A Randomized Trial of Acceptance and Commitment Therapy and Traditional Cognitive-Behavioral Therapy Self-Help Books for Social Anxiety

Examining processes of change for acceptance and commitment therapy and cognitive behavioral therapy self-help books with depressed college students

Given the prevalence of depression, it is worthwhile to consider a variety of treatment approaches to reach as many sufferers as possible, including highly accessible formats such as self-help books. Books based in acceptance and commitment therapy (ACT) and cognitive behavioral therapy (CBT) propose to treat depression through distinct processes of change, though the degree to which these treatments are distinguishable in this format is unclear. Furthermore, it is possible that some individuals may respond better to therapeutic processes from one approach over the other based on personal preferences. We tested the effects of ACT and CBT self-help books on processes of change in a sample of 139 depressed college students in which some participants were given a choice of treatment and others were randomized. Cognitive fusion, which improved better in the ACT group, was the only process of change that distinguished the two treatments. Additionally, early improvements in cognitive fusion were associated with less depression-related stigma at posttreatment. Lastly, randomization, instead of choosing a treatment, led to greater improvements in almost all processes of change. We discuss how these findings inform personalized care, tangible differences between ACT and CBT, and effective practices for treating depression at large scale.

Choosing ACT or CBT: A preliminary test of incorporating client preferences for depression treatment with college students

BACKGROUND

Depression is a significant concern among college students, who suffer at higher rates and with greater severity than the general population. Online self-help could reduce the burden currently placed on college counseling centers, and programs based in cognitive behavioral therapies (CBTs) have a strong evidence base. However, online CBTs for depression often suffer from low adherence rates. An understudied method for improving adherence in this population is offering students a choice between various CBTs.

METHODS

We conducted a randomized trial with 142 students with high levels of depression, with a subset of participants randomly receiving either traditional cognitive behavioral therapy (tCBT) or acceptance and commitment therapy (ACT) and an additional arm who could choose between the two.

RESULTS

Both treatments effectively reduced depression over 10 weeks, with ACT showing a slight advantage over tCBT. Surprisingly, students who were randomized to their treatment saw greater reductions in anxiety, and higher adherence to the program, than those who chose between the two.

LIMITATIONS

Our study suffered from a notable amount of dropout and our results should be considered preliminary. Our sample size was relatively small at posttreatment, limiting our ability to make strong conclusions about group differences. Additionally, further steps could have been taken to minimize the risk of bias when presenting treatment options to the choice group.

CONCLUSIONS

Our preliminary results suggest that simply providing students with an evidence-based resource may be more important than providing options and raise additional questions about the function of client preference in self-help dissemination.

Acceptance and Commitment Coaching for Music Performance Anxiety: Piloting a 6-Week Group Course With Undergraduate Dance and Musical Theatre Students

Treatments for students with problematic levels of music performance anxiety (MPA) commonly rely on approaches in which students are referred to psychotherapists or other clinical professionals for individual care that falls outside of their music training experience. However, a more transdisciplinary approach in which MPA treatment is effectively integrated into students' training in music/performing arts colleges by teachers who work in consultation with clinical psychologists may prove more beneficial, given the resistance students often experience toward psychotherapy. Training singing teachers, and perhaps music teachers at large, to use an evidence-based coaching strategy like Acceptance and Commitment Coaching (ACC) to directly manage students' MPA is one such approach. Building on the work of a previous study in which ACC was administered by a singing teacher to a musical theatre student with problematic MPA, we piloted the effectiveness of a six-session, group ACC course for a sample of performing arts students (N = 6) with MPA related to vocal performances, using a mixed-methods design. The coach here was also a singing teacher without a clinical background, and her training in ACC by a clinical psychologist was of a similar duration (8 h) as the previous teacher's (7 h). Similar to the musical theatre student, the students reported being significantly less fused with their MPA-related cognitions, more accepting of their MPA-related physiological symptoms, and more psychologically flexible while performing in general, and these improvements were maintained after 3 months. Furthermore, they appeared to lower their shame over having MPA and change how they thought in relation to one another. Of note, these improvements were similar to those shown by seven vocal students with MPA after they received Acceptance and Commitment Therapy from a clinical psychologist, but with larger reductions in shame and better acceptance of MPA, which suggests a non-clinical, group ACC intervention that includes supportive discussions to normalize MPA and challenges attempts to control it may be more helpful than individual psychotherapy. These results are promising and indicate a brief training in ACC (<10 h) may be sufficient for singing teachers to provide significant benefit for students with problematic MPA.

An Acceptance and Commitment Therapy Prototype Mobile Program for Individuals With a Visible Difference: Mixed Methods Feasibility Study

Background

Mobile apps may offer a valuable platform for delivering evidence-based psychological interventions for individuals with atypical appearances, or visible differences, who experience psychosocial appearance concerns such as appearance-based social anxiety and body dissatisfaction. Before this study, researchers and stakeholders collaboratively designed an app prototype based on acceptance and commitment therapy (ACT), an evidence-based form of cognitive behavioral therapy that uses strategies such as mindfulness, clarification of personal values, and value-based goal setting. The intervention also included social skills training, an established approach for increasing individuals’ confidence in managing social interactions, which evoke appearance-based anxiety for many.

Objective

In this study, the authors aim to evaluate the feasibility of an ACT-based app prototype via the primary objectives of user engagement and acceptability and the secondary feasibility objective of clinical safety and preliminary effectiveness.

Methods

To address the feasibility objectives, the authors used a single-group intervention design with mixed methods in a group of 36 participants who have a range of visible differences. The authors collected quantitative data via measures of program use, satisfaction ratings, and changes over 3 time points spanning 12 weeks in outcomes, including selected ACT process measures (experiential avoidance, cognitive defusion, and valued action), scales of appearance concerns (appearance-based life disengagement, appearance-fixing behaviors, appearance self-evaluation, and fear of negative appearance evaluation), and clinical well-being (depression and anxiety). Semistructured exit interviews with a subsample of 12 participants provided qualitative data to give a more in-depth understanding of participants’ views and experiences of the program.

Results

In terms of user engagement, adherence rates over 6 sessions aligned with the upper boundary of those reported across mobile mental health apps, with over one-third of participants completing all sessions over 12 weeks, during which a steady decline in adherence was observed. Time spent on sessions matched design intentions, and engagement frequencies highlighted semiregular mindfulness practice, mixed use of value-based goal setting, and high engagement with social skills training. The findings indicate a good overall level of program acceptability via satisfaction ratings, and qualitative interview findings offer positive feedback as well as valuable directions for revisions. Overall, testing for clinical safety and potential effectiveness showed encouraging changes over time, including favorable changes in appearance-related life disengagement, appearance-fixing behaviors, and selected ACT measures. No iatrogenic effects were indicated for depression or anxiety.

Conclusions

An ACT-based mobile program for individuals struggling with visible differences shows promising proof of concept in addressing appearance concerns, although further revisions and development are required before further development and more rigorous evaluation.