The Development and Initial Validation of the Cognitive Fusion Questionnaire

Acceptance and Commitment Therapy (ACT) emphasizes the relationship a person has with their thoughts and beliefs as potentially more relevant than belief content in predicting the emotional and behavioral consequences of cognition. In ACT, “defusion” interventions aim to “unhook” thoughts from actions and to create psychological distance between a person and their thoughts, beliefs, memories, and self-stories. A number of similar concepts have been described in the psychology literature (e.g., decentering, metacognition, mentalization, and mindfulness) suggesting converging evidence that how we relate to mental events may be of critical importance. While there are some good measures of these related processes, none of them provides an adequate operationalization of cognitive fusion. Despite the centrality of cognitive fusion in the ACT model, there is as yet no agreed-upon measure of cognitive fusion. This paper presents the construction and development of a brief, self-report measure of cognitive fusion: The Cognitive Fusion Questionnaire (CFQ). The results of a series of studies involving over 1,800 people across diverse samples show good preliminary evidence of the CFQ’s factor structure, reliability, temporal stability, validity, discriminant validity, and sensitivity to treatment effects. The potential uses of the CFQ in research and clinical practice are outlined.     

A Review of Outcome Studies on Cognitive-Behavioral Therapy for Reducing Fear-Avoidance Beliefs Among Individuals With Chronic Pain

In the last two decades, emerging research has focused on advancing the explanations of how chronic pain becomes disabling. The fear-avoidance model of pain suggests that fear of reinjury in chronic pain patients leads to avoidance of certain movements that subsequently results in more pain and disability from that lack of movement. The literature supporting this model of pain and disability has allowed specific therapeutic interventions to be developed aimed at reducing pain-related fears in an attempt to reduce the physical symptoms and disability of chronic pain. Studies using cognitive-behavioral interventions to reduce fear-avoidance beliefs are reviewed and the treatments are evaluated based on the studies’ effectiveness. The author concludes that graded exposure in vivo appears to be the most effective treatment for chronic pain in individuals with increased fear and avoidance.     

Beyond beliefs: Challenging obsessive thoughts and compulsive behaviours within a collaborative counselling relationship

Three clients with obsessive‐compulsive disorder were studied using a multiple case study approach. Clients' experiences of cognitive‐behavioural therapy, in particular the impact of having their beliefs challenged, and their responses to self‐monitoring tasks and behavioural experiments were investigated. Data included case notes made during therapy, pre‐ and post‐therapy questionnaires, and post‐therapy semi‐structured interviews. Qualitative analysis of the data identified clients' obsessive beliefs, general negative beliefs and meta‐cognitive beliefs, and explored any post‐therapy changes in these beliefs. The results demonstrated similarities between cases in obsessive beliefs (e.g. inflated responsibility for harm), general negative beliefs (e.g. feelings of failure), meta‐cognitive beliefs (e.g. the need to control thoughts) and affect (e.g. guilt). Questionnaire data from all three clients suggested no clinically significant post‐therapy changes in general negative beliefs and meta‐cognitive beliefs. However, idiosyncratic changes in obsessive beliefs were reported during therapy and at post‐therapy interview, and clients reported improved functioning and decreased levels of distress during therapy and at interview. Responses to challenge were uniformly positive, but reactions to self‐monitoring and behavioural experiments varied across cases. The implications of these findings for the treatment of obsessive‐compulsive disorder using cognitive behavioural techniques are discussed.     

Cognitive Factors in the Maintenance of PTSD

Abstract

Cognitive behavioural therapies have the strongest empirical support as the treatments of choice for Post-traumatic Stress Disorder (PTSD). Despite the relative efficacy of these treatments compared to other psychological treatments, and no treatment, a large proportion of PTSD patients retain their diagnosis after treatment. In this article, a review of cognitive factors that are suggested to be responsible for the maintenance of PTSD in unimproved patients is presented. Among these factors are: anger and rage, guilt and shame, attentional bias and memory bias, negative attributional style, low self-efficacy, cognitive avoidance, dysfunctional schemas, catastrophic interpretations of intrusive recollections and pathological trauma memory structures. In the discussion section, suggestions about how therapy programmes might be modified in order to maximize cognitive change are provided.     

Automatic processing of pain: the change of implicit pain associations after psychotherapy

This study explores the utility of a pain IAT for the assessment of dysfunctional cognitive beliefs in chronic pain patients before and after a cognitive behaviour therapy. A patient group suffering from chronic pain (N=25) treated with a 4-week cognitive behavioural psychotherapy is compared with an untreated healthy control group (N=27) at two points in time. In addition, both groups completed a self-esteem questionnaire (Rosenberg-scale) and a self-esteem IAT. In the clinical group a questionnaire assessing self-reported pain cognitions was administered. The pain IAT was able to differentiate between chronic pain patients and healthy controls before the treatment. Most important, pain-related implicit associations could be shown to change over the course of treatment in the clinical group of chronic pain patients. Results provide first evidence for an application of the IAT in chronic pain research.     

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.     

Effectiveness of an ACT‐based rehabilitation program for the treatment of chronic fatigue: Results from a 12‐months longitudinal study

Acceptance and Commitment Therapy (ACT) is potentially effective for treating chronic fatigue. Given the paucity of studies on this topic, we aimed to assess long‐term trajectories of primary (fatigue, quality of life and functional abilities) and secondary outcomes (anxious and depressive symptoms) of an ACT‐based rehabilitation program for patients with chronic fatigue. Further, we examined if changes in potential process variables (psychological inflexibility, metacognitive beliefs, and cognitive and behavioral responses to symptoms) during ACT predicted change in all outcomes across follow‐up. One‐hundred ninety‐five workers on sick leave (mean age: 43.61 ± 9.33 years; 80.5% females) with a diagnosis of chronic fatigue were enrolled in a manualized, 3.5‐week intensive return‐to‐work rehabilitation program based on ACT. All completed a battery of questionnaires at pre‐, post‐treatment, 6 and 12 months follow‐up. We found significant longitudinal changes in most primary and secondary outcomes from pre‐ up to 12 months follow‐up. All process variables significantly decreased from pre‐ up to 12 months follow‐up, and pre‐to‐post changes in fear avoidance beliefs were most often associated with a greater change in outcomes across follow‐up. Depressive symptomatology showed a similar trajectory of change to fatigue, meaning that scores were correlated at each time point and tended to converge over time. This suggests that both symptoms influence each other substantially over a year following the treatment. Concluding, results lend support to the effectiveness of an ACT‐based rehabilitation program for patients with chronic fatigue and provide preliminary evidence for the role of process variables and depressive symptomatology on subsequent change in outcomes.     

Long-term outcomes of Acceptance and Commitment Therapy in drug-dependent female inmates: A randomized controlled trial

The general aim of this randomized controlled trial was to test the long-term efficacy of acceptance and commitment therapy (ACT) compared to a cognitive behavioural therapy (CBT) condition in the treatment of drug abuse. Participants were 37 polydrug incarcerated females assessed with Mini International Neuropsychiatric Interview, Addiction Severity Index-6, Anxiety Sensitivity Index (ASI) and Acceptance and Action Questionnaire II at pre, post, and at 6-, 12- and 18-months follow-ups. The mixed lineal model analyses showed reductions in drug abuse, ASI levels and avoidance repertoire in both conditions, without any differences between groups. However, the percentages of mental disorders were reduced only in ACT participants. At the 18-month follow-up, ACT was better than CBT in the maintaining of abstinence rates. This data support the incubation pattern showed in previous ACT studies. To conclude, the ACT intervention seems to be an adequate treatment option for addictive behaviours and co-occurring disorders in incarcerated women.     

Changes in illness-related cognitions rather than distress mediate improvements in irritable bowel syndrome (IBS) symptoms and disability following a brief cognitive behavioural therapy intervention

Objective

A previous randomised controlled trial demonstrated that a cognitive behavioural therapy (CBT) self-management intervention significantly improved irritable bowel syndrome (IBS) symptoms and disability compared to treatment as usual (TAU). The current study analysed additional data to establish whether; 1) cognitive, behavioural and emotional factors hypothesized to perpetuate IBS symptoms and disability changed following CBT and, 2) ascertain if changes in these factors over the intervention period mediated treatment effects 6-months later.

Method

IBS patients (CBT = 31, TAU = 33) completed measures pre-and-post intervention including: Brief Illness Perception Questionnaire, Hospital Anxiety & Depression Scale and Cognitive and Behavioural Responses to Symptoms Questionnaire. Path models were evaluated to determine whether changes in cognitive and behavioural factors over the treatment period mediated treatment effects.

Results

Compared to TAU, CBT patients showed significant positive changes on several cognitive variables but not anxiety and depression following intervention. Positive change in illness perceptions following intervention mediated the treatment effect on improved IBS symptom severity and social adjustment six months later. Changes in damaging beliefs mediated the effect on social adjustment.

Conclusions

Change in cognition rather than mood mediated treatment related improvements. Changing negative perceptions of IBS appears to be a particularly important treatment mechanism.     

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.     

Experimental modification of beliefs in obsessive-compulsive disorder: a test of the metacognitive model

Metacognitive beliefs about the threatening meaning and significance of intrusions are fundamental to the development and maintenance of obsessive-compulsive disorder (OCD) in the metacognitive model (Cognitive therapy of anxiety disorders: a practice manual and conceptual guide, Chichester, UK, Wiley, 1997; Emotional disorders and metacognition: innovative cognitive therapy, Chichester, UK, Wiley, 2000). This predicts that reductions in metacognitive beliefs about intrusions will result in decreased anxiety and compulsions. It was hypothesized that brief (5min) exposure and response prevention configured as a behavioural experiment to challenge metacognitive beliefs would lead to reductions in anxiety, thought fusion beliefs and the urge to neutralize. Furthermore, these reductions would be greater than the effects observed in the same exposure and response prevention task, accompanied by a habituation rationale. The results were consistent with the hypotheses. The clinical implications for the treatment of OCD are discussed.     

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.     

Using Client Narratives to Identify Predictors of Outcome in Written Exposure Therapy and Cognitive Processing Therapy

Written exposure therapy (WET) is a brief, five-session treatment for posttraumatic stress disorder (PTSD) that aims to improve access to care. WET has been demonstrated to be an efficacious PTSD treatment with lower rates of dropout and noninferior PTSD symptom outcome compared to cognitive processing therapy (CPT), a 12-session, gold-standard treatment. To identify predictors of treatment outcome in both WET and CPT, the current study examined the content of participants’ written narratives. Participants were 123 adults with PTSD who were randomly assigned to receive WET (n = 61) or CPT (n = 62). The Change and Growth Experiences Scale (CHANGE) coding system was used to code all available narratives in both treatment conditions for variables hypothesized to be relevant to therapeutic change. Linear regression analyses revealed that in WET, higher average levels of accommodated (healthy, balanced) beliefs and an increase in accommodated beliefs from the first to the final impact statement predicted better PTSD symptom outcome at 12 weeks postrandomization. In CPT, higher average levels of overgeneralized and accommodated beliefs and lower levels of avoidance expressed in the narratives predicted better PTSD outcome. There were no significant predictors of outcome in analyses of change from the first to final impact statement in CPT. These findings add to research identifying predictors of change in WET and CPT by highlighting the importance of low avoidance in CPT and of trauma-related cognitions in both CPT and WET, even though WET is a brief written intervention that does not explicitly target cognitive change.     

Are fear-avoidance beliefs related to the inception of an episode of back pain? A prospective study

Abstract

Fear-avoidance beliefs and catastrophizing have been implicated in chronic pain and theoretical models have been developed that feature these factor in the transition from acute to chronic pain. However, little has been done to determine whether these factors occur in the general population or whether they arc associated with the inception of an episode of neck or back pain. The aim of this study was to evaluate prospectively the effects of fear-avoidance beliefs and catastrophizing on the development of an episode of self-reported pain and associated physical functioning. To achieve this, we selected a sample of 415 people from the general population who reported no spinal pain during the past year. At the pretest a battery of questionnaires was administered to assess beliefs about pain and activity and it featured the Pain Catastrophizing Scale and a modified version of the Fear-Avoidance Beliefs Questionnaire. One year later outcome was evaluated by self-reports of the occurrence of a pain episode as well as a self-administered physical function test. The results showed that scores on both fear-avoidme and cabstrophizing were quite low. During the one year follow-up, 19% of the sample suffered an episode of back pain. Those with scores above the median on fear-avoidance beliefs at the pretest had twice the risk of suffering an episode of back pain and a 1.7 times higher risk of lowered physical function at the follow-up. Catastrophizing was somewhat less salient, increasing the risk of pain or lowered function by 1.5. but with confidence intervals falling below unity. These data indicate that fear-avoidance beliefs may be involved at a very early pint in the development of pain and associated activity problems in people with back pain. Theoretically. our results support the idea that fear-avoidance beliefs may develop in an interaction with the experience of pain. Clinically, the results suggest that catastrophizing and particularly fear-avoidance beliefs are important in the development of a pain problem and might be of use in screening procedures.     

The cognitive-behavioural treatment of low self-esteem in psychotic patients: a pilot study

Low self esteem in individuals with a psychotic disorder is common and may be related to poorer clinical outcomes. However, there has been little research on devising treatment methods to improve self-esteem either generally or in psychotic patients in particular. The aims of this study were to evaluate the efficacy of a simple cognitive behavioural intervention to improve self esteem in psychotic patients who scored poorly on a self-esteem measure. This pilot study was a randomised control trial with a convenience sample of chronic psychotic inpatients. The cognitive behavioural self-esteem intervention, as an adjunct to treatment as usual (TAU), was compared to TAU alone in patients with psychosis. The individual self-esteem intervention as described by Tarrier (The use of coping strategies and self-regulation in the treatment of psychosis. (2001)) consisted of working with participants to elicit positive self-attributes and then identify specific behavioural examples to provide evidence of this attribute. Emphasis was given to any consequential change in the patient's belief that they had the attribute. The results indicated that this cognitive behavioural treatment for self-esteem used as an adjunct treatment in psychosis, resulted in clinical benefits in terms of increased self-esteem, decreased psychotic symptomatology and improved social functioning. These benefits were largely maintained at 3-month follow-up.     

The Cognitive‐Behavioural Theory and Treatment of Bulimia Nervosa: An Examination of Treatment Mechanisms and Future Directions

Enhanced cognitive‐behavioural therapy (CBT‐E) is the current treatment of choice for bulimia nervosa. While the cognitive‐behavioural theory and treatment of bulimia nervosa have made a substantial contribution to our understanding of the disorder, approximately half of patients treated with CBT‐E fail to achieve remission of binge eating and purging. There is evidence showing that mechanisms proposed by the CBT‐E model are associated with binge eating and purging symptoms, and therefore likely important targets for treatment. To identify future directions in improving the efficacy of this treatment, and informed by a model of the client change process, we review the evidence for the hypothesised treatment mechanisms of CBT‐E. We conclude that while the proposed treatment mechanisms of CBT‐E largely change over the course of treatment, there is limited evidence that the treatment manipulations of CBT‐E are responsible for the specific changes in the proposed treatment mechanisms. In addition, given a lack of research in this area, we could find no evidence that changes in the additional treatment mechanisms outlined in CBT‐E are associated with changes in the core symptomatology of binge eating and purging. Based on these findings, we recommend that future efforts are directed towards understanding the client change process in CBT‐E and outline three clear directions for research.     

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.     

Adjustment to chronic low back pain--the relative influence of fear-avoidance beliefs, catastrophizing, and appraisals of control

The present study investigated the relative extent to which patients' adjustment to chronic low back pain (CLBP) was influenced by their fear-avoidance beliefs, their tendency to catastrophize, and their appraisals of control. Eighty-three CLBP patients completed a series of self-report measures before participating in a physical therapist-led intervention. Hierarchical multiple regression analyses revealed that patients' perceptions of their ability to decrease pain explained a small, but statistically significant, proportion of the variance in pain intensity. In addition, patients' levels of catastrophizing, as well as their fear-avoidance beliefs about both work and physical activity, were independently associated with levels of disability. Interestingly, however, when exploring the relative predictive utility of these three psychological factors, it became evident that fear-avoidance beliefs about physical activity (FABs-PA) were the only significant predictor of patients' disability. Specifically, those patients who exhibited higher levels of FABs-PA tended to report greater levels of disability, even after adjusting for age, sex and pain intensity.     

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.     

Subtypes of obsessive-compulsive disorder: Implications for specialized cognitive behavior therapy

Although obsessive-compulsive disorder (OCD) is a heterogeneous condition, OCD subtypes have received limited attention in trials of cognitive behavior therapy (CBT). Because many patients with OCD do not respond optimally to CBT, it is important for clinicians to consider whether variability in treatment response is related to symptom presentation. Treatment modifications for patients without overt compulsions or with hoarding symptoms show promise. In this article we discuss the available research addressing the treatment of OCD subtypes, review the clinical characteristics and treatment recommendations for prominent OCD subtypes, raise the prospect of using dysfunctional beliefs as a potentially helpful conceptual approach to subtyping OCD and matching treatment to subtypes, and consider future directions in the treatment of OCD subtypes.