Cognitive Mediators of Treatment for Social Anxiety Disorder: Comparing Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy

Objective

To assess the relationship between session-by-session mediators and treatment outcomes in traditional cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for social anxiety disorder.

Method

Session-by-session changes in negative cognitions (a theorized mediator of CBT) and experiential avoidance (a theorized mediator of ACT) were assessed in 50 adult outpatients randomized to CBT (n = 25) or ACT (n = 25) for DSM-IV social anxiety disorder.

Results

Multilevel modeling analyses revealed significant nonlinear decreases in the proposed mediators in both treatments, with ACT showing steeper decline than CBT at the beginning of treatment and CBT showing steeper decline than ACT at the end of treatment. Curvature (or the nonlinear effect) of experiential avoidance during treatment significantly mediated posttreatment social anxiety symptoms and anhedonic depression in ACT, but not in CBT, with steeper decline of the Acceptance and Action Questionnaire at the beginning of treatment predicting fewer symptoms in ACT only. Curvature of negative cognitions during both treatments predicted outcome, with steeper decline of negative cognitions at the beginning of treatment predicting lower posttreatment social anxiety and depressive symptoms.

Conclusions

Rate of change in negative cognitions at the beginning of treatment is an important predictor of change across both ACT and CBT, whereas rate of change in experiential avoidance at the beginning of treatment is a mechanism specific to ACT.     

Changes in Cognitions, Emotions, and Behaviors in Depressed Patients and Their Spouses Following Marital Cognitive Therapy, Traditional Cognitive Therapy, Pharmacotherapy, and No Intervention

This study evaluated specific influences of a cognitive marital treatment (CMT) for depression based on an integration of cognitive theory of depression and systems theory. The effects of CMT on variables representing cognitions, emotions, and behaviors were compared with the effects of traditional cognitive therapy (CT), pharmacotherapy (PT), and no treatment (NT). Subjects were Major Depression Disorder and Dysthymic outpatients and their spouses. The changes considered were for pre–post treatment and pre-treatment–follow-up. CMT affected a wider range of variables than other treatments. In most instances it was also superior to the NT condition. Most of the gains were manifested at termination and lasted through follow-up. The variables affected by CMT were patients' and spouses' cognitions and emotions. PT had best effects on patients' emotions. CT affected patients' cognitions, but did not achieve superiority on any of the compared variables. None of the treatments produced significant changes in behaviors.     

Self-Presentation and Exercise

Preliminary research indicates that self-presentation may be an important antecedent and consequence of physical activity because it may affect people's exercise cognitions, attitudes, and behaviors. The specific purposes of this article were to review the literature on self-presentational processes with regard to (a) exercise behavior, (b) motivation to engage in physical activity, (c) the characteristics of the exercise environment, (d) subjective responses to acute exercise, and (e) the effects of exercise interventions on self-presentational concerns. Implications of a self-presentational perspective for examining exercise adherence and developing physical activity interventions are discussed.     

Psychological Flexibility as Shared Process of Change in Acceptance and Commitment Therapy and Exposure and Response Prevention for Obsessive-Compulsive Disorder: A Single Case Design Study

Changes in psychological flexibility were tracked in a combined protocol of exposure and response prevention (ERP) and acceptance and commitment therapy (ACT) for adults with OCD to assess if changes in psychological flexibility processes were unique to ACT intervention (e.g., not impacted by ERP). Using a nonconcurrent multiple baseline design, four participants received sessions of ERP and ACT while data was collected on psychological flexibility processes of change and OCD symptom severity. Results indicate treatment response for three of four participants based on OCD scores. Contrary to predictions, data suggest both ERP and ACT have positive effects on psychological flexibility. Implications of these findings are discussed in relation to recent research on ACT and ERP for OCD. This study also illustrates a type of research design that can be accomplished in clinical practice.     

Using session-by-session measurement to compare mechanisms of action for acceptance and commitment therapy and cognitive therapy

Debate continues about the extent to which postulated mechanisms of action of cognitive behavior therapies (CBT), including standard CBT (i.e., Beckian cognitive therapy [CT]) and acceptance and commitment therapy (ACT) are supported by mediational analyses. Moreover, the distinctiveness of CT and ACT has been called into question. One contributor to ongoing uncertainty in this arena is the lack of time-varying process data. In this study, 174 patients presenting to a university clinic with anxiety or depression who had been randomly assigned to receive either ACT or CT completed an assessment of theorized mediators and outcomes before each session. Hierarchical linear modeling of session-by-session data revealed that increased utilization of cognitive and affective change strategies relative to utilization of psychological acceptance strategies mediated outcome for CT, whereas for ACT the mediation effect was in the opposite direction. Decreases in self-reported dysfunctional thinking, cognitive "defusion" (the ability to see one's thoughts as mental events rather than necessarily as representations of reality), and willingness to engage in behavioral activity despite unpleasant thoughts or emotions were equivalent mediators across treatments. These results have potential implications for the theoretical arguments behind, and distinctiveness of, CT and ACT.     

Processes in acceptance and commitment therapy and the rehabilitation of chronic fatigue

Acceptance and commitment therapy (ACT) has never been tested for patients with chronic fatigue. We aimed to test if a 3.5‐week ACT rehabilitation program for patients with chronic fatigue improved quality of life (QoL), fatigue, and psychological flexibility. Further, to test if improvements in QoL and fatigue were associated with improvement in psychological flexibility, and if psychological flexibility explained variance above and beyond maladaptive cognitions typically targeted in CBT for fatigue. Patients (n = 140) who had been on sick leave > 8 weeks due to chronic fatigue received a 3.5‐week non‐controlled inpatient rehabilitation program based on ACT. A physician and a psychologist examined the patients, assessing medication use and SCID‐I diagnoses. Patients completed questionnaires about somatic complaints, psychological complaints, and maladaptive cognitions before and after treatment. At post‐treatment, patients reported improved QoL (p < 0.001; g = 1.07) and less fatigue (p < 0.001; g = 1.08), but not increased psychological flexibility (p = 0.6). Changes in psychological flexibility was associated with improved QoL, but not fatigue, in hierarchical regression analyses. When adjusting for other cognitions, changes in fear‐avoidance cognitions and all‐or‐nothing thoughts, but not psychological flexibility, were associated with improved QoL and fatigue. The ACT‐based treatment improved QoL and reduced fatigue for patients with chronic fatigue with large effect sizes. Improvement was associated with a reduction in fear‐avoidance cognitions and all‐or‐nothing thoughts, but not psychological flexibility.     

Processes in Group Cognitive and Behavioral Treatment for Hoarding

Processes that emerge in the course of group treatment, such as universality and mutual aid, have been posited to promote therapeutic change (e.g., Yalom, 1995); however, they have received relatively little attention in the group cognitive behavioral treatment (CBT) literature (Rose, 2004). Group CBT interventions have been successful in alleviating symptoms of mood and anxiety disorders, such as major depression and obsessive-compulsive spectrum disorder (e.g., Anderson & Rees, 2007; Himle et al., 2001). A specialized group CBT protocol has been developed to treat hoarding (Muroff et al., 2009; Steketee & Frost, 2007), characterized by excessive clutter in the home, difficulty discarding objects that appear of little value, and often excessive acquisition, resulting in significant distress and/or impairment (Frost & Hartl, 1996). Individual (Tolin, Frost, & Steketee, 2007) and group (Muroff et al.) CBT for hoarding have shown promising effects. An examination of group process factors relevant to hoarding, however, is critical in order to further understand and tailor group interventions for this complex problem. The current paper characterizes four group processes specific to group CBT for hoarding: (a) universality or inclusion may reduce stigma and shame about having hoarding; (b) cohesion seems to support attendance and to provide positive peer pressure to motivate change; (c) the opportunity to give mutual aid seems to instill hope and motivate change; (d) social contact and socializing may reduce social isolation, a characteristic of this population. Discussion includes specific case examples illustrating these group processes and their potential complexity, within the context of group CBT for hoarding. Recommendations are advanced for future directions in evaluating group CBT for hoarding, particularly the formal study of group process variables with this population.     

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.     

Treatments Addressing Pain-Related Fear and Anxiety in Patients with Chronic Musculoskeletal Pain: A Preliminary Review

Abstract

This review covers the current cognitive behavioural treatments available to address fear-avoidance beliefs in patients with chronic musculoskeletal pain (CMP). Four types of treatment protocols were identified for inclusion in the review: (a) graded in vivo exposure (GivE); (b) graded activity (GA); (c) acceptance and commitment therapy (ACT); and (d) mixed cognitive behavioural protocols. Most of the research suggests that GivE and ACT result in the best outcomes for treating fear-avoidance beliefs in patients with CMP. There is also a readily apparent paucity of research from North America; indeed, most of the available studies were conducted in the Netherlands and Scandinavia. This relative absence of North American research raises potentially important questions about the role of compensation status and access to care, which differ between countries, on treatment outcome. Implications and directions for future research are discussed.     

Indicatives,Subjunctives, and the Falsity of the Antecedent

It is widely held that there are important differences between indicative conditionals (e.g., “If the authors are linguists, they have written a linguistics paper”) and subjunctive conditionals (e.g., “If the authors had been linguists, they would have written a linguistics paper”). A central difference is that indicatives and subjunctives convey different stances toward the truth of their antecedents. Indicatives (often) convey neutrality: for example, about whether the authors in question are linguists. Subjunctives (often) convey the falsity of the antecedent: for example, that the authors in question are not linguists. This paper tests prominent accounts of how these different stances are conveyed: whether by presupposition or conversational implicature. Experiment 1 tests the presupposition account by investigating whether the stances project—remain constant—when embedded under operators like negations, possibility modals, and interrogatives, a key characteristic of presuppositions. Experiment 2 tests the conversational-implicature account by investigating whether the stances can be cancelled without producing a contradiction, a key characteristic of implicatures. The results provide evidence that both stances—neutrality about the antecedent in indicatives and the falsity of the antecedent in subjunctives—are conveyed by conversational implicatures.     

Directions in Specialized Cognitive Behavior Therapy for Resistant Obsessive-Compulsive Disorder: Theory and Practice of Two Approaches

This paper discusses specialized approaches developed for patients with obsessive-compulsive disorder (OCD) who are resistant to cognitive behavior therapy (CBT). Following a review of theoretical and outcome research, two approaches developed to resolve persistent OCD are described and illustrated. Cognitive therapy (CT) designed to address characteristic dysfunctional beliefs has shown promising results (Wilhelm et al., 2005; Wilhelm & Steketee, 2006). CT modules focus on understanding and correcting OCD-related beliefs (e.g., inflated responsibility, need for certainty, perfectionism) pertinent to each patient’s symptoms, using specialized strategies and behavioral experiments to test and modify maladaptive hypotheses and related negative emotions. CT appears to be acceptable to many patients and may reduce refusal rates and improve collaboration during exposure and response prevention (ERP). It is not yet clear whether this method improves outcomes for patients who have not responded to previous ERP. A schema-based CBT approach developed by Sookman and Pinard (1999, 2007) for resistant OCD of different subtypes aims to broaden the scope of CT, to improve patients’ capacity to fully engage in ERP, and to reduce susceptibility to relapse. Available results with previously CBT-resistant patients suggest this approach may improve learning during CT and collaboration in ERP, resulting in recovery for some patients. Criteria are outlined for defining CBT resistance and assessing treatment response using various outcome measures and stringent criteria. The ultimate goal of expert intervention for OCD is remission. The authors propose theory, practice, and research directions to help ameliorate symptoms and related difficulties in resistant OCD.     

A randomised worksite comparison of acceptance and commitment therapy and stress inoculation training

In this comparative intervention study, 107 working individuals with above average levels of distress were randomly assigned to one of three conditions: acceptance and commitment therapy (ACT; n = 37); stress inoculation training (SIT; n = 37); or a waitlist control group (n = 33). The interventions were delivered to small groups in the workplace via two half-day training sessions. ACT and SIT were found to be equally effective in reducing psychological distress across a three month assessment period. Mediation analysis indicated that the beneficial impact of ACT on mental health resulted from an increase in psychological flexibility rather than from a change in dysfunctional cognitive content. Contrary to hypothesis, a reduction in dysfunctional cognitions did not mediate change in the SIT condition. Results suggest that the worksite may offer a useful, yet underutilised, arena for testing cognitive-behavioural theories of change.     

An Open Trial of Acceptance and Commitment Therapy With Exposure and Response Prevention in an Intensive Outpatient Setting for Adults With OCD

Intensive outpatient treatment settings for adults with obsessive-compulsive disorder (OCD) are common, but data on their effectiveness are limited. The effectiveness of IOP treatment for adults with OCD using combined acceptance and commitment therapy (ACT) and exposure and response prevention (ERP) was studied with eight adults. The intervention was 15 hours per week for 3 weeks. Measures were collected at pretreatment, 1-week, 2-weeks, posttreatment, and at 1-month follow-up. At the end of treatment, all participants were in the mild range of OCD symptom severity with a mean symptom decrease of 58%. Psychological inflexibility, depression, anxiety, and stress significantly decreased through treatment and participants ended treatment below clinical range for psychological inflexibility and nonclinical to mild range for depression, anxiety, and stress. The results of this study provide preliminary support for the effectiveness of ACT and ERP in an intensive outpatient setting for adults with OCD. The focus of this paper is on the clinical application of this treatment.     

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.     

Exposure and Response Prevention and Habit Reversal Training: Commonalities, Differential Use, and Combined Applications

Obsessive-compulsive spectrum disorders (OCSDs) have compulsive (i.e., anxiety reductive) and impulsive (i.e., driven by emotional or involuntary impulses) features. The best established psychological treatments for these disorders are behavioral/cognitive-behavioral in nature. More specifically, exposure and response prevention (ERP) (with or without cognitive therapy) and habit reversal training (HRT) are commonly indicated in the treatment of OCSDs. This paper reviews the use of various components of these therapeutic approaches to treat compulsive and impulsive symptomology in individuals with variants of these disorders. Specifically, ERP monotherapy for compulsive (e.g., obsessive-compulsive, body dysmorphic) and impulsive symptoms (e.g., tics, trichotillomania) is discussed as well as a combined treatment approach that integrates elements of ERP and HRT for individuals displaying mixed symptomology. A case example is also provided that illustrates the successful application of various components of ERP and HRT to treat OCSD symptoms. Lastly, other potential OCSD treatments are discussed.     

Do Cognitive Behaviour Therapies Validate Cognitive Models of Mood Disorders? A Review of the Empirical Evidence

The efficacy of Cognitive Behaviour Therapy (CBT) in the treatment of depression is now established. However, explanations for the efficacy of CBT are mixed. The evidence needed to support the explanation advanced by cognitive theory is lacking. This paper critically reviews the available empirical evidence. Forty-four outcome or process studies of therapy with depression are reviewed and 21 of these are subjected to a meta-analysis to investigate the relationship between change in cognitions and change in level of depression during different kinds of therapy. Our analysis shows that: (1) change in cognitive style occurs in all four categories of treatment: CBT, Drug Therapy, Other-Psychological Therapy, and Waiting List; (2) there was a significant difference between Waiting List and all the active treatments in change in cognitions, but not between active treatments; (3) the degree of change in cognitive style is significantly related to change in depression as measured by the Beck Depression Inventory (BDI), but not the Hamilton Rating Scale for Depression (HRS-D); and (4) the relationship between cognitive change and depression is not unique to CBT. Our findings show that CBT does provide some support for the cognitive models of depression but the relationship between cognitive change and recovery from depression is not unique to CBT.     

Influence of co-morbid generalized anxiety disorder, panic disorder and personality disorders on the outcome of cognitive behavioural treatment of obsessive-compulsive disorder

This study examined co-morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive-compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co-morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention-to-treat criteria, patients with generalized anxiety disorder and/or panic disorder co-morbidity showed less treatment gains at post-treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post-treatment and the 12-month follow-up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co-morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12-month follow-up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post-treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.     

The Effect of Prominence and Cue Association on Retrieval Processes: A Computational Account

We present a comprehensive empirical evaluation of the ACT‐R–based model of sentence processing developed by Lewis and Vasishth (2005) (LV05). The predictions of the model are compared with the results of a recent meta‐analysis of published reading studies on retrieval interference in reflexive‐/reciprocal‐antecedent and subject–verb dependencies (Jäger, Engelmann, & Vasishth, 2017). The comparison shows that the model has only partial success in explaining the data; and we propose that its prediction space is restricted by oversimplifying assumptions. We then implement a revised model that takes into account differences between individual experimental designs in terms of the prominence of the target and the distractor in memory‐ and context‐dependent cue‐feature associations. The predictions of the original and the revised model are quantitatively compared with the results of the meta‐analysis. Our simulations show that, compared to the original LV05 model, the revised model accounts for the data better. The results suggest that effects of prominence and variable cue‐feature associations need to be considered in the interpretation of existing empirical results and in the design and planning of future experiments. With regard to retrieval interference in sentence processing and to the broader field of psycholinguistic studies, we conclude that well‐specified models in tandem with high‐powered experiments are needed in order to uncover the underlying cognitive processes.     

Is it the symptom or the relation to it? Investigating potential mediators of change in acceptance and commitment therapy for psychosis

Cognitive and behavioral interventions have been shown to be efficacious when used as an adjunct to pharmacotherapy for psychotic disorders. However, little previous research has investigated potential mediators of change in psychological treatments for psychosis. Acceptance and mindfulness-based therapies do not focus on directly reducing the psychotic symptoms themselves, but instead attempt to alter the patient's relationship to symptoms to decrease their negative impact. The current study examined this issue with data from a previously published randomized trial comparing brief treatment with Acceptance and Commitment Therapy (ACT) versus treatment as usual for hospitalized patients with psychotic symptoms (Gaudiano & Herbert, 2006a). Results showed that the believability of hallucinations at posttreatment statistically mediated the effect of treatment condition on hallucination-related distress. Hallucination frequency did not mediate outcome. The current study is a first step toward understanding the potential mechanisms of action in psychological treatments for psychosis.     

Acceptance and Commitment Therapy in the Rehabilitation of a Girl With Chronic Idiopathic Pain: Are We Breaking New Ground?

Wicksell and colleagues (2005) addressed the important and currently understudied realm of chronic idiopathic musculoskeletal pain treatment in children. They presented a brief overview of empirically supported treatments for children with chronic pain, detailed their case and intervention strategy, and offered conclusions regarding the potential efficacy and effectiveness of Acceptance and Commitment Therapy (ACT) for childhood chronic idiopathic musculoskeletal pain. Our commentary is divided into several sections. We begin by providing an overview and critique for each of the case conceptualization and the intervention strategy presented. This is followed by a brief discussion of whether or not Wicksell et al.'s ACT approach is fundamentally distinct from more traditional cognitive-behavior therapy (CBT) techniques. We also consider potential mechanisms of action and suggest future research directions needed to establish empirically supported treatments for chronic idiopathic pain in children.