Increasing valued behaviors precedes reduction in suffering: Findings from a randomized controlled trial using ACT

•Increased (re-)engagement in valued behaviors precedes reductions in suffering.•Working on valued behaviors should commence at the beginning of treatment.•Suffering, struggle, and values all change in therapeutically desired directions.

BackgroundPsychological flexibility theory (PFT) suggests three key processes of change: increases in value-directed behaviors, reduction in struggle with symptoms, and reduction in suffering. We hypothesized that Acceptance and Commitment Therapy (ACT) would change these processes and that increases in valued action and decreases in struggle would precede change in suffering.MethodData were derived from a randomized clinical trial testing ACT (vs. waitlist) for treatment-resistant patients with primary panic disorder with/without agoraphobia (n = 41). Valued behavior, struggle, and suffering were assessed at each of eight sessions.ResultsValued actions, struggle, and suffering all changed over the course of therapy. Overall changes in struggle and suffering were interdependent whereas changes in valued behavior were largely independent. Levels of valued behaviors influenced subsequent suffering, but the other two variables did not influence subsequent levels of valued action.DiscussionThis finding supports a central tenet of PFT that increased (re-)engagement in valued behaviors precedes reductions in suffering. Possible implications for a better understanding of response and non-response to psychotherapy are discussed.