Öst's (2008) methodological comparison of clinical trials of acceptance and commitment therapy versus cognitive behavior therapy: Matching Apples with Oranges?

Öst (2008) recently compared the methodological rigor of studies of acceptance and commitment therapy (ACT) and traditional cognitive behavior therapy (CBT). He concluded that the ACT studies had more methodological deficiencies, and thus the treatment did not qualify as an “empirically supported treatment.” Although Öst noted several important limitations that should be carefully considered when evaluating early ACT research, his attempt to devise an empirical matching strategy by creating a comparison sample of CBT studies to bolster his conclusions was itself problematic. The samples were clearly mismatched in terms of the populations being treated, leading to differences in study design and methodology. Furthermore, reanalysis showed clear differences in grant support favoring CBT compared with ACT studies that were not reported in the original article. Given the actual mismatch between the samples, Öst's methodological ratings are difficult to interpret and provide little useful information beyond what could already be gathered by a qualitative review of ACT study limitations. Such limitations are characteristic of the earlier randomized controlled trials of any emerging psychotherapeutic approach.     

Attention Training as a Low-Intensity Treatment for Concerning Anxiety in Clinic-Referred Youth

Although youth anxiety treatment research has focused largely on severe and impairing anxiety levels, even milder anxiety levels, including levels that do not meet full criteria for a diagnosis, can be impairing and cause for concern. There is a need to develop and test viable treatments for these concerning anxiety levels to improve functioning and reduce distress. We present findings from a randomized controlled efficacy trial of attention bias modification treatment (ABMT) and attention control training (ACT) for youths with concerning anxiety levels. Fifty-three clinic-referred youths (29 boys, M age = 9.3 years, SD age = 2.6) were randomized to either ABMT or ACT. ABMT and ACT consisted of attention-training trials in a dot-probe task presenting angry and neutral faces; probes appeared in the location of neutral faces in 100% of ABMT trials and 50% of ACT trials. Independent evaluators provided youth anxiety severity ratings; youths and parents provided youth anxiety severity and global impairment ratings; and youths completed measures of attention bias to threat and attention control at pretreatment, posttreatment, and 2-month follow-up. In both arms, anxiety severity and global impairment were significantly reduced at posttreatment and follow-up. At follow-up, anxiety severity and global impairment were significantly lower in ACT compared with ABMT. Attention control, but not attention bias to threat, was significantly improved at follow-up in both arms. Changes in attention control and attention focusing were significantly associated with changes in anxiety severity. Findings support the viability of attention training as a low-intensity treatment for youths with concerning anxiety levels, including levels that do not meet full criteria for a diagnosis. Superior anxiety reduction effects in ACT highlight the critical need for mechanistic research on attention training in this population.     

Efficacy of the third wave of behavioral therapies: a systematic review and meta-analysis

During the last two decades a number of therapies, under the name of the third wave of cognitive behavior therapy (CBT), have been developed: acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), cognitive behavioral analysis system of psychotherapy (CBASP), functional analytic psychotherapy (FAP), and integrative behavioral couple therapy (IBCT). The purposes of this review article of third wave treatment RCTs were: (1) to describe and review them methodologically, (2) to meta-analytically assess their efficacy, and (3) to evaluate if they currently fulfil the criteria for empirically supported treatments. There are 13 RCTs both in ACT and DBT, 1 in CBASP, 2 in IBCT, and none in FAP. The conclusions that can be drawn are that the third wave treatment RCTs used a research methodology that was significantly less stringent than CBT studies; that the mean effect size was moderate for both ACT and DBT, and that none of the third wave therapies fulfilled the criteria for empirically supported treatments. The article ends with suggestions on how to improve future RCTs to increase the possibility of them becoming empirically supported treatments.     

NSF programs in the behavioral and neural sciences

The National Science Foundation’s new Division of Behavioral and Neural Sciences supports basic research and related activities in psychology, ethology, anthropology, linguistics, and the neurosciences. Research equipment and facilities can be provided either through a grant supporting a research project or through a separate grant. The scientific importance and soundness of the research to be conducted, as evaluated by reviewers from the research community, are the main criteria for support. Preparation of proposals is briefly discussed, and sources of further information are noted.     

Randomized Controlled Trial of a Smartphone Application as an Adjunct to Acceptance and Commitment Therapy for Smoking Cessation

There is a major public health need for innovative and efficacious behavioral and cognitive interventions for smoking cessation. This randomized controlled trial evaluated the efficacy of an acceptance and commitment therapy (ACT) smartphone application in augmenting ACT group treatment for smoking cessation. One hundred fifty adults smoking 10 or more cigarettes per day were randomly assigned to 6 weekly group sessions of behavioral support, ACT, or ACT combined with the smartphone application. Access to the app was provided from the start of the in-person treatment until the 6-month follow-up assessment. Participants were encouraged to make their quit attempts after the third session, and the posttreatment assessment occurred 3 weeks later. Measures of smoking status and ACT processes were obtained at baseline, posttreatment, and 6-month follow-up. Biochemically verified quit rates in the combined, ACT, and behavioral support groups were 36% (p = .079 relative to ACT; p = .193 relative to behavioral support), 20% (p = .630 relative to behavioral support) and 24% at posttreatment, as compared with 24% (p = .630 relative to behavioral support), 24% (p = .630 relative to behavioral support) and 20% at follow-up. There was no significant difference (p = > .999) in the primary outcome of biochemically verified 7-day point-prevalence abstinence at 6-month follow-up between the combined and ACT groups. The combined group reported significantly greater smoking reduction, acceptance and present-moment awareness than the behavioral support group at posttreatment, but not at follow-up. There were no significant differences between the groups in positive mental health. Contrary to hypotheses, the ACT group did not display significant improvements in positive mental health or ACT processes relative to the behavioral support group at posttreatment or follow-up. Implications and directions for future research are discussed.     

A general rotation criterion and its use in orthogonal rotation

Measures of test parsimony and factor parsimony are defined. Minimizing their weighted sum produces a general rotation criterion for either oblique or orthogonal rotation. The quartimax, varimax and equamax criteria are special cases of the expression. Two new criteria are developed. One of these, the parsimax criterion, apparently gives excellent results. It is argued that one of the most important factors bearing on the choice of a rotation criterion for a particular problem is the amount of information available on the number of factors that should be rotated. This research was supported by the National Research Council of Canada research grant 291-13 to Dr. G. A. Ferguson.     

Improving the peer-review process for grant applications: reliability, validity, bias, and generalizability

Peer review is a gatekeeper, the final arbiter of what is valued in academia, but it has been criticized in relation to traditional psychological research criteria of reliability, validity, generalizability, and potential biases. Despite a considerable literature, there is surprisingly little sound peer-review research examining these criteria or strategies for improving the process. This article summarizes the authors' research program with the Australian Research Council, which receives thousands of grant proposals from the social science, humanities, and science disciplines and reviews by assessors from all over the world. Using multilevel cross-classified models, the authors critically evaluated peer reviews of grant applications and potential biases associated with applicants, assessors, and their interaction (e.g., age, gender, university, academic rank, research team composition, nationality, experience). Peer reviews lacked reliability, but the only major systematic bias found involved the inflated, unreliable, and invalid ratings of assessors nominated by the applicants themselves. The authors propose a new approach, the reader system, which they evaluated with psychology and education grant proposals and found to be substantially more reliable and strategically advantageous than traditional peer reviews of grant applications.     

Using Acceptance and Commitment Therapy to Guide Exposure-Based Interventions for Posttraumatic Stress Disorder

Exposure is considered one of the most effective interventions for PTSD. There is a large body of research for the use of imaginal and in vivo exposure in the treatment of PTSD, with prolonged exposure (PE) therapy being the most researched example. Acceptance and commitment therapy (ACT) has sometimes been called an exposure-based treatment, but how exposure is implemented in ACT for PTSD has not been well articulated. Although support for the use of ACT in PTSD treatment is limited to a handful of case studies and open trials, research suggests ACT is particularly useful in flexibly targeting avoidance behavior—arguably the most important process in the continued maintenance of PTSD symptoms. The purpose of this paper is to explore the use of exposure within ACT in PTSD treatment. Through an overview of PE and ACT, and with the use of case examples, we describe how ACT principles and techniques may inform exposure-based treatments for PTSD in order to create more flexible approaches. In addition, understanding exposure within an ACT framework may also contribute to clarifying processes of change.     

Assessing Social Affiliative Behavior: A Comparison of in Vivo and Video Tasks

Social affiliation, or engagement in positive social interactions, is often profoundly impaired in individuals with schizophrenia. Valid measures of social affiliation are needed to understand these impairments and their symptom and functional correlates; however, such measures are limited and have not been validated. This pilot study evaluated one such measure—the video-based Social Affiliation Interaction Task (SAIT)—and a novel in vivo behavioral measure, the Affiliative Conversation Task (ACT). Twenty participants with schizophrenia or schizoaffective disorder (SZ) and 35 nonpsychiatric controls (CT) completed both tasks and measures of negative symptoms and functioning. We explored group differences in social affiliation skills; convergent validity between social affiliation skill ratings from the two tasks; and concurrent validity with social affiliation skill ratings, negative symptoms, and functioning. SZ evidenced lower affiliation skill ratings than CT on the video SAIT, but not on the ACT, and the tasks displayed moderate convergent validity for affiliation skill ratings. Less affiliation skill in the SAIT was correlated with more negative symptoms and less functioning in the SZ group with medium effects, though the results were not significant. Findings suggest that the SAIT may be more sensitive to individual differences in skill level. Future research should continue to examine the SAIT for use in measuring affiliation skills.     

On Conducting Construct Validity Meta-Analyses for the Rorschach: A Reply to Tibon Czopp and Zeligman (2016)

We respond to Tibon Czopp and Zeligman's (2016) critique of our systematic reviews and meta-analyses of 65 Rorschach Comprehensive System (CS) variables published in Psychological Bulletin (2013). The authors endorsed our supportive findings but critiqued the same methodology when used for the 13 unsupported variables. Unfortunately, their commentary was based on significant misunderstandings of our meta-analytic method and results, such as thinking we used introspectively assessed criteria in classifying levels of support and reporting only a subset of our externally assessed criteria. We systematically address their arguments that our construct label and criterion variable choices were inaccurate and, therefore, meta-analytic validity for these 13 CS variables was artificially low. For example, the authors created new construct labels for these variables that they called “the customary CS interpretation,” but did not describe their methodology nor provide evidence that their labels would result in better validity than ours. They cite studies they believe we should have included; we explain how these studies did not fit our inclusion criteria and that including them would have actually reduced the relevant CS variables’ meta-analytic validity. Ultimately, criticisms alone cannot change meta-analytic support from negative to positive; Tibon Czopp and Zeligman would need to conduct their own construct validity meta-analyses.     

Conducting Outcomes Research in a Clinical Practice Setting: The Effectiveness and Acceptability of Acceptance and Commitment Therapy (ACT) in a Partial Hospital Program

Multiple challenges exist integrating research into clinical practice, particularly in acute care settings where randomized controlled trials may be impractical or unethical. Partial or day hospitals are one such setting. As compared to outpatients and inpatients, relatively little research is conducted or reported in partial hospital program (PHP) patients, leaving providers in this setting without a solid empirical basis from which to draw. We report treatment outcomes and patient satisfaction from the first 750 patients enrolled in a clinical research PHP utilizing the acceptance and commitment therapy (ACT) treatment model. ACT is a well-established, transdiagnostic behavior therapy. However, to date no study has examined the use of ACT in acute day hospitals. We hypothesized that applying ACT with this patient group would result in significantly improved depression, anxiety, functioning, and quality of life from intake to discharge. We additionally expected that patients would report high satisfaction with ACT treatment groups. Patients (n = 750 full sample, n = 518 completed treatment) completed daily measures of symptoms, functioning, and ACT processes at intake and discharge, and postgroup satisfaction surveys. Results showed significant improvements in symptoms and impairment. ACT process variables also increased over the course of treatment. Importantly, patient satisfaction was high for all groups. Thus, ACT provides an appropriate, flexible, effective, and satisfactory model for this patient group. A comparison of our findings using ACT to the limited research using other models in PHP settings is discussed, as well as challenges in the overall process of integrating research into routine clinical care.     

A Review of Behavioral Interventions for Anxiety‐Related Behaviors in Lower‐Functioning Individuals with Autism

Anxiety is highly prevalent in persons with autism and affects individuals with higher‐functioning autism (HFA) and lower‐functioning autism (LFA). Although there is emerging support for the efficacy of cognitive‐behavioral therapy (CBT) in treating anxiety in autism, these findings are largely based on HFA samples. Moreover, CBT may be inappropriate for individuals with LFA who may struggle to grasp the cognitive components of the therapy because of their more limited verbal abilities. Behavior analytic interventions may be better suited to treat anxiety in this population; however, the quantity and quality of the extant literature have yet to be reviewed. Toward this end, the extant behavioral intervention literature was reviewed. Seven studies met the inclusion criteria and were evaluated against quality indicators for within‐subject design research. Next, the efficacy of each treatment component was assessed using established criteria for defining empirically supported therapies. Results revealed behavioral interventions to be efficacious, with desensitization and reinforcement emerging as efficacious treatment components, while prompting, modeling, and antianxiety stimuli were established as possibly efficacious. However, given that some of the quality indicators were not met, these results should be interpreted with some caution. Additional research is needed to form a more conclusive evidence base for the treatment of anxiety in individuals with LFA. Copyright © 2016 John Wiley & Sons, Ltd.     

Evaluating Philosophy as Exploratory Research

This article addresses the question how philosophy should be evaluated in a research‐grant funding environment. It offers a new conception of philosophy that is inclusive and builds on familiar elements of professional, philosophical practice. Philosophy systematically questions the questions we ask, the concepts we use, and the values we hold. Its product is therefore rarely conclusive but can be embodied in everything we do. This is typical of explorative research and differentiates it from exploitative research, which constitutes the bulk of funded research activity. This article argues that exploratory research is crucial for long‐term progress and requires a distinct evaluative regime.     

“Age-associated memory impairment”: A critique

Abstract

This paper is a critical evaluation of the construct of age-associated memory impairment (AAMI) and the criteria for assigning the AAMI label. It is argued that AAMI should not be regarded as a clinical diagnosis; that the AAMI criteria fail to isolate selective memory impairments, ignore crucial longitudinal information, and are vague, arbitrary, and unreliable; that studies of memory loss should examine a wider range of subjects than those who meet the AAMI criteria-moreover, use of the criteria may impede research; and that treatment studies should await investigations of the biological antecedents of memory loss. Several recommendations address subject selection and assessment issues.     

The State of Dyadic Methodology: An Analysis of the Literature on Interventions for Military Couples

ABSTRACT

Military members and their spouses experience unique stressors compared with civilian couples, making them distinctively vulnerable to a number of marital and mental health concerns. However, the amount and quality of intervention research to guide treatment for military couples are unknown. Therefore, a systematic literature search of interventions for military couples was completed resulting in 10 articles that met the study's inclusion and exclusion criteria. Further, a rubric to assess dyadic methodology was created and utilized to determine the dyadic quality of the methodology of the sampled articles. The results of the systematic literature review revealed that (a) there are few evidence-based interventions for military couples in which both members of the dyad are included and (b) the methodology by which treatments are evaluated largely do not employ systemic or dyadic measures. Recommendations for future research with military couples includes the need for couple-focused interventions using experimental methodology, systemic theories to guide intervention and research, and appropriate dyadic assessment and analysis tools to determine the effectiveness of couple's interventions for military, reserve, and veteran populations.     

Paired associate learning of action verbs with visual-or motor-imaginal encoding instructions

Summary It is suggested that visual-imaginal encoding of actions, i.e., imagining seeing somebody else performing a described action, should be distinguished from motor-imaginal encoding, i.e., imagining how one performs the action oneself. While both kinds of encoding should provide good item-specific information, only visual-imaginal encoding should also lead to good relational encoding of word pairs. In three experiments in which subjects had to learn verb pairs, we obtained supporting data for this assumption. Although CR performance was equal to FR performance under visual-imaginal encoding, under motorimaginal encoding CR performance was worse than FR performance. In principle, this finding parallels results obtained with imagined noun pairs and with performed verb pairs.The research reported here was supported by a grant from the Deutsche Forschungsgemeinschaft to J. Engelkamp and Hubert D. Zimmer. The paper was prepared during a stay of these authors at the Centre d'Études de Psychologie Cognitive, enabled by a grant of PROCOPE 311 pro     

Maternal depression and developmental disability: research critique

Maternal depression in families having a child with a disability has been the subject of considerable research over the past 25 years. This review was designed to describe the literature on maternal depression, critique its research methodology, identify consensus findings across studies, and make recommendations for future research. A particular emphasis is on the distinction between exhibiting depressive symptoms and meeting clinical criteria for a depressive disorder, how or whether research studies made this distinction, and implications for our understanding of maternal adaptation to disability in a family member. Of the 42 articles reviewed, only eight were clinically diagnosed depression; most of them used a scale rating depressive symptoms. Across the studies, mothers of children with disabilities generally exhibited a higher than average rate of depressive symptoms and are more at risk for clinical depression, but the incidence may be lower than reported in previous literature. Child behavior problems, maternal stress, coping style, and support were consistently associated with depressive symptoms. We conclude that we know relatively little about clinical depression in mothers of children with disabilities. The distinction between clinical depression and depressive symptoms may be important in conceptualizing how a child with a disability can influence family members and the nature of support that may need to be provided. Future research should incorporate gold standard diagnostic tools and assess history, severity, and type of depression. Research is also needed to study treatments to reduce the occurrence of both depressive symptoms and clinical depression.     

Evaluation of the effectiveness of suicide prevention programs: a methodological perspective

Many studies that attempt to evaluate the effectiveness of treatment programs for suicidal patients are methodologically deficient in one or more areas. This paper outlines six criteria that should be met in designing such investigations: Patients should be randomly assigned to groups; at least 80% of the subjects who were initially enrolled should be followed up; the results should be both statistically significant and clinically important; all clinically relevant outcomes should be reported; the patients must be adequately described; and the new intervention should be feasible in other settings. It is shown that these criteria are both necessary and achievable.     

Acceptance and commitment therapy: model, processes and outcomes

The present article presents and reviews the model of psychopathology and treatment underlying Acceptance and Commitment Therapy (ACT). ACT is unusual in that it is linked to a comprehensive active basic research program on the nature of human language and cognition (Relational Frame Theory), echoing back to an earlier era of behavior therapy in which clinical treatments were consciously based on basic behavioral principles. The evidence from correlational, component, process of change, and outcome comparisons relevant to the model are broadly supportive, but the literature is not mature and many questions have not yet been examined. What evidence is available suggests that ACT works through different processes than active treatment comparisons, including traditional Cognitive-Behavior Therapy (CBT). There are not enough well-controlled studies to conclude that ACT is generally more effective than other active treatments across the range of problems examined, but so far the data are promising.