptance and Action Questionnaire (16-item version); BAFTBelievability
of Anxious Thoughts and Feelings Scale; QOLI Quality of Life Inventory.
All correlations p o .01.

likelihood estimation, both hierarchal nested models described in

Study 1 were tested using LISREL 8.8.
3.3. Results and discussion

More than 40% of the sample indicated they were receiving

mental health services (n 86), 141 participants reported having
received a mental health diagnosis in the past, and 103 reported
current medication use for psychological or emotional difculties.
Approximately 57% received a primary diagnosis of an anxiety
disorder by a mental health professional.
3.2.2. Materials
The assessment battery was identical to that reported in Study 1.
Internal consistencies for the present sample were as follows: ASI,
.90; AAQ, .76; BAFT, .85; BAI, .93; and QOLI, .80.
3.2.3. Statistical procedures
Identical procedures were followed as in Study 1. Briey, the
covariance matrix derived from the initial assessment phase of the
clinical trial was examined with path analysis. Employing maximum

No univariate or multivariate outliers were identied. Nine

individuals did not respond to a single item on one or more scales.
We chose to impute the within-participant item-level mean score
in these instances, given the low percentage of missing data.
However, three participants did not respond to at least 15% of the
items on one or more scales and were excluded from the analysis,
leaving 205 cases for evaluation.
Descriptive statistics and the correlation matrix of all measures
are presented in Table 3. Overall, sample characteristics were
comparable to those reported in Study 1. Participants were highly
anxious, and reported poor QOL and elevated levels of EA and
cognitive fusion. All correlations were signicant at p o.01.
Fig. 2 displays the path analysis model, 2, the 2 difference
test, and t statistics for both models. The gure is derived from
the full model, though non-signicant paths are not displayed.
Study 2 replicated the pattern of relations observed in Study 1.

Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i

C.R. Berghoff et al. / Journal of Contextual Behavioral Science ()

CT Model
Fusion
.57

.51
.70

ANX Sensitivity

.55
.20

ANX Symptoms

Quality of Life
.89
ACT Model
.53

Fusion
.57

.55

.51

ANX Sensitivity

.70

ANX Symptoms

.20
-.55

Avoidance

Quality of Life
.66

(df)

Effect

-.34

.53

Avoidance

Table 4
Decomposition of effects from the path analyses of Study 2.

GFI
CFI
CT Model
63.44(5)
0.89
0.87
ACT
13.97(3)
0.97
0.98
2(2) = 49.47, p < .001

NNFI
0.75
0.93

Fig. 2. Path models and t statistics for Study 2. All variables are observed. Path
coefcients are standardized (). Non-signicant paths are not displayed, though
the models are derived from the full analysis, not a reduced form. Statistically
signicant differences between the models are emphasized in bold print.
ANX Anxiety. AvoidanceExperiential Avoidance, as assessed by the Acceptance
and Action Questionnaire, 16-item version. Fusion Cognitive Fusion, as assessed
by the Believability of Anxious Feelings and Thoughts Scale. ANX Sensitivity
assessed by the Anxiety Sensitivity Index. ANX Symptoms assessed by the Beck
Anxiety Inventory. Quality of Life assessed by the Quality of Life Inventory. All
displayed paths are signicant at p o.01.

Theoretical predictions regarding QOL were better represented by

the ACT-representative statistical model than the CT-representative
statistical model. The chi-square difference test indicated that the
inclusion of paths from EA and cognitive fusion to QOL signicantly
improved the t of the model, 2(2)49.47, po.001. Also replicating the ndings of Study 1, all t statistics suggested a poor t of the
CT-representative model. All t indices (GFI, CFI, and NNFI) suggested
a good t of the ACT-representative model to the data, a slight
improvement over t indices observed in Study 1.
The standardized parameter estimates of the ACT-representative
model converged with the patterns observed in Study 1 (see Table 4).
EA was again the only direct, primary contributor to QOL ( .55,
po.01). The inclusion of the path from EA to QOL resulted in a nonsignicant relation between anxiety symptom severity and QOL
(  .12, p4.05). As in Study 1, EA (.20, po.01) and cognitive
fusion (.55, po.01) predicted AS, which in turn predicted anxious
symptom severity (.70, po.01). Overall, both models accounted
for 47% of the variance in AS and 49% of the variance in anxiety
symptom severity. As with Study 1, the ACT-representative model
accounted for three times the variance in QOL compared with CTrepresentative model (34% and 11%, respectively).
3.4. General discussion
To date, there have been surprisingly few studies examining
the comparative impact of putative change processes within CT
and ACT on outcome measures other than symptom severity. This
is unfortunate given that trends within evidence-based practice
suggest interventions ought to impact broader indices of functioning such as QOL. Indeed, one may be asymptomatic or fail to meet
diagnostic criteria for a psychological disorder post-intervention,

Parameter
estimate

ACT model
On anxiety sensitivity
Of experiential
.24
avoidance
Of cognitive fusion
.51
On anxiety symptom
severity
Of anxiety sensitivity
.70
On quality of life
Of experiential
 .09
avoidance
Of cognitive fusion
.00
Of anxiety symptom  .02
severity
tCBT model
On anxiety sensitivity
Of experiential
.24
avoidance
Of cognitive fusion
.51
On anxiety symptom
severity
Of anxiety sensitivity
.70
On quality of life
Of anxiety symptom  .05
severity

Standardized
estimate

R2

.47
.20

3.26n

.55

8.71n
.49

.70

13.90n

 .55

 7.55n

 .04
 .12

 .14
 1.85

.34

.47
.20

3.26n

.55

8.71n
.49

.70

13.90n

 .34

 5.12n

.11

Note: Estimates are of path coefcients.

n

p o .01.

yet continue to suffer from a range of functional impairments,

including poor QOL (Kazdin, 2001). Thus, identifying and evaluating processes that may either directly or indirectly impact broader
indices of functioning has practical implications for the design and
effective delivery of psychosocial interventions. This may yield
renements that streamline interventions to make them more
cost-effective, efcient, and broadly impactful.
The pattern of relations observed across studies was remarkably consistent. Initial evaluation of the statistical model representative of CT principles (e.g., Hofmann & Asmundson, 2008;
Hofmann et al., 2013) suggested that behavioral processes (EA and
cognitive fusion) impact cognitive processes (AS). In turn, AS
appeared to lead to anxious symptom severity (BAI), which
consequently predicted reported QOL (a theoretically consistent
pattern). Yet, across both studies, this model did not t the
observed data, suggesting the CT account is incomplete and that
processes other than symptom severity carry more impact and
weight on QOL. It is important to be mindful that we focused on a
subset of relevant processes, and whether the model could be
strengthened by inclusion of other relevant variables that may
account for QOL within CT (e.g., cognitive reappraisal) is worthy of
further investigation. It would be particularly useful to select key
constructs that are amenable to inuence through early intervention efforts or treatment itself, ensuring results are readily disseminated and applied through training programs and practice.
The model representative of ACT principles (e.g., Eifert &
Forsyth, 2005; Hayes et al., 2012) fared better, particularly in
highlighting the direct relation between EA and QOL over and
above anxious symptom severity. This statistical model provided a
good t to the data across both studies and accounted for a large
amount of the variance in QOL scores. Additionally, the robustness
of the model was demonstrated through replication across two
distinct samples with clinically elevated anxiety, a particular
strength of the present study. Collectively, the results suggest that
EA is strongly related to low QOL for highly anxious individuals,
more so than can be accounted for by anxiety symptom severity

Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i

C.R. Berghoff et al. / Journal of Contextual Behavioral Science ()

alone. In fact, the indirect path from EA through AS and anxious

symptom severity contributed marginal predictive value at best,
further supporting the notion that the relation between EA and
QOL occurs primarily through a direct path. These ndings offer
further support for both component (e.g., Butler & Ciarrochi, 2007;
Kashdan et al., 2008, 2010; Kashdan & Kane, 2010) and treatment
studies (e.g., Eifert et al., 2009; Forman et al., 2007; Hayes, Orsillo,
& Roemer, 2010; Wicksell, Melin, Lekander, & Olsson, 2009) that
have demonstrated a link between EA and QOL. Though the
present analyses are based on cross-sectional data and thus cannot
directly address temporal precedence, our ndings suggest that
targeting EA directly may offer a useful and efcient means of
affecting QOL in psychosocial interventions. Yet, it is also worth
noting that the measure used to assess EA in our analyses (AAQ;
Hayes et al., 2004) contains items than can be interpreted as
assessing valued action, a facet that is arguably related to QOL.
Thus, it is unclear if EA or valued action singularly, or a combination of the two constructs, is driving the relation between EA and
QOL. Disentangling such effects will be reliant upon development
of pure measures of EA in the future.
It appears that EA and cognitive fusion signicantly predict AS,
such that as EA and cognitive fusion increase, individuals become
more fearful of anxiety symptoms. While the relations between EA
and AS have previously been documented across a number of
behavioral difculties (e.g., anxiety: Kashdan, Zvolensky, &
McLeish, 2008; depression: Tull & Gratz, 2008; personality disorders: Gratz, Tull, & Gunderson, 2008; substance abuse: Forsyth,
Parker, & Finlay, 2003), we were unable to identify previous work
examining the relation between cognitive fusion and AS. While
our ability to make claims regarding causality is limited by our use
of data from a single time point, the patterns observed in our
results suggest that cognitive fusion may exert a strong inuence
on AS. Specically, the more real and believable anxious
thoughts and feelings seem to an individual (i.e., as one becomes
fused with aversive thoughts), the more fear evoking they become.
However, continued work in this area, especially in the form of
mediational analyses conducted as part of a clinical trial, may help
illuminate the inner workings of the ACT model. Such work also
has the potential to specify how ACT-proposed processes may
inuence and interact with traditional cognitive processes in the
formation, maintenance, and treatment of various forms of psychological and emotional suffering.
The AS to symptom severity path observed in our model
provides support for aspects of both CT and ACT. This effect was
observed across both studies reported herein and is consistent
with ndings from some tCBT outcome studies showing that
symptom change may result from cognitive changes (e.g.,
Hofmann et al., 2007; Meuret et al., 2010; Rapee et al., 2009).
When ACT processes are included, a possible explanation emerges
as to why symptom change often occurs following ACT interventions even when symptom reduction is not targeted directly (e.g.,
Arch, Eifert et al., 2012; Codd, Twohig, Crosby, & Enno, 2011;
Dalrymple & Herbert, 2007). That is, AS seems related to increased
anxiety symptom severity directly, and processes leading to AS,
such as cognitive fusion, may be important targets when symptom
reduction is the aim of treatment.
ACT suggests that cognitive fusion may inuence QOL outcomes
directly (Hayes et al., 2012; Arch, Wolitzky-Taylor et al., 2012), though
our ndings indicate that the total relation between cognitive fusion
on QOL is trivial when EA is included in the statistical model. Fusing
with thoughts may result in increased fear of anxious symptoms, but
this fear does not appear as debilitating to one's life as is engaging in
experientially avoidant behavior. However, effects of fusion on QOL
may be expressed behaviorally through EA and better captured by
measures such as the AAQ. This interpretation is consistent with the
strong correlation between EA and fusion observed in both studies.

Nonetheless, the indirect path of cognitive fusion through EA may be

an important topic for further exploration.
Though our model appears robust, we note that just two of six
ACT processes were evaluated. Our inability to fully represent
components of the ACT model of psychopathology likely contributed to the statistical model not providing an outstanding t to the
data across both studies. Future researchers may be able to
construct more complete models as psychometrically sound
assessment devices become available, though it is unlikely that
any model can fully capture all relevant variables and processes
(Freedman, 1987). Additionally, examination of supplementary
analyses automatically generated by LISREL suggested that t
could be improved by freeing the path from cognitive fusion to
anxiety symptom severity, a theoretically consistent modication
and one supported by previous mediational work (Arch, WolitzkyTaylor et al., 2012). However, this information should be formally
tested using an independent sample, given the likelihood of
capitalizing on chance correlations in the statistical methods we
have employed (Kelloway, 1998).
Finally, we chose to evaluate relatively simple models in this
initial evaluation of how ACT and CT processes function to impact
QOL. As such, our outcomes should be taken as preliminary.
Additional work with theoretically driven models similar to ours
may further elucidate how psychological and behavioral processes
function across various forms of human suffering and psychological health. For example, modeling efforts using recursive paths
could be employed to examine hypotheses regarding feedback
loops (e.g., cognitive fusion and AS could each inuence the other).
Additionally, one could hypothesize that AS contributes to the
development of EA, or fusion could be modeled to have an effect
on EA. Given that this is the rst attempt to compare the different
principles proposed by ACT and CT, and the previously mentioned
likelihood of capitalizing on chance correlations, we believe it best
to limit our data analysis to the models at hand. Using new
datasets (e.g., from clinical trials with multiple assessments across
time) to conduct formal analyses of mediating variables may be
particularly informative when examining such variations.
Before concluding, we wish to address several limitations of the
present work. First, our results were derived from international
community samples of highly educated, predominately White
females who reported signicant problems with anxiety. It
remains to be seen whether the present ndings generalize to
other populations. Indeed, condence in the model will be
increased with replication using more diverse samples presenting
with different forms of psychopathology or with sub-clinical or
non-clinical populations. However, our treatment-seeking samples
also appeared to be quite impaired (e.g., clinically relevant elevations in anxiety symptoms and severity, low QOL, previous anxiety
disorder related diagnoses, and current participation in treatment), thus adding to the relevance and generalizability of the
present ndings to clinical samples. Second, given that assessment
was limited to self-report, there is a possibly that the variance
explained was inated due to a common method factor. Inclusion
of multi-method measurement techniques, such as behavioral
measures, may help to address the impact of processes on varied
outcome measures of theoretical and practical interest. Third, we
limited our outcome measure to a single, widely used inventory of
QOL. It will be important to expand this line of work to other
available measures of QOL, including subdomains of QOL (e.g.,
family, work, health), as the inuence of process variables may
affect QOL differentially depending on context. Finally, as noted, a
number of participants reported active engagement in treatment
(i.e., psychotherapy and/or pharmacotherapy), activities that could
impact their responses to the questionnaires. It will be important
to identify the impact such activities may have using datasets with
the carrying capacity to perform such analyses.

Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i

C.R. Berghoff et al. / Journal of Contextual Behavioral Science ()

Overall, the ndings across both studies converged in a way

that point to targeting EA over anxious symptomatology, particularly when an intervention goal is to improve QOL. In fact, it
appears that anxiety symptom severity may be of little consequence to QOL when behavioral processes are accounted for. Our
ACT-derived statistical model explained approximately one-half
the variance in AS and anxiety symptom severity scores and onethird the variance of QOL. Practically speaking, these ndings
suggest that a large impact may be made upon individuals' lives
without addressing the form of private content such as thoughts,
feelings, or sensations. Rather, preventative and treatment interventions for anxiety that focus on behavioral constructs such as EA
and cognitive fusion may prove more helpful, cost effective, and
easier to disseminate than interventions that focus on symptom
change and alteration of private content.

Acknowledgment
This work was supported, in part, by New Harbinger Publications Inc., who generously provided us with the intervention
workbooks at reduced cost. New Harbinger Publications Inc. had
no role in the research design or collection, analysis, or interpretation of data.
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intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i

C.R. Berghoff et al. / Journal of Contextual Behavioral Science ()

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Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i