Is it the sound or your relationship to it? The role of acceptance in predicting tinnitus impact

Tinnitus is an experience of sound in the absence of an appropriate external source. A symptom that can accompany most central or peripheral dysfunctions of the auditory system, tinnitus can lead to significant distress, depression, anxiety, and decreases in life quality. This paper investigated the construct of psychological acceptance in a population of tinnitus patients. First, a cross-sectional study (N = 77) was conducted in which a tinnitus specific acceptance questionnaire was developed. Results showed that a Tinnitus Acceptance Questionnaire (TAQ) generated good internal consistency. A factor solution was derived with two factors: activity engagement and tinnitus supression. Second, a longitudinal study (N = 47) investigated the mediating role of acceptance on the relationship between tinnitus distress at baseline and tinnitus distress, anxiety, life quality, and depression at a 7-month follow-up. The results showed full mediation of activity engagement for depression and life quality at follow-up, partial mediation for tinnitus distress, and no mediation for anxiety. The role of acceptance in the negative impact of tinnitus distress merits further investigation.     

Differences in baseline and process variables between non-responders and responders in Internet-based cognitive behavior therapy for chronic tinnitus

Although Internet-based cognitive behavior therapy (iCBT) is an effective treatment for chronic tinnitus, several patients do not improve. In the current study, baseline and process variables were compared between non-responders and responders. Data from patients participating in two randomized controlled trials on iCBT for chronic tinnitus were re-analyzed. Based on the literature, a pre-post difference on the “Tinnitus Handicap Inventory” (THI) of less than seven points improvement was used to operationalize non-response. Associations between non-response and baseline variables (age, gender, and questionnaire scores), patient progress (THI), the process of the therapeutic alliance (“Working Alliance Inventory-Short Revised”; WAI-SR), as well as other process variables (number of logins, amount of messages sent from therapists to patients) were investigated. The results showed that non-responders had a less favorable change on the THI than responders already at mid-treatment (p < .05). The alliance (WAI-SR) during iCBT was not associated with non-response. Non-responders showed more severe sleep disturbances, logged in less in the iCBT platform, and received fewer messages from the therapists than responders, but these differences were mostly not significant anymore when correcting for multiple testing. To conclude, no symptom change in the first half of iCBT for chronic tinnitus patients is a risk factor of not benefiting from iCBT.     

An Experimental Investigation of Cognitive Defusion

The current study compared cognitive defusion with other strategies in reducing the impact of experimentally induced negative emotional states. Sixty-seven undergraduates were assigned to one of three conditions (cognitive defusion, thought suppression, or control) and instructed in standardized approaches relevant to each condition before viewing film clips intended to elicit fear, sadness, and disgust. Participants then rated their experience of each emotion and completed a Stroop task intended to indirectly measure emotional arousal. While participants did not show any differences in their experience of emotions through self-report, significant differences on the Stroop task provided evidence of varying degrees of arousal between participants using defusion, suppression, and control strategies, with thought suppression and defusion showing the greatest reduction in arousal. These findings were retained after controlling for individual differences in negative affect and suggest that defusion is an effective strategy for reducing emotional distress but raise questions about the specific mechanisms involved in the process.

     

Acceptance and commitment therapy versus tinnitus retraining therapy in the treatment of tinnitus: a randomised controlled trial

The study compared the effects of Acceptance and Commitment Therapy (ACT) with Tinnitus Retraining Therapy (TRT) on tinnitus impact in a randomised controlled trial. Sixty-four normal hearing subjects with tinnitus were randomised to one of the active treatments or a wait-list control (WLC). The ACT treatment consisted of 10 weekly 60 min sessions. The TRT treatment consisted of one 150 min session, one 30 min follow-up and continued daily use of wearable sound generators for a recommended period of at least 8 h/day for 18 months. Assessments were made at baseline, 10 weeks, 6 months and 18 months. At 10 weeks, results showed a superior effect of ACT in comparison with the WLC regarding tinnitus impact (Cohen’s d = 1.04), problems with sleep and anxiety. The results were mediated by tinnitus acceptance. A comparison between the active treatments, including all assessment points, revealed significant differences in favour of ACT regarding tinnitus impact (Cohen’s d = 0.75) and problems with sleep. At 6 months, reliable improvement on the main outcome measure was found for 54.5% in the ACT condition and 20% in the TRT condition. The results suggest that ACT can reduce tinnitus distress and impact in a group of normal hearing tinnitus patients.     

Longitudinal treatment mediation of traditional cognitive behavioral therapy and acceptance and commitment therapy for anxiety disorders

ObjectiveTo assess the relationship between session-by-session putative mediators and treatment outcomes in traditional cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for mixed anxiety disorders.MethodSession-by-session changes in anxiety sensitivity and cognitive defusion were assessed in 67 adult outpatients randomized to CBT (n = 35) or ACT (n = 32) for a DSM-IV anxiety disorder.ResultsMultilevel mediation analyses revealed significant changes in the proposed mediators during both treatments (p < .001, d = .90–1.93), with ACT showing borderline greater improvements than CBT in cognitive defusion (p = .05, d = .82). Anxiety sensitivity and cognitive defusion both significantly mediated post-treatment worry; cognitive defusion more strongly predicted worry reductions in CBT than in ACT. In addition, cognitive defusion significantly mediated quality of life, behavioral avoidance, and (secondary) depression outcomes across both CBT and ACT (p < .05, R² change = .06–.13), whereas anxiety sensitivity did not significantly mediate other outcomes.ConclusionsCognitive defusion represents an important source of therapeutic change across both CBT and ACT. The data offered little evidence for substantially distinct treatment-related mediation pathways.     

Change Processes in Residential Cognitive and Interpersonal Psychotherapy for Social Phobia: A Process-Outcome Study

The purpose of this study was to test cognitive and interpersonal models for improving social phobia. Eighty patients with social phobia were randomized to 10-week residential cognitive (RCT) or residential interpersonal psychotherapy (RIPT). They completed process measures every Thursday and a sub-outcome measure every Monday. The ratings were analyzed with mixed models. Weekly changes in the process variables derived from the cognitive model (self-focus, estimated probability and estimated cost of negative social events, safety behaviors) predicted subsequent weekly changes in social anxiety. Changes in the interpersonal variable perceived acceptance by others also predicted subsequent changes in social anxiety. On the other hand, changes in social anxiety predicted changes in the four cognitive variables. There were no interactive effects of process with treatment. The cognitive variables decreased during treatment to a similar degree in both treatments. The results indicate that, to reduce social anxiety, therapy should target self-focus, estimated probability and cost of feared social events, safety behaviors, and perceived acceptance by others. The process of improvement may involve positive cycles in that a reduction of social anxiety, in turn, appeared to impact self-focus, probability, cost, and safety behaviors.     

The Impact of Treatment Components Suggested by the Psychological Flexibility Model: A Meta-Analysis of Laboratory-Based Component Studies

An important aspect of psychotherapy research is the examination of the theoretical models underlying intervention approaches. Laboratory-based component research is one useful methodology for this endeavor as it provides an experimental means of testing questions related to intervention components and the change process they engage with a high level of control and precision. A meta-analysis was conducted of 66 laboratory-based component studies evaluating treatment elements and processes that are suggested by the psychological flexibility model that underlies Acceptance and Commitment Therapy (acceptance, defusion, self as context, committed action, values, and present moment), but also touches on a variety of contextual forms of cognitive behavior therapy. Significant positive effect sizes were observed for acceptance, defusion, present moment, values, mixed mindfulness components, and values plus mindfulness component conditions compared to inactive comparison conditions. Additional analyses provided further support for the psychological flexibility model, finding larger effect sizes for theoretically specified outcomes, expected differences between theoretically distinct interventions, and larger effect sizes for component conditions that included experiential methods (e.g., metaphors, exercises) than those with a rationale alone. Effect sizes did not differ between at-risk/distressed and convenience samples. Limitations with the meta-analysis and future directions for laboratory-based component research are discussed.     

Tinnitus

Tinnitus is defined as the perception of sound in the absence of an acoustic stimulus. With a prevalence of about 10-15% among adults tinnitus is a common symptom. If tinnitus persists for a longer time and if the patient does not adapt to it, a range of associated problems can be found. The most common problems are sleep disturbance, emotional disturbance and concentration problems. Given the distress caused by tinnitus the risk of patients falling into a vicious circle of increased attention to tinnitus, dysfunctional appraisal processes, negative emotions and avoidance behaviour increases. This in turn, can severely affect tinnitus distress and quality of life in the long run. Different treatment approaches for tinnitus have been developed and cognitive-behavioural forms of treatment in particular were found to be effective in reducing tinnitus distress. The present paper provides an overview of the symptom tinnitus, etiological models, diagnostic approaches and different forms of treatment.     

Cognitive-behavioural treatment for tinnitus: A difficult case

Abstract

Tinnitus is a commonly seen and difficult to cure symptom of ear disease. This case study describes an example of cognitive-behavioural treatment for tinnitus. The patient was a 66-year-old woman with prior medical and psychiatric history. Cognitive-behavioural assessment revealed that her thoughts about the cause of her tinnitus made her focus on it and experience annoyance. The aim of treatment was to decrease the annoyance associated with the tinnitus and consisted of applied relaxation and cognitive distraction techniques. Daily registrations of tinnitus distress and annoyance, and general well-being were collected at pretreatment, mid-treatment and post-treatment on visual analogue scales. No clear effects were found on these measures, although loudness showed a slight tendency to decrease. The patient also completed a questionnaire at pretreatment and post-treatment on which no benefits were found. Verbal report and an in-session behavioural test showed positive effects of treatment, but were not mirrored in the self-reported results. The importance of reporting treatment failures is emphasized.     

Acceptance and Defusion

The waves and generations of behavioral and cognitive therapy are normal features of a progressive science. Two of the key processes in modern CBT are briefly examined: defusion and acceptance. Both had important antecedents in the work of Aaron Beck, among others; at the same time, they both represent meaningful changes. This dialectic of continuity and change is to be celebrated—it means our current work stands on the shoulders of past intellectual giants. The entire field owes a permanent debt of gratitude to Aaron T. Beck.     

Challenging anxious cognitions or accepting them? Exploring the efficacy of the cognitive elements of cognitive behaviour therapy and acceptance and commitment therapy in the reduction of children's fear of the dark

Anxiety is highly prevalent in pre-adolescent children. Distorted cognitions are characteristic for dysfunctional levels of anxiety. However, applying cognitive elements in pre-adolescent children cannot be fully ascertained, as it is not until adolescence before children can apply logical and abstract reasoning in a sophisticated manner. Cognitive behaviour therapy (CBT) and acceptance and commitment therapy (ACT) both target distorted cognitions. Whereas CBT encourages children to change the content of negative cognitions by applying cognitive restructuring, ACT stimulates youth to have a more accepting attitude towards these thoughts by applying cognitive defusion. The current study examined the efficacy of applying cognitive elements and compared the cognitive elements of CBT and ACT in pre-adolescent children. We included no behavioural elements to specifically study the developmental appropriateness of the cognitive elements in this age group. Highly anxious children, aged 8–12 years were randomised to a 30-minute cognitive restructuring (n = 21) or cognitive defusion intervention (n = 22). Subjective fear of the dark levels, behavioural darkness toleration, and comprehension and fun associated with the interventions were assessed. Both interventions had a significantly positive impact on children's fear of the dark. Cognitive restructuring led to more favourable results on subjective fear than cognitive defusion, no differences were found for darkness toleration.     

The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains

Although cognitive therapy for depression is an efficacious treatment, questions about the aspects of the therapy that are most critical to successful implementation remain. In a sample of 60 cognitive therapy patients with moderate to severe depression, we examined three aspects of therapists’ adherence to cognitive therapy techniques, the patients’ facilitation or inhibition of these techniques, and the therapeutic alliance as predictors of session-to-session symptom improvement across the first five therapy sessions. Two elements of therapist adherence (viz., cognitive methods and negotiating content/structuring sessions) emerged as the strongest predictors of symptom improvement. Patient facilitation or inhibition of therapist adherence also predicted subsequent symptom change. Neither adherence to behavioral methods/homework nor the therapeutic alliance was a significant predictor in parallel analyses. Although alliance scores did not predict subsequent symptom change, they were significantly predicted by prior symptom change. These findings support the model of change that motivates cognitive therapy for depression, and they highlight the potential role of patient facilitation of therapists’ adherence in treatment response.     

Differential outcomes of skill training,group counseling,and individual cognitive therapy for persons with acquired visual impairment

As part of the Living Skills Training Program, group counseling and individual cognitive therapy were implemented to decrease psychological distress for adults with acquired visual impairment. This quasi‐experimental design study compared the outcomes of a 6‐month skill training program combined with a group counseling program (n = 37), with (n = 9) or without (n = 10) individual cognitive therapy, and with a control group (n = 42). The outcome measures were the Profile of Mood States and the Nottingham Adjustment Scale Japanese Version. The results showed that participants with low psychological distress decreased anxiety and increased acceptance of disability, even when they did not participate in group counseling. However, among the participants with high distress, they did not show any improvement without group counseling or individual therapy. The participants with high distress who engaged in group counseling showed an improving trend in attitudes toward others. Moreover, the participants who chose to engage in individual therapy in addition to group counseling showed decreased tension‐anxiety, depression, and fatigue, and significantly improved acceptance of disability. These results suggest that group counseling, combined with individual cognitive therapy, can be an effective part of rehabilitation treatment for clients who have high psychological distress.     

Improvements in Depression and Mental Health After Acceptance and Commitment Therapy are Related to Changes in Defusion and Values-Based Action

Acceptance and commitment therapy (ACT) has been found to be effective for various mental health disorders but the processes through which it affects change remain unclear. Much process research in the area is on physical rather than mental health, and focuses on the broad concept of psychological flexibility with little research on specific mechanisms identified in theory such as fusion and values. This study explored whether there was a relationship between two of the main ACT processes (cognitive defusion and values) and levels of depression and distress. Thirty-three participants completed questionnaires at the start and end of their treatment measuring general mental health and distress, depression, levels of cognitive fusion and how much they were living in line with their values and how important their values were to them. Results showed reductions in levels of fusion and increases in values-based action were significantly related to reductions in distress and depression. There was no correlation between changes in values importance and changes in distress or depression. This study therefore suggests decreased defusion and increased values-based action is an important mechanism in the efficacy of ACT in those with depression and mental health problems. The study is however limited by a small sample size and future research with a sample large enough for mediation analysis would be beneficial.     

The Effects of Therapist Competence in Assigning Homework in Cognitive Therapy With Cluster C Personality Disorders: Results From a Randomized Controlled Trial

Therapist competence in assigning homework was used to predict mid- and posttreatment outcome for patients with Cluster C personality disorders in cognitive therapy (CT). Twenty-five patients that underwent 40 sessions of CT were taken from a randomized controlled trial (Svartberg, Stiles, & Seltzer, 2004). Therapist competence in assigning homework was rated by 2 independent raters assessing a session early in treatment (mostly Session 6) using the Cognitive Therapy Scale (CTS; Young & Beck, 1980). Higher ratings of therapist competence in assigning homework predicted a positive outcome at both mid- and posttreatment, even when controlling for initial symptom improvement. The results indicated that therapist competence in assigning homework is important for both symptom reduction and personality change in CT in the treatment of patients with Cluster C personality disorders.     

An Evaluation of Two Types of Cognitive Intervention in the Management of Chronic Tinnitus

Abstract

Fifty-four subjects with chronic distressing tinnitus were randomly allocated to one of four experimental treatment conditions: (1) attention control and imagery training (AC1); (2) cognitive restructuring (CR); (3) combined attention control and imagery training plus cognitive restructuring (ACI + CR); and (4) a waiting list control (WLC). Significant overall improvements were found on measures of distress associated with tinnitus, and on a number of other measures of cognition and coping strategies. These improvements were maintained at the six-month follow-up. Relative to the WLC, the three treatment conditions (combined) were associated with improvements in tinnitus-related distress, reductions in tinnitus-related dysfunctional cognitions and an increase in the frequency of use of coping strategies. There was a significant effect in favour of the ACI group compared to the CR group on the measure of irrational beliefs. The analyses also revealed that the combined treatment condition (ACI + CR) showed significantly greater improvement on a measure of psychological distress and achieved a higher clinical response rate compared to the two single treatments. There were significant improvements from pretreatment to follow-up on some measures, although the mean scores revealed that some of the gains had been lost at this stage on the main measure of tinnitus-related distress. There were no significant group X time effects for any of the dependent variables at the six-month follow-up. The results were interpreted as supporting the practice of combining the two cognitive approaches.     

Prediction of treatment outcome among patients with irritable bowel syndrome treated with group cognitive therapy

Using a sample of over 125 patients with irritable bowel syndrome (IBS) who were treated with cognitive therapy administered in small groups, we sought to predict end of treatment and 3-month follow-up improvement in two changes indices of gastrointestinal (GI) symptoms (Pain/Discomfort Index which assessed change in abdominal pain, abdominal tenderness and bloating and Bowel Regularity Index which assessed change in diarrhea and constipation). We also sought to predict scores on IBS specific quality of life (QOL) and overall level of psychological distress using the Global Severity Index (GSI) of the Brief Symptom Inventory (BSI). Significant, but modest, levels of prediction were found for prediction of improvement in GI symptoms (4-15% of variance). Stronger significant prediction was obtained for the QOL and global psychological distress measure with R(2)'s ranging from 0.36 to 0.50. A wide variety of demographic, GI symptom, psychological status and psychiatric status variables entered the final prediction equations.     

Behaviorally treated irritable bowel syndrome patients: a four-year follow-up

Nineteen of 27 patients suffering from Irritable Bowel Syndrome (IBS) who had completed a multicomponent treatment involving progressive muscle relaxation, thermal biofeedback, cognitive therapy and IBS education were located and evaluated 4 yr posttreatment. Seventeen of 19 (89.5, or 63% of the total original sample) rated themselves as more than 50% improved. Six of the 12 patients (50%) who submitted symptom monitoring diaries met our criteria for clinical improvement, i.e. achieving at least a 50% reduction in primary IBS symptom scores. The means on all measures at long-term follow-up were lower than those obtained prior to treatment. When follow-up symptom means were compared with pretreatment means, significant (P less than 0.05) reductions were obtained on abdominal pain/tenderness, diarrhea, nausea, and flatulence.     

Autobiographical Memory in Patients with Tinnitus

Studies on psychiatric patients have found that their memories of the past are often unspecific and overgeneral, but the extent to which this is the case for patients with somatic problems has so far only been examined in patients with chronic pain and in patients with diabetes. The present study investigated autobiographical memories in 19 tinnitus patients and 19 controls without tinnitus. Participants were administered the autobiographical memory test (AMT), the Controlled word association test, and self-report measures of depression, anxiety, and tinnitus distress. Compared to control participants, tinnitus patients had difficulty retrieving specific memories and showed longer retrieval latencies. Additionally, tinnitus patients had fewer specific memories to positive cue words. While AMT responses were associated with depression scores, the difference between controls and patients remained significant for positive cue words after controlling for depression scores. Results suggest that cognitive components should be an integral element of the psychological management of tinnitus. The use in future studies of experimental methods such as AMT in health psychology is encouraged.