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

A non-inferiority randomized controlled trial comparing behavioral sleep interventions in women veterans: An examination of pain outcomes

OBJECTIVE

Insomnia is known to exacerbate pain symptoms. The purpose of the present study was to compare the secondary effects of cognitive behavioral therapy for insomnia (CBTI) against a novel treatment for insomnia called acceptance and behavioral changes for insomnia (ABC-I) among individuals with comorbid pain. Differences in the potential mechanisms through which these treatments impact pain were also examined.

METHODS

Data consisted of a secondary analysis from a randomized comparative effectiveness trial of CBT-I and ABC-I among women veterans with insomnia and comorbid pain. Pain outcomes, beliefs about sleep, and psychological flexibility were assessed at baseline, post-treatment, and at three-months follow-up.

RESULTS

At baseline, 93 women veterans reported comorbid insomnia and pain (mean age = 46.7; 33.3% Black, 24.7% Hispanic/Latina). Both CBT-I (n = 48) and ABC-I (n = 45) were associated with decreased pain intensity (p < .001, Cohen's d = 0.41-0.67) and pain interference (p < .001, Cohen's d = 0.71-0.77) at post-treatment and three-months follow-up, with results indicating that ABC-I was non-inferior to CBT-I for pain improvement. Both conditions were associated with greater psychological flexibility post-treatment, and CBT-I resulted in larger reductions in dysfunctional beliefs about sleep (p = .01, Cohen's d = 0.59).

CONCLUSION

CBT-I and ABC-I both had positive secondary effects on pain with ABC-I being non-inferior to CBT-I with respect to its impact on pain. The mechanisms of change associated with these treatments may differ with CBT-I leading to greater reductions in dysfunctional beliefs. Hybrid treatments which incorporate an acceptance and commitment approach to both insomnia and pain warrant further examination.

Effects and Mechanisms of a Web- and Mobile-Based Acceptance and Commitment Therapy Intervention for Anxiety and Depression Symptoms in Nurses: Fully Decentralized Randomized Controlled Trial

BACKGROUND

Acceptance and commitment therapy (ACT) is a promising intervention for improving mental health. However, there is limited evidence on its effectiveness for nurses, particularly in web- and mobile-based intervention forms, in mitigating anxiety and depression symptoms.

OBJECTIVE

In this study, we aimed to examine the effect and underlying psychological mechanisms of a web- and mobile-based ACT intervention on nurses' anxiety and depression symptoms.

METHODS

In this fully decentralized randomized controlled trial, nurses were recruited nationwide across China through advertisements and posters. They were randomly assigned to either the 5-week fully automated intervention or the waiting group. Primary outcomes (anxiety and depression symptoms); secondary outcomes (sleep quality, burnout, and work performance); and mediators (psychological flexibility, cognitive defusion, mindfulness, and values) were assessed using the Wenjuanxing platform. Data collectors were blinded to the group assignments throughout the study period.

RESULTS

A total of 145 nurses with anxiety or depression symptoms were randomly assigned to either the intervention group (n=72, 49.7%) or the control group (n=73, 50.3%); 97.2% (n=141) were female. During the study, 36 (24.8%) nurses were lost to follow-up, and 53 (73.6%) completed the entire intervention. Nurses in the intervention group showed significant improvement in anxiety (d=0.67, 95% CI 0.33-1.00) and depression symptoms (d=0.58, 95% CI 0.25-0.91), and the effects were sustained for 3 months after the intervention (anxiety: d=0.55, 95% CI 0.22-0.89; depression: d=0.66, 95% CI 0.33-1.00). Changes in psychological flexibility, cognitive defusion, and values mediated the effect of the intervention on anxiety and depression symptoms, while mindfulness did not have a mediating effect.

CONCLUSIONS

The web- and mobile-based ACT intervention used in this study significantly improved nurses' anxiety and depression symptoms by improving psychological flexibility, cognitive defusion, and values. The results provide new ideas for hospital administrators to prevent and intervene in nurses' psychological issues.

TRIAL REGISTRATION

Chinese Clinical Trial Register ChiCTR2200059218; https://tinyurl.com/4mb4t5y9.

Multilevel associations of emotion regulation strategy use during psychotherapy for depression: A longitudinal study

BACKGROUND

People with depression select avoidant emotion regulation (ER) strategies more often than engagement strategies. While psychotherapy improves ER strategies, examining the week-to-week changes in ER and their relationship to clinical outcomes is warranted to understand how these interventions work. This study examined the changes in six ER strategies and depressive symptoms during virtual psychotherapy.

METHODS

Treatment-seeking adults (N = 56) with moderate depression severity completed a baseline diagnostic interview and questionnaires and were followed for up to 3 months as they completed virtual psychotherapy in an unrestricted format (e.g., individual) and orientation (e.g., cognitive-behavioral therapy; CBT). Participants completed weekly assessments of depression and six ER strategies along with assessments of CBT skills and participant-rated CBT components for each psychotherapy session. Multilevel modeling was used to examine associations between within-person changes in ER strategy use and weekly depression scores, controlling for between-person effects and time.

RESULTS

Depressive symptoms, rumination, and experiential avoidance decreased non-linearly over time while cognitive reappraisal and acceptance increased non-linearly. Controlling for CBT skills, within-person increases in acceptance and cognitive reappraisal, as well as within-person decreases in experiential avoidance, were associated with fewer depressive symptoms over time. People who reported greater CBT components in their sessions also reported fewer depressive symptoms over time.

LIMITATIONS

The study was unable to make more causal inferences or standardize the type, baseline, or length of psychotherapy received.

CONCLUSIONS

Improvements in ER strategies were associated with depression symptom reduction during psychotherapy. Future research to elucidate ER strategies as mediators of treatment response is warranted.

A prospective examination of the role of psychological (in)flexibility in posttraumatic stress: A cross-lagged panel design

Functional contextualist models of psychopathology suggest that psychological inflexibility and psychological flexibility are of central importance for understanding the development and maintenance of posttraumatic stress (PTS) symptomatology. To our knowledge, these two constructs and their domain-specific factors (e.g., cognitive fusion, experiential avoidance) have not been assessed in their entirety and examined in relation to PTS symptoms using a longitudinal study design. As such, the primary aim of the present study was to use cross-lagged panel analysis, an analytic approach that allows stronger causal inferences to be made regarding the nature of temporal relations among study variables, to determine the directional relations among PTS symptoms and psychological flexibility and inflexibility over an eight-month time period. Trauma-exposed adults (N = 810), recruited online via Amazon's Mechanical Turk (MTurk), completed a battery of self-report measures via a secure online platform at three time points, spanning eight months. Results suggest that the relationship between psychological inflexibility and PTS symptoms is bidirectional and mutually reinforcing. In contrast, significant prospective relations were not observed between psychological flexibility and PTS symptoms. Results of a follow-up exploratory path analysis showed that cognitive fusion was the only psychological inflexibility subfactor that partially mediated the relationship between PTS symptoms from baseline to the eight-month follow-up assessment. Taken together, these results suggest that psychological inflexibility, and primarily the domain of cognitive fusion, maintains PTS symptoms following trauma exposure. As such, it may important to integrate cognitive defusion techniques into evidence-based treatments for Posttraumatic Stress Disorder (PTSD).

The role of psychological flexibility in acceptance-enhanced behavior therapy for trichotillomania: Moderation and mediation findings

Trichotillomania is characterized by recurrent pulling out of one's hair, leading to significant hair loss and accompanied by clinically significant distress and/or functional impairment. The current study used data from a randomized controlled trial comparing the effectiveness of acceptance-enhanced behavior therapy (AEBT) to psychoeducation plus supportive therapy (PST; active control) for trichotillomania in an adult sample. The objectives were to examine the moderating and mediating influence of trichotillomania-specific psychological flexibility in treatment for trichotillomania. Participants with lower baseline flexibility performed better in AEBT than PST in terms of greater symptom reduction and quality of life. Lower baseline flexibility also predicted higher likelihood of disorder recovery in AEBT relative to PST. In addition, relative to PST, symptom reduction in AEBT was mediated by psychological flexibility, controlling for anxiety and depression. These findings suggest that psychological flexibility is a relevant process of change in the treatment of trichotillomania. Clinical implications and directions for future research are discussed.

Psychological inflexibility explains social anxiety over time: a mediation analyses with a clinical adolescent sample

Social Anxiety Disorder (SAD) has its usual onset during adolescence when it is a highly prevalent and debilitating condition. Evidence regarding the processes that underline social anxiety and SAD is not compelling, especially in adolescents. Within an Acceptance and Commitment Therapy (ACT) framework, the causal role of ACT processes on adolescents' social anxiety and how these processes contribute to sustain social anxiety over time is still unknown. Hence, this study explored the role of psychological inflexibility (PI) and acceptance and committed action (as psychological flexibility processes) on social anxiety over time, in a clinical sample of adolescents. Twenty-one adolescents (Mage = 16.19, SD = 0.750) with a primary diagnosis of SAD completed a set of self-report measures assessing PI, acceptance (i.e., willingness to experience social anxiety symptoms), action (i.e., moving towards valued life directions despite social anxiety symptoms) and social anxiety. Path analysis was used to investigate a mediation model linking acceptance, committed action, and PI to social anxiety, directly and indirectly. Findings revealed that acceptance and action were negatively and directly associated with PI after 10-weeks. In turn, PI yielded a positive and direct effect on social anxiety after another 12-weeks. PI totally mediated the relation between acceptance and action and social anxiety, with significant indirect effects. Overall, findings offer evidence for the applicability of the ACT model to adolescent SAD and support the use of clinical interventions targeting PI to understand and alleviate adolescents' social anxiety.

A longitudinal investigation of the role of perceived autonomy support from coaches in reducing athletes' experiential avoidance: The mediating role of subjective vitality

Experiential avoidance, a personality trait that refers to individuals' tendency to avoid negative experiences, can have a negative impact on athletes' goal achievement. For this reason, it is crucial to identify the factors that can mitigate such a tendency. Drawing on self-determination theory and referring specifically to the function of subjective vitality, we first hypothesize that perceived autonomy support from coaches is positively associated with athletes' subjective vitality, which in turn is negatively associated with athletes' experiential avoidance. Data were collected from one hundred eighty-five high school athletes in Taiwan using a three-wave, time-lagged survey design spanning a period of seven months. These athletes were drawn from ten senior high schools and were in their second year of high school. The results of regression analysis showed that perceived autonomy support from coaches at Time 1 was associated with higher vitality among athletes at Time 2, which was, in turn, associated with lower levels of experiential avoidance at Time 3, conditional on the athletes' experiential avoidance at Time 2. While perceived autonomy support from coaches at Time 1 was also associated with lower experiential avoidance at Time 2, experiential avoidance at Time 2 was not associated with vitality at Time 3 after controlling for vitality at Time 2. The results of mediation analysis further supported the claim that vitality is a critical mediator of the relationship between perceived autonomy support from coaches and athletes' experiential avoidance. Implications concerning the identification of this mediator are discussed.

Sound Tolerance Conditions (Hyperacusis, Misophonia, Noise Sensitivity, and Phonophobia): Definitions and Clinical Management

Purpose: For some people, exposure to everyday sounds presents a significant problem. The purpose of this tutorial was to define and differentiate between the various sound tolerance conditions and to review some options for their clinical management.

METHOD

We informally reviewed the literature regarding sound tolerance conditions. The terminology and definitions provided are mostly consistent with how these terms are defined. However, many inconsistencies are noted. Methods of assessment and treatment also differ, and different methodologies are briefly described.

RESULTS

Hyperacusis describes physical discomfort or pain when any sound reaches a certain level of loudness that would be tolerable for most people. Misophonia refers to intense emotional reactions to certain sounds (often body sounds such as chewing and sniffing) that are not influenced by the perceived loudness of those sounds. Noise sensitivity refers to increased reactivity to sounds that may include general discomfort (annoyance or feeling overwhelmed) due to a perceived noisy environment, regardless of its loudness. Phonophobia, as addressed in the audiology profession, describes anticipatory fear of sound. Phonophobia is an emotional response such as anxiety and avoidance of sound due to the "fear" that sound(s) may occur that will cause a comorbid condition to get worse (e.g., tinnitus) or the sound itself will result in discomfort or pain. (Note that phonophobia is a term used by neurologists to describe "migraineur phonophobia"-a different condition not addressed herein.) Conclusions: The literature addresses sound tolerance conditions but reveals many inconsistencies, indicating lack of consensus in the field. When doing an assessment for decreased sound tolerance, it is important to define any terms used so that the patient and all health care professionals involved in the care of the patient are aligned with the goals of the treatment plan. Treatment generally involves gradual and systematic sound desensitization and counseling.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20164130.

Is ACT-Informed Exposure a Viable Treatment for Excoriation Disorder? A Multiple Baseline Study

This study piloted the use of ACT-informed exposure as an adjunct to habit reversal training (HRT) for excoriation disorder (ExD). Using a nonconcurrent multiple baseline single case design, four participants completed sessions of exposure and HRT. Repeated measures and self-report data were collected on skin picking and psychological flexibility. Two participants completed HRT followed by exposure, and two participants completed exposure followed by HRT. Results support the effectiveness of HRT in reducing picking. Results suggest exposure may have some impact in reducing picking, but effects were weaker compared to HRT. Contrary to predictions, repeated measures and self-report data did not indicate consistent improvement in psychological flexibility during exposure phases. As any reduction in picking may be clinically meaningful and all participants maintained gains at follow-up, there is some indication that exposure may be a second-line treatment worth further study. Limitations and future areas of research are discussed.

Toward a Unified Framework for Positive Psychology Interventions: Evidence-Based Processes of Change in Coaching, Prevention, and Training

Since 2000, research within positive psychology has exploded, as reflected in dozens of meta-analyses of different interventions and targeted processes, including strength spotting, positive affect, meaning in life, mindfulness, gratitude, hope, and passion. Frequently, researchers treat positive psychology processes of change as distinct from each other and unrelated to processes in clinical psychology. This paper presents a comprehensive framework for positive psychology processes that crosses theoretical orientation, links coherently to clinical psychology and its more dominantly "negative" processes, and supports practitioners in their efforts to personalize positive psychological interventions. We argue that a multi-dimensional and multi-level extended evolutionary approach can organize effective processes of change in psychosocial interventions, by focusing interventions on context-appropriate variation, selection, and retention of processes, arranged in terms of key biopsychosocial dimensions across psychological, biophysiological, and sociocultural levels of analysis. We review widely studied positive psychology constructs and programs and show how this evolutionary approach can readily accommodate them and provide a common language and framework for improving human and community flourishing. We conclude that Interventions should start with the person, not the protocol.

A meta-analysis of emotional regulation outcomes in psychological interventions for youth with depression and anxiety

Difficulties in applying emotional regulation (ER) skills are associated with depression and anxiety symptoms, and are common targets of treatment. This meta-analysis examined whether improvements in ER skills were associated with psychological treatment outcomes for depression and/or anxiety in youth. A multivariate, random-effects meta-analysis was run using metafor in R. Inclusion criteria included studies that were randomized controlled trials (RCTs) of a psychological intervention for depression and/or anxiety in patients aged 14-24, were peer reviewed, were written in English, measured depression and/or anxiety symptoms as an outcome and measured ER as an outcome. Medline, Embase, APA PsycInfo, CINAHL and The Cochrane Library were searched up to 26 June 2020. Risk of bias (ROB) was assessed using the Cochrane Collaboration Risk of Bias 2.0 tool. The meta-analysis includes 385 effect sizes from 90 RCTs with total N = 11,652. Psychological treatments significantly reduced depression, anxiety, emotion dysregulation (k = 13, Hedges' g = 0.54, P < 0.001, 95% confidence interval (CI) = 0.30-0.78) and disengagement ER (k = 83, g = 0.24, 95% CI = 0.15-0.32, P < 0.001); engagement ER also increased (k = 82, g = 0.26, 95% CI = 0.15-0.32, P < 0.001). Improvements in depression and anxiety were positively associated with improved engagement ER skills, reduced emotion dysregulation and reduced disengagement ER skills. Sensitivity considered study selection and publication bias. Longer treatments, group formats and cognitive-behavioural orientations produced larger positive associations between improved ER skills and reduced symptoms. ER skill improvement is linked to depression and anxiety across a broad range of interventions for youth. Limitations of the current study include reliance on self-report measures, content overlap between variables and inability to test the directionality of associations.

Decentering as a core component in the psychological treatment and prevention of youth anxiety and depression: a narrative review and insight report

Decentering is a ubiquitous therapeutic concept featuring in multiple schools of psychological intervention and science. It describes an ability to notice to day-to-day psychological stressors (negative thoughts, feelings, and memories) from an objective self-perspective and without perseverating on the themes they represent. Thus, decentering dampens the impact and distress associated with psychological stressors that can otherwise increase mental ill health in vulnerable individuals. Importantly, the strengthening of decentering-related abilities has been flagged as a core component of psychological interventions that treat and prevent anxiety and depression. We provide an in-depth review evidence of the salutary effects of decentering with a special focus on youth mental health. This is because adolescence is a critical window for the development of psychopathology but is often under-represented in this research line. A narrative synthesis is presented that integrates and summarizes findings on a range of decentering-related abilities. Section 1 reviews extant conceptualizations of decentering and data-driven approaches to characterize its characteristic. A novel definition is then offered to guide future empirical research. Section 2 overviews laboratory-based research into the development of decentering as well as its relationship with anxiety and depression. Section 3 examines the role decentering-related skills play in psychological interventions for anxiety and depression. Critically, we review evidence that treatment-related increases in decentering predict latter reductions in anxiety and depression severity. Each section highlights important areas for future research. The report concludes by addressing the vital questions of whether, how, why and when decentering alleviates youth anxiety and depression.

Defining and measuring "psychological flexibility": A narrative scoping review of diverse flexibility and rigidity constructs and perspectives

Psychological flexibility (PF) is a popular construct in clinical psychology. However, similar constructs have existed since the mid-20th century, resulting in different terms, definitions and measures of flexibility, hindering the advancement of the field. The main measure of PF - the Acceptance and Action Questionnaire (AAQ-II; Bond et al., 2011) - has also been heavily criticized. To move towards definitional consensus and improved measurement, we surveyed the literature to map PF and related-terms, examine definitional overlaps, and assessthe psychometric quality of prominent flexibility measures. A scoping review was conducted in two databases (PsycNET and SCOPUS). Twenty-three flexibility constructs appeared across 220 articles, and twelve measures were included and rated for quality. PF, psychological inflexibility (PI), and cognitive flexibility (CF) were most prominent. Definitional similarities among prominent flexibility constructs emerged, namely handling distress or interference, taking action, and meeting goals or values. The Personalized Psychological Flexibility Index (PPFI; Kashdan, Disabato, Goodman, Doorley, & McKnight, 2020) appears to be the best measure available to assess PF. Problems with the current use of the AAQ-II were apparent, hindering current knowledge of PF. Definitional consensus and measurement development are vital to advance the field. To this end, recommendations and next steps for researchers and practitioners are outlined.

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.

One year follow-up and mediation in cognitive behavioral therapy and acceptance and commitment therapy for adult depression

BACKGROUND

Existing therapies for depression are effective, but many patients fail to recover or relapse. To improve care for patients, more research into the effectiveness and working mechanisms of treatments is needed. We examined the long-term efficacy of Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) for Major Depressive Disorder (MDD), testing the hypothesis that CBT outperforms ACT and that both therapies work through their designated mechanisms of change.

METHODS

We conducted a randomized controlled trial with 82 patients suffering from MDD. Data were collected before, during and after treatment, and at 12-month follow-up, assessing symptoms of depression, quality of life, dysfunctional attitudes, decentering, and experiential avoidance.

RESULTS

Patients in both conditions reported significant and large reductions of depressive symptoms (d = - 1.26 to - 1.60) and improvement in quality of life (d = 0.91 to - 1.28) 12 months following treatment. Our findings indicated no significant differences between the two interventions. Dysfunctional attitudes and decentering mediated treatment effects of depressive symptoms in both CBT and ACT, whereas experiential avoidance mediated treatment effects in ACT only.

CONCLUSIONS

Our results indicate that CBT is not more effective in treating depression than ACT. Both treatments seem to work through changes in dysfunctional attitudes and decentering, even though the treatments differ substantially. Change in experiential avoidance as an underlying mechanism seems to be an ACT-specific process. Further research is needed to investigate whether ACT and CBT may work differently for different groups of patients with depression.

TRIAL REGISTRATION

clinicaltrials.gov; NCT01517503 . Registered 25 January 2012 - Retrospectively registered.

Decentering, Acceptance, and Non-Attachment: Challenging the Question "Is It Me?"

Among mindfulness measures the three constructs acceptance, decentering, and non-attachment are psychometrically closely related, despite their apparent semantic differences. These three facets present robust psychometric features and can be considered core themes in most "third wave" clinical models. The aim of the present study was to explore the apparently different content domains (acceptance, decentering, and non-attachment) by administering various psychometric scales in a large sample of 608 volunteers. Resilience and depression were also assessed. Exploratory and confirmatory factor analyses performed in two randomly selected subsamples showed a bifactor approximation. The explained common variance suggested a unidimensional nature for the general factor, with good psychometric properties, which we named "Delusion of Me" (DoM). This construct is also strongly correlated with resilience and depression, and appears to be a solid latent general construct closely related to the concept of "ego." DoM emerges as a potentially transdiagnostic construct with influence on well-being and clinical indexes such as resilience and depression. Further studies should analyze the potential utility of this new construct at a therapeutic level.

A process-based approach to psychological diagnosis and treatment:The conceptual and treatment utility of an extended evolutionary meta model

For half a century, the dominant paradigm in psychotherapy research has been to develop syndrome-specific treatment protocols for hypothesized but unproved latent disease entities, as defined by psychiatric nosological systems. While this approach provided a common language for mental health problems, it failed to achieve its ultimate goal of conceptual and treatment utility. Process-based therapy (PBT) offers an alternative approach to understanding and treating psychological problems, and promoting human prosperity. PBT targets empirically established biopsychosocial processes of change that researchers have shown are functionally important to long terms goals and outcomes. By building on concepts of known clinical utility, and organizing them into coherent theoretical models, an idiographic, functional-analytic approach to diagnosis is within our grasp. We argue that a multi-dimensional, multi-level extended evolutionary meta-model (EEMM) provides consilience and a common language for process-based diagnosis. The EEMM applies the evolutionary concepts of context-appropriate variation, selection, and retention to key biopsychosocial dimensions and levels related to human suffering, problems, and positive functioning. The EEMM is a meta-model of diagnostic and intervention approaches that can accommodate any set of evidence-based change processes, regardless of the specific therapy orientation. In a preliminary way, it offers an idiographic, functional analytic, and clinically useful alternative to contemporary psychiatric nosological systems.

The buffering effect of attentional control on the relationship between cognitive fusion and anxiety

Cognitive fusion has been identified as a risk factor for anxiety. Evidence suggests that those with better attentional control may be able to flexibly shift attention from an internal to external focus, thus reducing contact with negative self-referent thoughts. As such, attentional control was examined as a moderator of the relation between cognitive fusion and anxiety in this two-part study. Adult participants (N = 597) completed self-report measures in Study 1. In Study 2, adult student participants (N = 173) completed self-report measures of cognitive fusion and anxiety, as well as behavioral measures that assessed three specific attentional control processes (i.e., inhibition, shifting, working memory updating). As predicted, attentional control moderated the relation between cognitive fusion and anxiety such that the strength of the relation decreased as attentional control increased. The results of Study 2 suggest that inhibitory ability is the attentional control process that accounts for this effect. Taken together, results suggest the possibility that attentional control (especially inhibitory ability) may be a protective factor against the development of anxiety among those with higher levels of cognitive fusion. The use of experimental and longitudinal study designs will be an important next step in this line of research to further clarify the nature of relations among cognitive fusion, attentional control, and anxiety. Results from an exploratory analysis, in which depressive symptoms served as the outcome variable, will also be discussed.

Development and Initial Validation of a Brief Questionnaire on the Patients' View of the In-Session Realization of the Six Core Components of Acceptance and Commitment Therapy

Background

Assessing in-session processes is important in psychotherapy research. The aim of the present study was to create and evaluate a short questionnaire capturing the patients' view of the in-session realization of the six core components of Acceptance and Commitment Therapy (ACT).

Method

In two studies, psychotherapy patients receiving ACT (Study 1: n = 87) or Cognitive-Behavioral Therapy (CBT) (Study 2, Sample 1: n = 115; Sample 2: n = 156) completed the ACT session questionnaire (ACT-SQ). Therapists were n = 9 ACT therapists (Study 1) and n = 77 CBT trainee therapists (Study 2).

Results

Factor structure: Exploratory factor analyses suggested a one-factor solution for the ACT-SQ. Reliability: Cronbach's alpha of the ACT-SQ was good (Study 1: α = .81; Study 2, Sample 1: α = .84; Sample 2: α = .88). Convergent validity: The ACT-SQ was positively correlated with validated psychotherapeutic change mechanisms (p < .05). Criterion validity: Higher ACT-SQ scores were associated with better treatment outcomes (p < .05).

Conclusion

The study provides preliminary evidence for the reliability and validity of the ACT-SQ to assess the in-session realization of the six core components of ACT in the patients' view. Further validation studies and ACT-SQ versions for therapists and observers are necessary.

Comparing the Efficacy of Defusion, Self-as-Context, and Distraction Strategies for Getting Rid of Possessions

Interventions for hoarding disorder need to target difficulty letting go of items to reduce clutter and improve functioning. The present studies were designed to test the efficacy of brief cognitive interventions for letting go of possessions and self-report outcomes. Participants (N = 67 in Study 1; N = 110 in Study 2) received training on defusion or distraction in Study 1 and defusion, self-as-context, or distraction in Study 2 and completed measures at pre- and postintervention. Study 1 found no differences between defusion and distraction on saving, self-rated discomfort with discarding, or perceived importance of the target belonging. In Study 2, participants provided most favorable feedback for self-as-context compared to defusion and distraction, indicating promise of this strategy. Nonetheless, findings from both studies overall provide minimal support for use of present procedures to reduce saving. Limitations include use of nonclinical samples and single-item variables to obtain participant feedback.

Are Processes in Acceptance & Commitment Therapy (ACT) Related to Chronic Pain Outcomes Within Individuals Over Time? An Exploratory Study Using n-of-1 Designs

Introduction

Acceptance & Commitment Therapy (ACT) explicitly postulates experiential avoidance (EA) and values-based living (VBL) as essential treatment processes. As outcomes from between-subject studies cannot readily be generalized to within-subject processes in individuals, we explored the unfolding of, and relationship between, EA and VBL and levels of pain interference in daily life and emotional well-being within individuals experiencing chronic pain.

Methods

Using n-of-1 designs, three participants following a multidisciplinary treatment program filled out a 12-item daily questionnaire (87-110 days). After multiple imputation of missing data, McKnight Time-series analysis procedures were performed for each participant separately. The interrelationships of EA, VBL and pain intensity, and the relationship of EA and VBL beyond pain intensity with both chronic pain outcomes were assessed both concurrently (same day) and prospectively (consecutive days).

Results

Both EA and VBL were associated with at least one of five outcome variables (four domains of pain interference and emotional well-being) beyond pain intensity in two participants, but not in the third participant. These associations primarily existed for concurrent, but not consecutive, days. In contrast to VBL, EA was not associated with emotional well-being for any of the three participants.

Conclusions

Although the finding that ACT-processes were associated with pain outcomes on concurrent days is consistent with ACT theory, the absence of such associations on consecutive days means that alternative explanations cannot be rule out. One possibility is that pain interference fluctuates within days at a higher variability rate than was currently assessed. Future research should consider using a higher measurement frequency to be able to grasp time-lagged effects.

Examining the Interrelation Among Change Processes: Decentering and Anticipatory Processing Across Cognitive Behavioral Therapy for Social Anxiety Disorder

As evidence grows supporting certain mechanisms of change in psychological treatments and we improve statistical approaches to measuring them, it is important that we also explore how mechanisms and processes are related to each other, and how they together affect treatment outcomes. To answer these questions about interrelating processes and mechanisms, we need to take advantage of frequent assessment and modeling techniques that allow for an examination of the influence of one mechanism on another over time. Within cognitive behavioral therapy, studies have shown support for both decentering, the ability to observe thoughts and feelings as objective events in the mind, and anticipatory processing, the repetitive thinking about upcoming social situations, as potentially related mechanisms of change. Therefore, the current study examined weekly ratings of decentering and a single-item anticipatory processing question to examine the interrelation among these change mechanisms in 59 individuals who received a 12-weeks of Cognitive Behavioral Group Therapy for social anxiety disorder. Overall, these results found that both anticipatory processing and decentering changed over the course therapy for clients. Change in both anticipatory processing and decentering was related to outcome. The bivariate latent difference score analysis showed that anticipatory processing was a leading indicator of change in decentering, but not the reverse, indicating that change in anticipatory processing is leading to change in decentering. It may be that with the focus on cognitive reappraisal in this treatment, that reducing anticipatory processing is freeing up the cognitive resources for decentering to occur.

Mechanisms and moderators in mindfulness- and acceptance-based treatments for binge eating spectrum disorders: A systematic review

OBJECTIVE

Increasing evidence suggests that mindfulness- and acceptance-based psychotherapies (MABTs) for bulimia nervosa (BN) and binge eating disorder (BED) may be efficacious; however, little is known about their active treatment components or for whom they may be most effective.

METHODS

We systematically identified clinical trials testing MABTs for BN or BED through PsychINFO and Google Scholar. Publications were categorized according to analyses of mechanisms of action and moderators of treatment outcome.

RESULTS

Thirty-nine publications met inclusion criteria. Twenty-seven included analyses of therapeutic mechanisms, and five examined moderators of treatment outcome. Changes were largely consistent with hypothesized mechanisms of MABTs, but substandard mediation analyses, inconsistent measurement tools, and infrequent use of mid-treatment assessment points limited our ability to make strong inferences.

DISCUSSION

Analyses of mechanisms of action and moderators of outcome in MABTs for BN and BED appear promising, but the use of more sophisticated statistical analyses and adequate replication is necessary.

Evaluating ACT Processes in Relation to Outcome in Self-Help Treatment for Anxiety-Related Problems

Evaluating how, for whom, and under what conditions psychosocial treatments work is an important component of anxiety disorder treatment development. Yet, research regarding mediators and moderators of self-help interventions is sparse. The current project is a secondary analysis of mediators, moderators, and correlates of outcome of a randomized wait-list-controlled trial assessing acceptance and commitment therapy (ACT) self-help bibliotherapy for anxiety and related problems. Participants (n = 503) were randomized to an immediate workbook (n = 256) or wait-list condition (n = 247). Nonparametric bootstrapped mediation analyses showed that pre-post positive changes in ACT treatment processes accounted for the relation between treatment and pre-post improvement on the primary outcomes of anxiety symptoms, depressive symptoms, and quality of life. Results indicated no baseline variables were significant moderators. Finally, hierarchical regression analyses indicated that the degree of improvement for each primary outcome was positively correlated with the degree to which participants reported applying the workbook material to their day-to-day life, over and above how much of the book they reported reading. This study provided support for the ACT model of change in a self-help context and highlighted the importance of actively applying self-help material, addressing theoretical and practical questions about how and why ACT self-help works.

Identifying COPD patients at risk for worse symptoms, HRQoL, and self-efficacy: A cluster analysis

OBJECTIVES

To identify clusters of chronic obstructive pulmonary disease (COPD) patients with distinct beliefs about their illness in terms of symptoms, health-related quality of life (HRQoL), self-efficacy, and daily life physical activity (DLPA).

METHODS

This cross-sectional study included 150 COPD outpatients. The patients' illness perceptions, clinical control, HRQoL, self-efficacy, and DLPA (accelerometry) were evaluated. A cluster analysis was conducted using data from the Illness Perceptions Questionnaire - Revised to establish groups of patients with distinct illness perceptions. Differences between clusters were tested using a T-test or a Mann-Whitney U test.

RESULTS

The cluster analysis revealed two groups: distressed ( n = 95) and coping ( n = 55). Despite the fact that both clusters presented similar pulmonary function, between-cluster differences were observed in their self-efficacy, dyspnea, HRQoL, clinical control ( p < 0.001), and educational level ( p = 0.002). The levels of DLPA did not differ between the clusters.

DISCUSSION

We observed that clinically stable COPD patients who displayed higher emotional representations and less coherence had heightened symptoms, poorer HRQoL, worse self-efficacy, and lower educational levels. These results emphasize the need to routinely evaluate illness perceptions in COPD patients to target and tailor the proper treatment to improve these important health outcomes.

Identifying the Underlying Mechanisms of Change During Acceptance and Commitment Therapy (ACT): A Systematic Review of Contemporary Mediation Studies

Background: Mediation studies test the mechanisms by which interventions produce clinical outcomes. Consistent positive mediation results have previously been evidenced (Hayes et al., 2006) for the putative processes that compromise the psychological flexibility model of acceptance and commitment therapy (ACT). Aims: The present review aimed to update and extend the ACT mediation evidence base by reviewing mediation studies published since the review of Hayes et al. (2006). Method: ACT mediation studies published between 2006 and 2015 were systematically collated, synthesized and quality assessed. Results: Twelve studies met inclusion criteria and findings were synthesized by (a) the putative processes under investigation, and (b) the outcomes on which processes were tested for mediation. Mediation results were found to be generally consistent with the psychological flexibility model of ACT. However, studies were limited in methodological quality and were overly focused on a small number of putative processes. Conclusions: Further research is required that addresses the identified methodological limitations and also examines currently under-researched putative processes.

Psychedelics and the new behaviourism: considering the integration of third-wave behaviour therapies with psychedelic-assisted therapy

This narrative review examines evidence related to the potential for third wave behaviour therapies to serve as adjuncts to psychedelic-assisted therapy. It identifies shared theoretical foundations for both approaches, and notes enhanced mindfulness, decentering, emotion regulation, and distress tolerance as common mechanisms of action. It also identifies potential targets for which both approaches have demonstrated therapeutic potential, including problematic substance use, self-directed and other-directed violence, and mood disorders. Based on these commonalities, there is a call for research on the potential integration of psychedelic-assisted therapy and third wave behaviour therapies including Dialectical Behaviour Therapy, Acceptance and Commitment Therapy, and Mindfulness Based Cognitive Therapy.

Patients' comprehension and skill usage as a putative mediator of change or an engaged target in cognitive therapy: Preliminary findings

BACKGROUND

The skills that patients learn in cognitive therapy (CT) and use thereafter may mediate improvement in depression during and after intervention.

METHOD

We used a sequential, three-stage design: acute phase (523 outpatients received 12-14 weeks of CT); 8-month experimental phase (responders at higher risk were randomized to continuation phases: C-CT, C-fluoxetine or C-pill placebo); and 24 months of longitudinal, post-treatment follow-up. Path analyses estimated mediation by skill measured by the Skills of Cognitive Therapy (SoCT: Patient and Observer [Therapist] versions).

RESULTS

Better SoCT scores predicted lower depressive symptoms both in CT and C-CT. In CT depressive symptoms did not predict subsequent changes in skills. During CT and C-CT, when averaged across patients and therapists, skills predicted subsequent decreases in depressive symptoms.

LIMITATIONS

Generalization of findings may be limited by the trial's methodology.

CONCLUSION

Further rigorous investigation of the role of patient CT skills stands to increase understanding of mediators of change or engaged targets in psychosocial intervention.

Psychometric properties of the Valued Living Questionnaire Adapted to Dementia Caregiving

OBJECTIVES

Caring for a relative with dementia is associated with physical and emotional health problems in caregivers. There are no studies analysing the role of personal values in the caregiver stress process. This study aims to analyse the psychometric properties of the Valued Living Questionnaire Adapted to Caregiving (VLQAC), and to explore the relationship between personal values and stressors, coping strategies and caregiver distress.

METHOD

A total of 253 individual interviews with caregivers of relatives with dementia were conducted, and the following variables were assessed: personal values, stressors, cognitive fusion, emotional acceptance, depression, anxiety, and satisfaction with life. An exploratory factor analysis and hierarchical regression analyses were carried out.

RESULTS

Two factors were obtained, Commitment to Own Values and Commitment to Family Values which explain 43.42% of variance, with reliability coefficients (Cronbach's alpha) of .76 and .61, respectively. Personal values had a significant effect on emotional distress (depression and anxiety) and satisfaction with life, even when controlling for socio-demographic variables, stressors and coping strategies.

CONCLUSION

Results suggest that the personal values construct of dementia caregivers is two-dimensional. The personal values of the caregivers play an important role in accounting for distress and satisfaction with life in this population.

Acceptance and commitment therapy universal prevention program for adolescents: a feasibility study

BACKGROUND

There is a need to prevent anxiety and depression in young people and mindfulness contains important emotion regulation strategies. Acceptance and commitment therapy (ACT), a mindfulness-based therapy, has yet to be evaluated as a prevention program, but has demonstrated an ability to reduce symptoms of anxiety and depression in adult and adolescent populations. This study examines the feasibility of using an ACT-based prevention program in a sample of year 10 (aged 14-16 years) high school students from Sydney, Australia.

METHODS

Participants were allocated to either their usual classes or to the ACT-based intervention. Participants were followed for a period of 5 months post-intervention and completed the Flourishing Scale, Depression Anxiety Stress Scale, and a program evaluation questionnaire. Analyses were completed using intention-to-treat mixed models for repeated measures.

RESULTS

The results indicated that the intervention was acceptable to students and feasible to administer in a school setting. There were no statistically significant differences between the conditions, likely due to the small sample size (N = 48). However, between-group effect sizes demonstrated small to large differences for baseline to post-intervention mean scores and medium to large differences for baseline to follow-up mean scores, all favouring the ACT-based condition.

CONCLUSION

The results suggest that an ACT-based school program has potential as a universal prevention program and merits further investigation in a larger trial. Trial registration Australian New Zealand Clinical Trials Registry. Trial ID: ACTRN12616001383459. Registered 06/10/2016. Retrospectively registered.

Intervening variables in group-based acceptance & commitment therapy for severe health anxiety

OBJECTIVE

The present study is based on a previously reported successful randomized controlled trial (RCT) on Acceptance and Commitment Group therapy (ACT-G) for severe health anxiety (HA) and investigates intervening variables of ACT for HA. The process primarily targeted by ACT is psychological flexibility (PF). No randomized study has yet examined the possible intervening variables of ACT for HA.

METHODS

126 patients diagnosed with severe HA were enrolled in the RCT of which 107 were included in the analyses. The outcome measure was illness worry (Whiteley Index) and included process variables were PF and facets of mindfulness.

RESULTS

Statistically significant indirect effects (IE) of ACT-G on the outcome of illness worry 6 months after treatment were found for PF (IE = -5.5, BCa 99% CI -12.3;-1.2) and one mindfulness subscale, namely 'non-react' (IE = -6.5 BCa 99% CI -15.3: 1.0).

CONCLUSION

In line with the ACT model of change, PF may have a small to moderate IE on decrease in illness worry. Of the mindfulness scales, only 'non-react' showed a significant IE. Although tentative, due to no active comparison control condition, these results support that PF is a intervening variable in ACT treatment aimed at reducing illness worry in patients with severe HA.

Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy

Since the introduction of Beck's cognitive theory of emotional disorders, and their treatment with psychotherapy, cognitive-behavioral approaches have become the most extensively researched psychological treatment for a wide variety of disorders. Despite this, the relative contribution of cognitive to behavioral approaches to treatment are poorly understood and the mechanistic role of cognitive change in therapy is widely debated. We critically review this literature, focusing on the mechanistic role of cognitive change across cognitive and behavioral therapies for depressive and anxiety disorders.

Reductions in experiential avoidance as a mediator of change in symptom outcome and quality of life in acceptance-based behavior therapy and applied relaxation for generalized anxiety disorder

As a field, we lack information about specific mechanisms that are responsible for changes that occur over the course of treatments for anxiety disorders (Kazdin, 2007). Identifying these mechanisms would help streamline evidence-based approaches, increase treatment response rates, and aid in the dissemination and implementation of evidence-based approaches in diverse contexts. The current study examined reductions in experiential avoidance (EA; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), attempts to control or eliminate distressing internal experiences, regardless of behavioral consequences, as a potential mechanism of change in participants with a principal diagnosis of generalized anxiety disorder (GAD) receiving either acceptance-based behavior therapy (ABBT) or applied relaxation (AR). Participants' EA scores across treatment on the Acceptance and Action Questionnaire (AAQ) were used to calculate slopes, which were used as predictors in a series of linear regressions. Greater change in EA across treatment significantly predicted change in worry (PSWQ) and quality of life (QOLI) across both treatments. These results contribute to the body of literature on common mechanisms of change across traditional CBTs and mindfulness and acceptance-based approaches.

Mechanisms of change in psychotherapy for depression: An empirical update and evaluation of research aimed at identifying psychological mediators

We present a systematic empirical update and critical evaluation of the current status of research aimed at identifying a variety of psychological mediators in various forms of psychotherapy for depression. We summarize study characteristics and results of 35 relevant studies, and discuss the extent to which these studies meet several important requirements for mechanism research. Our review indicates that in spite of increased attention for the topic, advances in theoretical consensus about necessities for mechanism research, and sophistication of study designs, research in this field is still heterogeneous and unsatisfactory in methodological respect. Probably the biggest challenge in the field is demonstrating the causal relation between change in the mediator and change in depressive symptoms. The field would benefit from a further refinement of research methods to identify processes of therapeutic change. Recommendations for future research are discussed. However, even in the most optimal research designs, explaining psychotherapeutic change remains a challenge. Psychotherapy is a multi-dimensional phenomenon that might work through interplay of multiple mechanisms at several levels. As a result, it might be too complex to be explained in relatively simple causal models of psychological change.

The Mindful Way Through the Semester: Evaluating the Impact of Integrating an Acceptance-Based Behavioral Program Into a First-Year Experience Course for Undergraduates

Preventing and reducing depression in first-year college students are crucial areas in need of attention and resources. Programs that are cost-effective and time-efficient, that have replicable benefits across samples, are sorely needed. This study aims to examine whether a previously studied acceptance-based behavioral (ABBT) program, the Mindful Way Through the Semester (MWTS), is effective in comparison to a control condition at decreasing levels of depression and enhancing acceptance and academic values when integrated into a first-year undergraduate experience course. The current study also sought to examine the association between change in acceptance, mindfulness practice, and values practice on outcomes. Two hundred thirteen students were assigned to either the MWTS workshop condition or the control condition (in which the first-year experience curriculum as usual was received). Results revealed that the workshop condition produced larger decreases in depression over the course of the semester relative to the control condition, but only for participants endorsing higher levels of depression at baseline. Further, for participants in the workshop condition, changes in depression were negatively associated with changes in acceptance (i.e., larger increases in acceptance associated with larger decreases in depression), an association that was not statistically significant in the control group. Lastly, for participants in the workshop condition who endorsed higher levels of depression at baseline, mindfulness and values practice was associated with greater reductions in depression. Implications of these findings for future interventions are discussed.

Evaluating the Effectiveness of ACT for Anxiety Disorders in a Self-Help Context: Outcomes From a Randomized Wait-List Controlled Trial

Rigorous evaluations of cognitive behavioral self-help books for anxiety in pure self-help contexts are lacking. The present study evaluated the effectiveness of an Acceptance and Commitment Therapy (ACT) self-help workbook for anxiety-related concerns, with no therapist contact, in an international sample. Participants (N=503; 94% mental health diagnosis) were randomized to an immediate workbook (n=256) or wait-list condition (n=247). Assessments at pretreatment, 12weeks, 6months, and 9months evaluated anxiety and related symptoms, quality of life, and ACT treatment processes (e.g., psychological flexibility). Participants in the wait-list arm crossed over to the workbook following the 12-week assessment. The workbook condition yielded significant improvements on all assessments from pre- to posttreatment relative to wait-list, and these gains were maintained at follow-ups. The pattern observed in the wait-list condition was virtually identical to the active treatment arm after receiving the workbook, but not before. Attrition was notable, but supplemental analyses suggested dropout did not influence treatment effects for all but one measure. Overall, findings provide preliminary support for the effectiveness of this self-help workbook and suggest ACT-based self-help bibliotherapy might be a promising low-cost intervention for people experiencing significant anxiety-related concerns.

How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms

BACKGROUND

Acceptance and Commitment Therapy (ACT) has been demonstrated to be effective in reducing depressive symptoms. However, little is known how and for whom therapeutic change occurs, specifically in web-based interventions. This study focuses on the mediators, moderators and predictors of change during a web-based ACT intervention.

METHODS

Data from 236 adults from the general population with mild to moderate depressive symptoms, randomized to either web-based ACT (n = 82) or one of two control conditions (web-based Expressive Writing (EW; n = 67) and a waiting list (n = 87)), were analysed. Single and multiple mediation analyses, and exploratory linear regression analyses were performed using PROCESS and linear regression analyses, to examine mediators, moderators and predictors on pre- to post- and follow-up treatment change of depressive symptoms.

RESULTS

The treatment effect of ACT versus the waiting list was mediated by psychological flexibility and two mindfulness facets. The treatment effect of ACT versus EW was not significantly mediated. The moderator analyses demonstrated that the effects of web-based ACT did not vary according to baseline patient characteristics when compared to both control groups. However, higher baseline depressive symptoms and positive mental health and lower baseline anxiety were identified as predictors of outcome across all conditions. Similar results are found for follow-up.

CONCLUSIONS

The findings of this study corroborate the evidence that psychological flexibility and mindfulness are distinct process mechanisms that mediate the effects of web-based ACT intervention. The results indicate that there are no restrictions to the allocation of web-based ACT intervention and that web-based ACT can work for different subpopulations.

TRIAL REGISTRATION

Netherlands Trial Register NTR2736 . Registered 6 February 2011.