Cristea, 2013

Key Constructs in “Classical” and “New Wave” Cognitive BehavioralPsychotherapies: Relationships Among Each Otherand With Emotional Distress

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

1Babes-Bolyai University, Cluj-Napoca2University of Pisa3Mount Sinai School of Medicine

Objective: We aimed to relate key constructs from three forms of cognitive behavioral ther-apy that are often placed in competition: rational emotive behavior therapy, cognitive therapy, andacceptance and commitment therapy. The key constructs of the underlying theories (i.e., irrationalbeliefs/unconditional self-acceptance, dysfunctional cognitions, experiential avoidance/psychologicalinflexibility) of these therapies have not been explicitly studied in their relationships to each other andwith emotional distress. Method: We used a cross-sectional design. The variables were selectedto indicate key constructs of the three major forms of therapy considered. Study 1 used a sample of152 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 thetherapies considered, had medium to high associations to each other and to distress. Experientialavoidance was found to mediate the relationship between the other, schema-type cognitive constructsand emotional distress. Moreover, multiple mediation analysis in Study 2 seemed to indicate that theinfluence of the more general constructs on distress was mediated by experiential avoidance, whoseeffect 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 underlyingtheory, the relationships between them can no longer be ignored and cognitive behavioral therapytheoretical models reliably accounting for these relationships should be proposed and tested. C© 2013Wiley Periodicals, Inc. J. Clin. Psychol. 69:584–599, 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). Theirshift relates to changing the way we look at the very basis of CBT, namely, the status of cognitivechange.

Clark (1995), in common with other leading cognitive therapists asserts that a fundamentalpostulate of the cognitive model of psychopathology is that cognitive change is central to treatingpsychological disorders, stating that “all therapies work by altering dysfunctional cognitions,either directly or indirectly” (p. 158). While they still view cognitions as highly relevant topsychopathology, 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 theadaptation of the AAQ-II, Dr. Krisztina Szabo for providing the study database for the Romanian adaptationof the AAQ-II, as well as Dr. Andrew Hayes and Dr. Kristopher Preacher for important advice on mediationprocedures.

Please address correspondence to: Ioana A. Cristea, Babes-Bolyai University, Department of Clin-ical Psychology and Psychotherapy, No.37, Republicii St., 400015, Cluj-Napoca, Romania. E-mail:[email protected]

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 69(6), 584–599 (2013) C© 2013 Wiley Periodicals, Inc.Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21976

Key Constructs in Cognitive Behavioral Therapies 585

producing therapeutic change. More precisely, from this perspective, while thoughts are stillessential in causing and maintaining emotional disorders, the objective of therapy is not to alterthe actual content of dysfunctional thoughts, but to transform their function in determiningpsychopathology, by modifying the individual’s relationship to these thoughts. As such, thesethird 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 measuringcognitive change (i.e., changes in measures of cognitive constructs, such as dysfunctionalbeliefs) and relating it to changes in therapeutically relevant outcomes, such as distress ormeasures of specific psychopathology. Third wave CBTs focus on measuring processes otherthan cognitive change (e.g., experiential avoidance), deemed as etiologically relevant in causingpsychopathology, 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, REBT’s modelstates that it is not the event itself causing our emotional states, but our beliefs related tothat event. Regarding beliefs, it distinguishes between two key evaluation/appraisal “styles”:irrational and rational. The irrational evaluations are not logical, do not have factual supportin reality, and/or hinder the person from achieving his/her goals, while the rational ones arelogical, have empirical support, and/or help the person achieve his/her goals. The REBTtherapeutic stance involves changing the patient’s dysfunctional emotions and behaviors bymeans of changing the irrational beliefs into rational ones and by promoting the patient’sunconditional self-acceptance (David, Montgomery, Macavei, & Bovbjerg, 2005). Studies havelinked 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 thoughts–“hot” versus “cold”cognitions (David, Miclea, & Opre, 2004). Beck’s CT focuses primarily on “cold” cognitions,mental representations of relevant circumstances (Lazarus, 1991), in the forms of dysfunctionaldescriptions and inferences. The difference between these two is that, whereas descriptionsmerely present an observed fact (e.g., “It’s 10 o’clock and my wife is not home”), inferencesextend further from the perceived fact (e.g., “The fact that she is not home at this hour showsshe is having an affair”–“jumping to conclusion” dysfunctional belief). In contrast, therapiessuch as REBT focus mainly on “hot” cognitions in the form of evaluations (appraisals), whichrefer to the ways in which “cold” cognitions/representations are processed in terms of theirrelevance for personal well-being (Lazarus, 1991; e.g., “The fact that she is having an affair iscatastrophic for me”–“awfulizing” irrational belief). Studies have linked dysfunctional attitudesto distress, such as depression, anxiety, and hostility (Whittal & Dobson, 1991) and depressedmood (Henriques & Leitenberg, 2002). They have also been related to psychopathology, such asdepression (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 waveCBTs, especially regarding the investigation of its proposed theory. New wave CBTs downplaythe importance of explicit cognitive restructuring/challenging of the content of thoughts infavor of methods that attempt to alter the function of the thoughts and not their content. Morespecifically, they aim to change the individual’s relationship to dysfunctional beliefs (i.e., the

586 Journal Of Clinical Psychology, June 2013

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 pro-cesses postulated to be at the root of psychopathology. One such process is experiential avoid-ance/psychological inflexibility. Experiential avoidance (EA) refers to excessive negative evalua-tions of unwanted thoughts, feelings, bodily sensations, memories, or behavioral predispositions,as well as an unwillingness to experience these private events, and deliberate efforts to controlthem or be rid of them (Hayes et al., 1999). EA is proposed to represent a stronger contributorto psychopathology than the content (e.g., intensity, frequency, negative valence) of private psy-chological 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 processesof 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 corecognitive processes in REBT (see David, Lynn, & Ellis, 2009). For CT we chose dysfunctionalattitudes (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, sinceit is at the heart of ACT and one of the most investigated ACT components (Hayes et al., 2004). Toour knowledge, associations between irrational beliefs/unconditional self-acceptance (REBT),dysfunctional cognitions (CT), experiential avoidance/psychological inflexibility (ACT), andemotional distress have not been examined within a single study.

Our other objective involved determining the relative contributions of the constructs topsychological 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 distresswas 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 toexperiencing distress (Study 1) and a clinical sample (Study 2). The study design, as well as theprocedure and the instruments used, were consistent across studies.

Measures

Clinical diagnosis. We used the Structured Clinical Interview for Diagnostic and Statisti-cal 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 appliedonly 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/heragreement on a 5-point Likert scale, ranging from 0 (strongly disagree) to 4 (strongly agree). Theitems denote beliefs an individual might hold about particular situations and are formulated ineither irrational or rational terms. We computed both irrationality and rationality scores. TheABS 2 was adapted and validated on the Romanian population (Macavei, 2002). Reliability wasassessed on a sample of 340 individuals and indicated good internal consistency (Cronbach’s


alpha of 0.88 for the total scale). Factor analysis on the Romanian ABS 2 supported the presenceof 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 Ellis’s theory of un-conditional self acceptance, a central concept of REBT. The person has to evaluate the degreeof agreement with 20 assertions on a 7-point Likert scale. Higher scores indicate higher un-conditional self-acceptance. The USAQ was adapted on the Romanian population (Macavei,2007). Reliability analysis on a sample of 437 individuals indicated good internal consistency(Cronbach’s alpha = 0.73). Validity analysis showed positive associations between unconditionalself-acceptance and rational beliefs, and negative ones between unconditional self-acceptanceand 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 person’s dysfunctional attitudes, which function asschemata through which the individual builds his/her view of reality. It comprises 40 items for-mulated as assertions to be rated on a 7-point Likert scale, ranging from total agreement to totaldisagreement. Even though this scale was initially developed to measure cognitions relevant todepression, subsequent studies showed it measured more general cognitive vulnerabilities (Dyck,1992). The DAS-A was adapted for the Romanian population (Macavei, 2006). Reliability analy-sis on a sample of 701 individuals indicated a value of Cronbach’s alpha of 0.86. Validity analysisshowed that the scale correlated positively with other measures of dysfunctional thinking, aswell as with negative emotions. Moreover, the DAS-A was able to discriminate between subjectswith high and low levels of negative emotions.

Experiential avoidance/psychological inflexibility. The Acceptance and Action Ques-tionnaire (AAQ-II; Bond et al., 2011) is a revised form of the AAQ (Hayes et al., 2004), which wasoriginally developed to provide an internally consistent measure of the ACT treatment modeland behavioral effectiveness. The instrument comprises seven items, representing statementsthat 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). Factorialanalysis showed the AAQ-II is a one-dimensional measure that assesses the key ACT constructreferred to, variously, as experiential avoidance or psychological inflexibility. Confirmatory fac-tor analysis indicated that it did so in a comparable manner across very different samples. TheAAQ-II was translated into Romanian for the purpose of this study (details of the procedure areavailable upon request). It presented very good internal consistency (Cronbach’s alpha = 0.88for 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 com-prises 39 items that are adjectives describing emotions, both negative and positive. The subjectis asked to rate the suitability of each item in assessing how he/she has felt during the last2 weeks, on a 5-point Likert scale. The global negative emotions score was used in the currentstudies 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 verygood internal consistency for the negative emotions scale (Cronbach’s Alpha = 0.94). Validityanalysis revealed a two-factor structure, with a general distress factor accounting for around60% of the variance, and a second factor, named functional distress, for around 28% of thevariance.

Procedure

Participants were asked for consent and then given the scales. They were told the data wouldbe used for study purposes and they could receive a personalized interpretation of the resultsshould they wish to.


Data Analysis

We applied correlational and mediational analysis. For mediational analysis, we used the boot-strapping procedure for assessing indirect effects (Preacher & Hayes, 2008). We used the Preacherand Hayes (2008) mediation script for SPSS for calculations.

We calculated effect sizes for the mediational models following the procedure recommendedby Preacher and Kelley (2011), using the MBESS package (Kelley & Lai, 2010). Given theinherent difficulties of estimating effect sizes for mediation procedures, the authors recommenda standardized index called kappa-squared (i.e., κ2), which represents the magnitude of theindirect effect relative to the maximum possible indirect effect, given the design of the study andthe distributional particularities of the variables considered.

Study 1

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

Method

One hundred and fifty-two student participants took part in the study. The gender distributionwas 22.4% males (n = 34) and 77.6% females (n = 118). Ages ranged from 17 to 25 years, witha mean age of 21.71 (standard deviation [SD] = 1.33). None of the subjects had had any priorexperience with any of the forms of therapy taken into account. Absence of psychopathology wasassessed 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 studydue 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. Themean score for distress, reported on the PED/PAD, qualifies the sample as having a high level ofnegative emotions, according to comparisons with Romanian norms (Opris & Macavei, 2007).

Correlational analysis. The association between the cognitive variables from each therapyapproach considered and their associations with distress are presented in Table 2.

The results from the correlational analysis showed a significant and high positive correla-tion between irrational beliefs and dysfunctional attitudes, as well as a significant and medium

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

N Min Max Mean SD

USAQ Unconditional self-acceptance 151 42 120 80.08 13.27AAQ-II Experiential avoidance 152 7 46 21.21 8.51DAS-A Dysfunctional attitudes 149 44 214 124.01 29.65ABS 2 Global Irrationality 152 4 216 99.14 42.83ABS 2 Rationality 152 36 163 102.05 22.38PED/PAD Distress 150 32 127 61.93 22.73

Note. USAQ = Unconditional Self-Acceptance Questionnaire; AAQ-II = Acceptance and Action Ques-tionnaire 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 2Correlations Between the Cognitive and Subjective/Emotional Variables in Study 1

Cognitive variables 1 2 3 4 5 6

1. USAQ Unconditional self-acceptance —2. AAQ-II Experiential avoidance −.55∗ —3. DAS-A Dysfunctional attitudes −.61∗ .53∗ —4. ABS 2 Global Irrationality −.38∗ .40∗ .60∗ —5. ABS 2 Rationality .19 −.21 −.40∗ −.88∗ —Subjective-emotional variables6. PED/PAD Distress −.42∗ .60∗ .32∗ .24∗ −.14 —

Note. USAQ = Unconditional Self-Acceptance Questionnaire; AAQ-II = Acceptance and Action Ques-tionnaire; 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 be-liefs and dysfunctional attitudes are both core beliefs, organized as evaluative and, respectively,descriptive/inferential schemas, and thus strongly related to each other. One theoretical pos-sibility is that the core irrational beliefs prime the generation of dysfunctional cognitions innegative situations and then both generate more specific evaluative and descriptive/inferentialbeliefs in the form of automatic thoughts (David et al., 2009).

The small correlation between rational beliefs and unconditional self-acceptance may indicatethey represent different aspects of adaptive thinking. Unconditional self-acceptance denotes thenotion that “the individual fully and unconditionally accepts himself whether or not he be-haves 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 thanother types of rational/functional beliefs, aiming at more radical, profound modifications ofan individual’s life philosophy (Ellis, 1994). Experiential avoidance/psychological inflexibilitydisplayed medium to high positive correlations with cognitive constructs related to dysfunc-tional thinking (irrationality, dysfunctional attitudes), pointing to the existence of a degree ofoverlap.

Also experiential avoidance had a medium to high negative correlation (r = −0.55) withunconditional self-acceptance, which again could imply they deal with related, yet distinct,approaches to acceptance. The REBT concept of unconditional self-acceptance might be relatedto 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 byREBT 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 tworepresent distinct constructs.

The associations between these constructs and distress were consistent with the underlyingtheories. Irrationality had medium positive correlation with distress (see David et al., 2005).Dysfunctional attitudes also had medium positive correlations to distress (see de Graaf etal., 2009). As expected from the ACT literature (e.g., Hayes et al., 2004), experiential avoid-ance/psychological inflexibility bore high positive associations with distress.

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


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

The results indicated that experiential avoidance/psychological inflexibility acted as a media-tor 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 betweenunconditional self-acceptance and emotional distress, indirect effect = −.52, SE = .10, 95%CI (bias corrected and accelerated) = –.74 to −.34, and between dysfunctional attitudes andemotional 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 effectscontained zero, indicating the absence of mediation. Figure 1 depicts the significant mediationmodels.

Effect sizes were calculated for all significant mediation models. In the first one, with experien-tial avoidance mediating the relationship between global irrationality and emotional distress, κ2


took the value of .25, 95% CI (bias corrected) = .14 to .35. In the second model, where experien-tial avoidance mediated the relationship between unconditional self-acceptance and emotionaldistress, κ2 was .28, 95% CI (bias corrected) = .19 to .37. In the case of experiential avoidancemediating the relationship between dysfunctional attitudes and emotional distress, κ2 was .31,95% CI (bias corrected) = .22 to .40.

We underscore that irrational beliefs and dysfunctional cognitions are conceptualized as corebeliefs, vulnerability factors, coded as underlying schemata (Beck, 1995; Ellis, 1994); hence, theyare more general and not easily experienced directly. Moreover, by interaction with specificactivating events, they generate automatic thoughts that are experienced consciously and areassociated with dysfunctional feelings and behaviors. According to ACT theory, experientialavoidance might include the lack of willingness to experience (i.e., rather than alter the contentor frequency of) these automatic thoughts (i.e., unwanted private events – in ACT terms; Hayeset al., 1999). Thus, if these constructs are related to each other, the effect of irrational beliefs anddysfunctional cognitions on distress could be mediated on one hand by experiential avoidance,and on the other hand by automatic thoughts. Regarding experiential avoidance, our studyprovides support for this prediction. Other studies sustain the mediating role of automaticthoughts in the relationship between deeper level cognitive constructs (e.g., irrational beliefs)and distress (Szentagotai & Freeman, 2007). However, there are no studies investigating all ofthese constructs in the same research design.

Consequentially, some interesting conjectures emerged after Study 1, regarding the rela-tionship between experiential avoidance and automatic thoughts as mediators between moregeneral, deeper, schema-type constructs and distress. One theoretical possibility would be thatirrational beliefs and/or dysfunctional cognitions represent underlying cognitive vulnerabilitiesthat in negative situations generate automatic thoughts (specific cognitions, evaluative and/ordescriptive/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 reboundeffect of suppression (i.e., the “white bear” effect–Wegner, Schneider, Carter, & White, 1987).

Study 2

In Study 2, we aimed to see whether the mediation models supported in Study 1 were valid inthe case of a clinical sample. We used the same measures of beliefs and distress so as to makethe results comparable to the ones for the healthy sample. We also wanted to check which ofthe two theoretical predictions regarding the potential role of automatic thoughts, advancedconsequently to Study 1, better described the relationships between the constructs considered.Thus, we also measured automatic thoughts as a potential mediator in the relationship betweenmore 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 oftherapy taken into account. Subjects were recruited from an ongoing randomized clinical trialcomparing various forms of CBT for GAD. All participants were diagnosed with GAD afterhaving 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 measureof automatic thoughts. Questionnaires were completed at baseline before the participants wererandomized in any of the treatment groups.

Automatic thoughts were measured with the Automatic Thoughts Questionnaire (ATQ; Hol-lon & Kendall, 1980). This instrument comprises 15 statements that represent dysfunctionalself-related automatic thoughts. The subject has to rate them in terms of frequency of occurrenceon a 5-point Likert scale, ranging from 1 (never) to 5 (almost always). The ATQ was adapted on


the Romanian population (Moldovan, 2007), on a sample of 240 individuals, showing excellentreliability (Cronbach’s alpha = .92). Validity analysis indicated the scale correlated positivelywith other measures of dysfunctional thinking (irrational beliefs, dysfunctional attitudes) andnegatively with unconditional self-acceptance and self-esteem.

We employed the same data analysis procedure as in Study 1 (correlational and mediationanalysis), but additionally we tested multiple step mediation. We applied the Hayes, Preacher,and Myers (2011) multiple step multiple mediation procedure in which mediators are allowedto influence each other, implemented in the MEDTHREE script for SPSS. We reported biascorrected and accelerated confidence intervals for 5000 bootstrap samples.

Results and Discussions

Descriptive data. Means and standard deviations, as well as minimum and maximumvalues for the main variables included in the study, are presented in Table 3. Predictably, theclinical sample scored high on measures of emotional distress, both compared with the normativevalues 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 approachconsidered (REBT, CT, ACT) and their associations with distress are presented in Table 4.

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

N Min Max Mean SD

USAQ Unconditional self-acceptance 28 45 109 70.14 16.97AAQ-II Experiential avoidance 28 13 47 33.25 8.81DAS-A Dysfunctional attitudes 27 106 231 151.67 31.17ABS 2 Global Irrationality 28 29 234 121.75 52.81ABS 2 Rationality 28 34 130 90.91 25.79PED/PAD Distress 28 26 132 86.57 28.31

Note. USAQ = Unconditional Self-Acceptance Questionnaire; AAQ-II = Acceptance and Action Ques-tionnaire 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 4Correlations Between the Cognitive and Subjective/Emotional Variables in Study 2

Cognitive variables 1 2 3 4 5 6 7

1. USAQ Unconditional self-acceptance —2. AAQ-II Experiential avoidance −.62∗ —3. DAS-A Dysfunctional attitudes −.67∗ .47∗ —4. ABS 2 Global Irrationality −.77∗ .61∗ .80∗ —5. ABS 2 Rationality .69∗ − .48 −.74∗ −.95∗ —6. ATQ Automatic thoughts −.38 .74* .57∗ .58∗ −56∗ —Subjective-emotional variables7. PED/PAD Distress −.59∗ .75∗ .58∗ .75∗ −.70∗ .79∗ —

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


The correlation pattern was similar to the one obtained in Study 1. However the correlationswere higher than those for the sample in Study 1. Functional, protective constructs such asrationality or unconditional self-acceptance had medium to high degrees of correlation,higher than in Study 1. Their associations with the ACT construct of experiential avoid-ance/psychological inflexibility were also medium to high (albeit not significant for rationality).Automatic thoughts were, as expected from the literature, highly correlated with distress. Theydisplayed medium correlations with the more broad, core cognitive constructs (irrationality, dys-functional attitudes), indicating they represent different, but related constructs. We also notedthere 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 andeffective in generating emotional distress in the case of a clinical sample.

Simple mediation analysis. The results indicated experiential avoidance/psychologicalinflexibility acted as a mediator in the relationship between global irrationality and emotionaldistress, indirect effect = .15, SE = .06, 95% CI (bias corrected and accelerated) = .06 to.30. Experiential avoidance/psychological inflexibility also mediated the relationship betweenunconditional 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 attitudesand 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 theindirect effect contained zero). A graphic representation of the mediation models is presented inFigure 2.

Effect sizes were calculated for all three mediation models. In the first one, with experientialavoidance mediating the relationship between global irrationality and emotional distress, κ2

took the value of .34, 95% CI (bias corrected) = .16 to .53. In the second model, where experien-tial avoidance mediated the relationship between unconditional self-acceptance and emotionaldistress, κ2 was .39, 95% CI (bias corrected) = .17 to .59. In the case of experiential avoidancemediating the relationship between dysfunctional attitudes and emotional distress, κ2 = .32, 95%CI (bias corrected) = .10 to .51.

The results were therefore consistent with those of Study 1, indicating that the effects ofmore general, schema-like cognitive variables (irrationality, unconditional self-acceptance, dys-functional attitudes) on emotional distress were carried out through the mediation of the morecircumscribed construct of experiential avoidance.

Multiple step mediation analysis. We also tested two alternative multiple mediationmodels, corresponding to the two possible paths we anticipated theoretically: with automaticthoughts as mediator 1 and experiential avoidance as mediator 2, and, respectively, with ex-periential avoidance as mediator 1 and automatic thoughts as mediator 2. As predictors weconsecutively 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 playedthe role of mediator 1 and automatic thoughts the role of mediator 2: with irrationality as thepredictor, 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 (biascorrected 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. Foreach of the alternative models (automatic thoughts as mediator 1 and experiential avoidance asmediator 2), the confidence intervals of the indirect effect contained zero, indicating the absenceof 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 ofthe 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


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

self-acceptance shared significant variance with ACT acceptance (understood as the oppositeprocess of experiential avoidance; see Bond et al., 2011 for details), but each maintained astandalone, 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 includesACT acceptance of unwanted thoughts or experiences. REBT’s preferential, rational formulationof desires or goals (e.g., “I would like to get a good result and do my best to get it, but I acceptthat it might not happen no matter how hard I try”) might intersect with core acceptancecomponents developed in ACT. Schema-type constructs like irrational beliefs and dysfunctionalattitudes were significantly associated with experiential avoidance, but a non-negligible part ofeach of them remained distinct. The observed overlap may be because of the characteristics ofrigidity and inflexibility expressed by all three constructs.

The second major conclusion was that experiential avoidance/psychological inflexibility me-diated the relationship between the cognitive constructs (e.g., irrationality, unconditional self-acceptance, dysfunctional attitudes) and distress. The effect held for both the student sample


Figure 3. Multiple step mediation diagrams for Study 2. Values are path coefficients representing stan-dardized regression weights and standard errors (in parentheses). The c path coefficient refers to the totaleffect of the independent variable (IV) on the dependent variable (DV). The c-prime path coefficient refersto 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 themediation analyses conducted by Kashdan, Barrios, Forsyth, and Steger (2006), in which rigid,inflexible coping mechanisms affected distress and adaptation via experiential avoidance. Whilewe 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 fortriggering avoidant response tendencies that in turn are responsible for sustaining distress.


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 byacting upon experiential avoidance, which in turn primed automatic thoughts that were the mostproximal to distress. In an integrated CBT theory we can argue that during an activating eventdeeper, schema type constructs activate experiential avoidance which in turn primes automaticthoughts 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, werecommend the testing of these multiple mediation models on larger samples.

We used a robust method for testing mediation–bootstrapping–which has the advantage ofbeing independent from sample sizes and not assuming a normal distribution of the indirecteffects (Preacher & Hayes, 2008). The values for our effect sizes (around .30) indicated wemanaged to show a consistent part of the maximum indirect effect that could have been attainedgiven the design and distribution characteristics. Preacher and Kelley (2011) also gave sometentative benchmark values for kappa-squared, warning they are to be interpreted cautiously.The values proposed are same ones as for Cohen’s r2–small, medium and large effect sizescorrespond to values of 0.01, 0.09, and 0.25, respectively (Cohen, 1988, pp. 79–81). In ourcase, all of the confidence intervals for the effect sizes included 0.25, indicating large effectsizes.

Theoretically, from a classical CBT standpoint, these results seem to reinforce the notionthat irrational beliefs and/or dysfunctional cognitions are underlying cognitive vulnerabilityfactors that in negative situations activate experiential avoidance, which in turn primes automaticthoughts, possibly by a mechanism similar to Wegner et al.’s (1987) white bear effect (i.e., avoidedthoughts return with more frequency, generating distress). However, our results can also beintegrated in a third wave CBT (i.e., ACT) perspective. It could be that irrational beliefs anddysfunctional cognitions, by being rigid and inflexible, represent barriers in the pursuit of valuedgoals and, thus, foster experiential avoidance/psychological inflexibility.

The cross-sectional nature of our study does not warrant us to draw conclusions aboutthe effects that changes in these constructs may have on changes in distress. An interestingconjecture could be that a change only in experiential avoidance and/or automatic thoughtsmight momentarily reduce distress, but leave the client with deeper, schema-type latent cognitivevulnerabilities (e.g., irrational beliefs, dysfunctional cognitions), which might become activatedin future situations and foster the cycle all over again. Future randomized controlled trials withfollow-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-basedcognitive therapy (MBCT), cognitive reactivity posttreatment was not related with depressivesymptoms 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 betweendysfunctional thoughts and the emotional outcomes, we note that another study (Manicavasagar,Perich, & Parker, 2012) looking at cognitive predictors of change (rumination) did not reportdifferences 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 testrelationships between constructs in psychotherapeutic models, both in general and for specificdisorders. Nonetheless, because all measures were taken at the same time point, we cannotconclude that the proposed mediators do indeed account for changes in the dependent variable(distress). Future studies should address this limitation by measuring hypothesized mediatorsprior 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 justone. Future studies could include more processes coming from ACT and third wave approachesin relationship to more classical CBT constructs and with distress to test for complex mediationmodels. Last, procedural limitations should also be noted. While the measures for constructsin 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 experientialavoidance/psychological inflexibility (AAQ-II) had not been previously used. However we did


report good psychometric properties on both samples used in our studies. Also it is possible thatthe screening questionnaire of the SCID used to rule out participants with psychopathology inStudy 1 might have had some false negatives.

The study should be replicated on other samples of participants, especially on various clinicalsamples. Moreover, research efforts should be devoted to formulating a CBT paradigm thatwould explain and integrate these findings.

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