Acceptance and commitment therapy for the treatment of stress among social workers: a randomized controlled trial

Chronic stress increases the risk of health problems and absenteeism, with negative consequences for individuals, organizations and society. The aim of the present study was to examine the effect of a brief stress management intervention based on the principles of Acceptance and Commitment Therapy (ACT) on stress and general mental health for Swedish social workers (n = 106) in a randomized, controlled trial. Participants were stratified according to stress level at baseline in order to examine whether initial stress level moderated the effect of the intervention. Two thirds of the participants had high stress levels at baseline (Perceived Stress Scale; score of ≥ 25). The results showed that the intervention significantly decreased levels of stress and burnout, and increased general mental health compared to a waiting list control. No statistically significant effects were, however, found for those with low levels of stress at baseline. Among participants with high stress, a substantial proportion (42%) reached criteria for clinically significant change. We concluded that the intervention successfully decreased stress and symptoms of burnout, and increased general mental health. Evidence is, thus, provided supporting ACT as brief, stress management intervention for social workers.     

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.     

Acceptance and commitment therapy and behavioral activation for the treatment of depression: description and comparison

The field of clinical behavior analysis is growing rapidly and has the potential to affect and transform mainstream cognitive behavior therapy. To have such an impact, the field must provide a formulation of and intervention strategies for clinical depression, the "common cold" of outpatient populations. Two treatments for depression have emerged: acceptance and commitment therapy (ACT) and behavioral activation (BA). At times ACT and BA may suggest largely redundant intervention strategies. However, at other times the two treatments differ dramatically and may present opposing conceptualizations. This paper will compare and contrast these two important treatment approaches. Then, the relevant data will be presented and discussed. We will end with some thoughts on how and when ACT or BA should be employed clinically in the treatment of depression.     

Acceptance and commitment therapy: Altering the verbal support for experiential avoidance

Acceptance and Commitment Therapy (ACT) is a behavior-analytically-based psychotherapy approach that attempts to undermine emotional avoidance and increase the capacity for behavior change. An overview of this approach is given, followed by several specific examples of the techniques used within ACT. In each instance the behavioral rationale of these techniques is described. A contemporary view of verbal relations provides the basis for new approaches to adult outpatient psychotherapy.     

A preliminary investigation of acceptance and commitment therapy as a treatment for chronic skin picking

The effectiveness of a deliberately limited version of Acceptance and Commitment Therapy (ACT) for chronic skin picking was evaluated in a pair of multiple baseline across participants designs. Self-monitoring of skin picking showed that four of the five participants reached near zero levels of picking by post-treatment, but these gains were not fully maintained for three of the four participants at follow-up. The findings of the self-reported skin picking were generally corroborated by ratings of photographs of the damaged areas and by ratings on a validated measure of skin picking severity. All participants rated the intervention as socially acceptable, and reductions were found on measures of anxiety, depression, and experiential avoidance for most participants as a result of the intervention. Results support the construction of more comprehensive ACT protocols for skin picking.     

Narrative exposure therapy for posttraumatic stress disorder in tortured refugees: A preliminary uncontrolled trial

Halvorsen, J.Ø. & Stenmark, H. (2010). Narrative exposure therapy for posttraumatic stress disorder in tortured refugees: A preliminary uncontrolled trial. Scandinavian Journal of Psychology 51, 495–502. Torture has severe mental health effects, especially in terms of posttraumatic stress disorder (PTSD) and depression. However, there is still a lack of empirical treatment studies. The present paper presents data on 16 torture survivors receiving 10 sessions of narrative exposure therapy (NET). Symptoms of PTSD and depression, assessed by Clinician‐Administered PTSD Scale (CAPS) and Hamilton Rating Scale for Depression (HRSD), decreased significantly from pre‐treatment to 6‐month follow‐up, with Cohen’s d effect sizes of 1.16 and 0.84, respectively. Although treatment gains were moderate, further research on evidence‐based treatments for PTSD and depression in refugee torture survivors is warranted.     

A preliminary investigation of acceptance and commitment therapy as a treatment for marijuana dependence in adults

In this investigation, 3 adults who met criteria for marijuana dependence were treated using an abbreviated version of acceptance and commitment therapy (ACT). The treatment was delivered in eight weekly 90-min individual sessions. The effects of the intervention were assessed using a nonconcurrent multiple baseline across participants design. Self-reported marijuana use, confirmed through oral swabs, reached zero levels for all participants at posttreatment. At a 3-month follow-up, 1 participant was still abstinent and the other 2 were using but at a lower average level of consumption compared to baseline. Depression, anxiety, withdrawal symptoms, and general levels of experiential avoidance generally improved. This preliminary test suggests that additional development and testing of ACT for marijuana use are warranted.     

Group-based treatment for internalized stigma among persons with severe mental illness: findings from a randomized controlled trial

Elevated internalized stigma is common and is linked to subjective and objective outcomes for severe mental illness. The authors developed a manualized group-based intervention (Narrative Enhancement/Cognitive Therapy; NECT) to address internalized stigma in severe mental illness. The purpose of the present study was to evaluate the feasibility and effectiveness of NECT. In total, 144 individuals were screened at two sites to evaluate if they met criteria for "elevated" internalized stigma; 39 and were eligible were randomized to NECT or to treatment as usual (TAU) and were assessed at baseline, posttreatment, and 3-month follow-up. Fifteen of the 21 individuals assigned to NECT were classified as "exposed" to treatment. Intent-to-treat analyses found no significant difference between the NECT and TAU groups. A comparison of exposed versus unexposed participants noted trends for exposed participants to have improved more in two aspects of self-stigma as well as insight. We conclude that NECT is feasible and tolerable, but findings did not support the hypothesis that NECT was more effective than TAU, although small sample size and significant dropout may have restricted the ability to detect an effect.     

A randomized controlled trial of strong minds: A school-based mental health program combining acceptance and commitment therapy and positive psychology

To date, most early intervention programs have been based on emotion regulation strategies that address dysfunctional cognitive appraisals, problem-solving skills, and rumination. Another emotion regulation strategy, ‘acceptance’ training, has largely been overlooked. To examine the efficacy of this strategy, a school-based mental health program combining positive psychology with acceptance and commitment therapy (Strong Minds) was evaluated in a randomized controlled trial with a sample of 267 Year 10 and 11 high-school students in Sydney, Australia. Mixed models for repeated measures examined whether the program led to reductions in symptoms amongst students who commenced the program with high depression, anxiety, and stress scores, and increased wellbeing scores amongst all students. Results demonstrated that compared to controls, participants in the Strong Minds condition with elevated symptom scores (n = 63) reported significant reductions in depression (p = .047), stress (p = .01), and composite depression/anxiety symptoms (p = .02) with medium to strong effect sizes (Cohen's d = 0.53, 0.74, and 0.57, respectively). Increased wellbeing (p = .03) in the total sample and decreased anxiety scores (p = .048) for students with elevated symptoms were significant for Year 10 students with medium effect sizes (Cohen's d = 0.43 and 0.54, respectively). This study tentatively suggests that including the emotion regulation strategy of acceptance in early intervention programs may be effective in reducing symptoms and improving wellbeing in high school students. Further research to investigate the generalizability of these findings is warranted.     

Evaluation of a healthy-weight treatment program for bulimia nervosa: a preliminary randomized trial

Objective: Conduct a randomized treatment trial to test whether healthy dieting maintains bulimic symptoms or effectively reduces this eating disturbance.

Methods: Female participants (n=85) with full- and sub-threshold bulimia nervosa were randomly assigned to a 6-session healthy dieting intervention or waitlist condition and assessed through 3-month follow-up.

Results: Relative to control participants, intervention participants showed modest weight loss during treatment and demonstrated significant improvements in bulimic symptoms that persisted through follow-up.

Discussion: These preliminary results suggest that this intervention shows potential for the treatment of bulimia nervosa and may be worthy of future refinement and evaluation. Results also provide experimental evidence that dieting behaviors do not maintain bulimia nervosa, suggesting the need to reconsider maintenance models for this eating disorder.     

Both early and late changes in psychological variables relate to treatment outcome for musculoskeletal pain patients at risk for disability

We know little about why some people get better after psychological treatments for pain disability, whereas other people do not. In order to understand differences in treatment response, we need to explore processes of change during treatment. It has been suggested that people with pain complaints who change early in treatment have better outcomes. Therefore, we aimed to investigate whether changes in psychological variables at different time points are related to outcome, and whether early or late changes are better predictors of outcome. We used the fear avoidance model as a theoretical framework. We followed 64 patients weekly over 6–7 weeks and then determined outcome. Our findings indicate that people who decrease in catastrophizing and function early in treatment as well as in depressive symptoms, worry, fear avoidance beliefs and function late in treatment have better outcomes. Early decreases in function, and late decreases in depressive symptoms and worry uniquely predict improvements in disability. While early and late changes covaried concurrently, there were no significant sequential relationships between early and late changes. Changes in the proposed process variables in the fear avoidance model, early as well as late in treatment, thus add valuable information to the explanation of outcome.     

Mindfulness-based cognitive therapy improves emotional reactivity to social stress: results from a randomized controlled trial

The high likelihood of recurrence in depression is linked to a progressive increase in emotional reactivity to stress (stress sensitization). Mindfulness-based therapies teach mindfulness skills designed to decrease emotional reactivity in the face of negative affect-producing stressors. The primary aim of the current study was to assess whether Mindfulness-Based Cognitive Therapy (MBCT) is efficacious in reducing emotional reactivity to social evaluative threat in a clinical sample with recurrent depression. A secondary aim was to assess whether improvement in emotional reactivity mediates improvements in depressive symptoms. Fifty-two individuals with partially remitted depression were randomized into an 8-week MBCT course or a waitlist control condition. All participants underwent the Trier Social Stress Test (TSST) before and after the 8-week trial period. Emotional reactivity to stress was assessed with the Spielberger State Anxiety Inventory at several time points before, during, and after the stressor. MBCT was associated with decreased emotional reactivity to social stress, specifically during the recovery (post-stressor) phase of the TSST. Waitlist controls showed an increase in anticipatory (pre-stressor) anxiety that was absent in the MBCT group. Improvements in emotional reactivity partially mediated improvements in depressive symptoms. Limitations include small sample size, lack of objective or treatment adherence measures, and non-generalizability to more severely depressed populations. Given that emotional reactivity to stress is an important psychopathological process underlying the chronic and recurrent nature of depression, these findings suggest that mindfulness skills are important in adaptive emotion regulation when coping with stress.     

Internet-based acceptance and commitment therapy for psychological distress experienced by people with hearing problems: a pilot randomized controlled trial

Psychological distress is common among people with hearing problems, but treatments that specifically target this aspect have been almost non-existent. In this pilot randomized controlled trial, an eight-week long Internet-based treatment, informed by Acceptance and Commitment Therapy, was administered to explore the feasibility and efficacy of such a treatment. Included participants were randomized to either treatment (n = 31) or wait-list control (n = 30) condition. All participants were measured prior to randomization and immediately after treatment ended using standardized self-report instruments measuring hearing-related emotional and social adjustment (Hearing Handicap Inventory for the Elderly – S, HHIE-S), quality of life (Quality of Life Inventory, QOLI), and symptoms of depression and anxiety (Patient health Questionnaire, PHQ-9 and Generalized Anxiety Disorder scale, GAD-7). Linear mixed effects regression analysis using the full intention-to-treat sample demonstrated that the treatment had superior outcomes on the main outcome measure as compared with the control group, Cohen’s d = 0.93, 95% CI [0.24, 1.63]. The benefits of treatment over control were also evident in scores of depression, Cohen’s d = 0.61, 95% CI [0.04, 1.19], and quality of life, Cohen’s d = 0.88, 95% CI [0.14, 1.61]. The results provide preliminary support for Internet-delivered acceptance and commitment therapy as a potentially effective treatment of psychological symptoms associated with hearing problems.     

The prevention of chronic pain and disability: a preliminary investigation.

A preliminary investigation was undertaken on 117 acute back pain cases, to assess the utility of counseling at the acute stage upon the course of recovery over the subsequent 6 months. In addition, the extent to which psychological reactions to acute injury would allow the 'tagging' of individuals at risk for chronic pain problems, was studied. The minimal rehabilitation counseling proved inadequate to effect the course of recovery, but remarkably accurate predictions were possible at the sub-chronic point (3 months) as to who would make complete recoveries.     

Transdiagnostic Internet treatment for anxiety disorders: A randomized controlled trial

Clinician-guided Internet-based cognitive behavioural therapy (iCBT) programs are clinically effective at treating specific anxiety disorders. The present study examined the efficacy of a transdiagnostic Internet-based cognitive behavioural treatment (iCBT) program to treat more than one anxiety disorder within the same program (the Anxiety Program). Eighty six individuals meeting diagnostic criteria for generalized anxiety disorder (GAD), panic disorder, and/or social phobia were randomly assigned to a treatment group, or to a waitlist control group. Treatment consisted of CBT based online educational lessons and homework assignments, weekly email or telephone contact from a clinical psychologist, access to a moderated online discussion forum, and automated emails. An intention-to-treat model using the baseline-observation-carried-forward principle was employed for data analyses. Seventy-five percent of treatment group participants completed all 6 lessons within the 8 week program. Post-treatment data was collected from 38/40 treatment group and 38/38 control group participants, and 3-month follow-up data was collected from 32/40 treatment group participants. Relative to controls, treatment group participants reported significantly reduced symptoms of anxiety as measured by the Generalized Anxiety Disorder - 7 Item, Social Phobia Screening Questionnaire, and the Panic Disorder Severity Rating Scale - Self Report Scale, but not on the Penn State Worry Questionnaire, with corresponding between-groups effect sizes (Cohen’s d) at post-treatment of 0.78, 0.43, 0.43, and 0.20, respectively. The clinician spent a total mean time of 46 min per person over the program, participants rated the procedure as moderately acceptable, and gains were sustained at follow-up. Modifications to the Anxiety program, based on post-treatment feedback from treatment group participants, were associated with improved outcomes in the control group. These results indicate that transdiagnostic programs for anxiety disorders may be successfully administered via the Internet.     

Cognitive behavior therapy for driving fear: A pilot randomized controlled trial

Fear of driving is common in clinical practice, while its treatment programs are understudied. This is the first randomized controlled trial to evaluate a newly developed protocol for cognitive behavior therapy (CBT) for driving fear compared with a wait list and to use specific assessment scales. 34 participants (30 women, 4 men) in an outpatient psychotherapy clinic were randomly allocated to either 18 sessions of CBT or a wait list (n = 17 each). After treatment, CBT was significantly more efficacious than the wait list with large effect sizes on the Instrument for Fear of Driving (IFD) (Cohen’s d = 2.58) and on the Driving Cognitions Questionnaire (DCQ) (Cohen’s d = 2.14). Driving fear is a condition treatable by CBT and the suggested protocol is safe, feasible and acceptable. Further studies with larger samples and active controls (e.g., virtual reality therapy) are required to draw generalizable conclusions on effect sizes.