This 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.

Background: Nonresponsiveness to therapy is generally acknowledged, but only a few studies have tested switching to psychotherapy. This study is one of the first to examine the malleability of treatment-resistant patients using acceptance and commitment therapy (ACT). Methods: This was a randomized controlled trial that included 43 patients diagnosed with primary panic disorder and/or agoraphobia (PD/A) with prior unsuccessful state-of-the-art treatment (mean number of previous sessions = 42.2). Patients were treated with an ACT manual administered by novice therapists and followed up for 6 months. They were randomized to immediate treatment (n = 33) or a 4-week waiting list (n = 10) with delayed treatment (n = 8). Treatment consisted of eight sessions, implemented twice weekly over 4 weeks. Primary outcomes were measured with the Panic and Agoraphobia Scale (PAS), the Clinical Global Impression (CGI), and the Mobility Inventory (MI). Results: At post-treatment, patients who received ACT reported significantly more improvements on the PAS and CGI (d = 0.72 and 0.89, respectively) than those who were on the waiting list, while improvement on the MI (d = 0.50) was nearly significant. Secondary outcomes were consistent with ACT theory. Follow-up assessments indicated a stable and continued improvement after treatment. The dropout rate was low (9%). Conclusions: Despite a clinically challenging sample and brief treatment administered by novice therapists, patients who received ACT reported significantly greater changes in functioning and symptomatology than those on the waiting list, with medium-to-large effect sizes that were maintained for at least 6 months. These proof-of-principle data suggest that ACT is a viable treatment option for treatment-resistant PD/A patients. Further work on switching to psychotherapy for nonresponders is clearly needed.

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Herrn Frieboes gebührt Dank für seine klare Darstellung der Leistung "ambulante Soziotherapie" (AST) der Gesetzlichen Krankenversicherung nach §37a SGB V [6]. Gleichzeitig machen seine Ausfüh-rungen deutlich, wie fragwürdig diese Leistung ist. Es gibt Grund, sowohl aus wissenschaftlichen wie aus gesundheitspolitischen Erwägungen am Nutzen der AST zu zweifeln.AST verfolgt die Zielsetzung, bei Personen mit schweren psychischen Störun-gen Krankenhausbehandlung zu vermeiden oder zu verkürzen und die notwendige medizinische Inanspruchnahme sicherzustellen. Frieboes weist darauf hin, dass AST bisher nicht ausreichend wissenschaftlich geprüft ist. Dasjenige Behandlungsmodell, das AST im Hinblick auf die intendierten Ziele am ehesten ent- Leserbrief