Randomized controlled trial of acceptance and commitment therapy versus traditional cognitive behavior therapy for social anxiety disorder: Symptomatic and behavioral outcomes

Symptom distress and psychosocial functioning improve bidirectionally during cognitive-behavioral therapy for anxiety disorders

The efficacy of cognitive-behavioral therapy (CBT) for reducing anxiety disorder symptoms is well documented. However, limited research has investigated how symptom amelioration is temporally associated with changes in psychosocial functioning, such as interpersonal and social role functioning, during CBT. Participants were 288 (M age = 37.00 [SD = 14.41]; 59.0% female; 69.0% White; 6.6% Hispanic/Latino) outpatients diagnosed with an anxiety disorder who received CBT at a specialized hospital-based clinic. Participants completed the Outcome Questionnaire-45, a measure of symptom distress, social role performance, and interpersonal problems, at initial assessment and prior to each treatment session. Symptom distress and indicators of psychosocial functioning were robustly related during 25 sessions of CBT. Cross-lagged analyses revealed that reductions in symptom distress predicted subsequent improvements in psychosocial functioning during treatment, and vice versa. Associations from symptom distress to subsequent psychosocial functioning evidenced larger effect sizes than the reverse. Lower levels of severity at intake and presence of comorbid depression attenuated the association between symptom reduction and subsequent social role performance improvement. In sum, anxiety symptoms and psychosocial functioning bidirectionally improve during CBT for anxiety disorders. Maximally effective treatments may be those that simultaneously ameliorate symptoms and focus on improving functioning in key domains.

The Idionomic Future of Cognitive Behavioral Therapy: What Stands Out From Criticisms of ACT Development

The present special section critical of Acceptance and Commitment Therapy or Training (ACT in either case) and its basis in psychological flexibility, relational frame theory, functional contextualism, and contextual behavioral science (CBS) contains both worthwhile criticisms and fundamental misunderstandings. Noting the important historical role that behavior analysis has played in the cognitive behavioral therapy (CBT) tradition, we argue that CBS as a modern face of behavior analytic thinking has a potentially important positive role to play in CBT going forward. We clarify functional contextualism and its link to ethical behavior, attempting to clear up misunderstandings that could seriously undermine genuine scientific conversations. We then examine the limits of using syndromes and protocols as a basis for further developing models and methods; the role of measurement and processes of change in driving progress toward more personalized interventions; how pragmatically useful concepts can help basic science inform practice; how both small- and large-scale studies can contribute to scientific progress; and how all these strands can be pulled together to benefit humanity. In each area, we argue that further progress will require major modifications in our traditional approaches to such areas as psychometrics, the conduct of randomized trials, the analysis of findings using traditional normative statistics, and the use of data from diverse cultures and marginalized populations. There have been multiple generational shifts in our field's history, and a similar shift appears to be taking place once again.

The illusion of inclusion: contextual behavioral science and the Black community

Anti-racism approaches require an honest examination of cause, impact, and committed action to change, despite discomfort and without experiential avoidance. While contextual behavioral science (CBS) and third wave cognitive-behavioral modalities demonstrate efficacy among samples composed of primarily White individuals, data regarding their efficacy with people of color, and Black Americans in particular, is lacking. It is important to consider the possible effects of racial stress and trauma on Black clients, and to tailor approaches and techniques grounded in CBS accordingly. We describe how CBS has not done enough to address the needs of Black American communities, using Acceptance and Commitment Therapy (ACT) and Functional Analytic Psychotherapy (FAP) as examples. We also provide examples at the level of research representation, organizational practices, and personal experiences to illuminate covert racist policy tools that maintain inequities. Towards eradicating existing racism in the field, we conclude with suggestions for researchers and leadership in professional psychological organizations.

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.

Please Don’t Compliment Me! Fear of Positive Evaluation and Emotion Regulation—Implications for Adolescents’ Social Anxiety

In recent years, fear of positive evaluation has emerged as one of the key aspects of social anxiety, alongside fear of negative evaluation. Fears of evaluation intensify during adolescence, a time when individuals are expected to navigate new, emotionally challenging situations. The purpose of this study was to examine the associations between social anxiety, fear of positive and negative evaluation, and three emotion regulation strategies relevant to social anxiety, i.e., suppression, acceptance, and rumination. To this end, data were collected from 647 adolescents via an online survey and analyzed using structural equation modeling. We found that fear of negative evaluation was significantly related to rumination, whereas fear of positive evaluation was significantly and negatively related to acceptance. We further found an indirect effect of social anxiety on suppression via fear of positive evaluation and acceptance in a serial mediation and an indirect effect of social anxiety on rumination via fear of negative evaluation. Not only do fears of positive and negative evaluation appear to be distinct constructs, but they are also differentially associated with three emotion regulation strategies pertinent to social anxiety. Fear of evaluation and its associations with emotion regulation deficits might hinder the therapeutic process by acting as a deterrent to positive reinforcement or potentially impeding the development of a successful therapeutic alliance.

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.

A systematic review and meta-analysis of acceptance- and mindfulness-based interventions for DSM-5 anxiety disorders

This meta-analysis systematically reviewed the evidence on standardized acceptance-/mindfulness-based interventions in DSM-5 anxiety disorders. Randomized controlled trials examining Acceptance and Commitment Therapy (ACT), Mindfulness-Based Cognitive Therapy (MBCT), and Mindfulness-Based Stress Reduction (MBSR) were searched via PubMed, Central, PsycInfo, and Scopus until June 2021. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for primary outcomes (anxiety) and secondary ones (depression and quality of life). Risk of bias was assessed using the Cochrane tool. We found 23 studies, mostly of unclear risk of bias, including 1815 adults with different DSM-5 anxiety disorders. ACT, MBCT and MBSR led to short-term effects on clinician- and patient-rated anxiety in addition to treatment as usual (TAU) versus TAU alone. In comparison to Cognitive Behavioral Therapy (CBT), ACT and MBCT showed comparable effects on both anxiety outcomes, while MBSR showed significantly lower effects. Analyses up to 6 and 12 months did not reveal significant differences compared to TAU or CBT. Effects on depression and quality of life showed similar trends. Statistical heterogeneity was moderate to considerable. Adverse events were reported insufficiently. The evidence suggests short-term anxiolytic effects of acceptance- and mindfulness-based interventions. Specific treatment effects exceeding those of placebo mechanisms remain unclear. Protocol registry: Registered at Prospero on November 3rd, 2017 (CRD42017076810).

Acceptance and commitment therapy in adult cancer survivors: a systematic review and conceptual model

PURPOSE

People with cancer experience significant physical and psychological symptoms, during as well as after primary treatment. Acceptance and Commitment Therapy (ACT), a psychological intervention, reduces both types of symptoms among individuals with chronic pain and emotional distress. Due to the unique challenges of cancer survivorship, this systematic review critically evaluates and synthesizes the literature on the context, mechanisms, and effect of ACT among adult cancer survivors.

METHODS

Articles were retrieved from the CINAHL, MEDLINE via Ovid, Web of Science, PsycInfo, Scopus, Embase, Google Scholar, and Cochrane databases. Selected grey literature portals, clinical trial registries, and conference proceedings were also searched. The NIH tools were used to assess study quality and the revised Cochrane Risk-of-Bias tool to assess risk of bias RESULTS: Thirteen articles, reporting on 537 cancer survivors with various cancer types, were included. ACT significantly reduced anxiety, depression, and fear of cancer recurrence and improved psychological flexibility and quality of life. Outcomes such as pain and insomnia were understudied. Lack of participant blinding and non-random assignment were the most common methodological issues. A conceptual model is proposed that describes the possible influencing factors of an ACT-based intervention in cancer survivors.

CONCLUSION

Review findings suggest that ACT is an effective intervention to improve some of the common concerns among cancer survivors. While all the studies in the review were recent (published 2015-2019), they examined only a limited number of outcomes. Hence, more methodologically rigorous studies which examine the effect of ACT on other troubling symptoms among cancer survivors are warranted.

IMPLICATIONS FOR CANCER SURVIVORS

Incorporating ACT into comprehensive post-treatment survivorship care can enhance psychological flexibility and reduce anxiety, depression, and fear.

Correlates of Quality of Life in Anxiety Disorders: Review of Recent Research

PURPOSE OF REVIEW

Anxiety disorders are highly prevalent conditions that have a detrimental impact on quality of life (QOL), particularly when left untreated. In the present review, we summarize recent literature, published within the last 3 years, on QOL in anxiety disorders, with a focus on factors that may play a role in the relationship between anxiety and QOL.

RECENT FINDINGS

We organize our findings into four categories: (1) subjective distress, (2) behavioral responses, (3) functional impairment, and (4) clinical factors. Results indicate that greater anxiety symptom severity is linked with poorer QOL, and cognitive behavioral therapies for anxiety yield positive effects on QOL. Additional transdiagnostic mechanisms are highlighted, including anxiety sensitivity, distress tolerance, emotion regulation, and avoidant coping. We examine the role of functional impairment, and we discuss factors related to treatment, including comorbidity and longitudinal effects. We also consider early research from the COVID-19 pandemic. Understanding the underlying factors that contribute to QOL detriments provides important insight into the impact of anxiety disorders and identifies targets for enhancing QOL through treatment.

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.

Piloting a New Model for Treating Music Performance Anxiety: Training a Singing Teacher to Use Acceptance and Commitment Coaching With a Student

Thus far, treatments for music performance anxiety (MPA) have focused primarily on interventions administered by psychologists and mental health clinicians with training and education in psychotherapy. While these interventions are promising or even efficacious, many musicians prefer not to work with a psychotherapist due to stigma and lack of time/access. Student musicians are particularly vulnerable to developing MPA, and while they may prefer consulting with their teachers about MPA over psychotherapists, many teachers feel unqualified to help. Here, we investigated an alternative intervention model, in which a clinical psychologist with MPA expertise trained a singing teacher with no training or education in psychotherapy to use an evidence-based coaching model, Acceptance and Commitment Coaching (ACC), with a student vocalist with problematic MPA, in a single-subject design format. ACC is a version of Acceptance and Commitment Therapy (ACT) that has been used under various names with non-clinical populations to help enhance psychological flexibility, e.g., with athletes, at the workplace, with undergraduates, and others. The teacher received approximately seven hours of ACC training via Skype. In turn, she provided six one-hour ACC sessions to a university student vocalist. Materials for the training and coaching sessions were taken from an ACC book and an ACT-based self-help book for musicians, and the teacher also adhered to a GROW model of coaching. The student made clinically significant improvements in two ACT-based processes believed to correlate with improved psychological flexibility in previous ACT for MPA psychotherapy research, i.e., acceptance of MPA-related discomfort and defusion from MPA-related thoughts. The student also reported a significant shift had occurred in his thinking: he became more willing to have his MPA, and so he volunteered to sing in classes early in the upcoming semester, and he auditioned for & won a lead role in a musical, both of which he previously avoided doing. ACC appears to be a promising MPA intervention that can be administered by a music teacher without training or education in psychotherapy, and it may help schools who do not employ psychologists and are therefore unable to follow best practice guidelines for treating MPA.

Typical symptom change patterns and their predictors in patients with social anxiety disorder: A latent class analysis

OBJECTIVES

The use of trajectories and analysis of change patterns is a promising way toward better differentiation of subgroups in psychotherapy studies. Research on change patterns in social anxiety disorder (SAD) are still rare, although SAD is one of the most common mental disorders. In a secondary analysis of data from the SOPHO-NET-trial (ISRCTN53517394) this study aimed to investigate change patterns and their predictors in a sample of SAD patients.

METHODS

Patients with SAD (N = 357) were randomly assigned to cognitive-behavioral or psychodynamic therapy. The Liebowitz Social Anxiety Scale (LSAS) was assessed at 1^st session (pre), 8th session, 15th session and at the end of treatment (post). We used latent state variables and latent class analysis for the classification of change patterns and logistic regression for the identification of different predictors.

RESULTS

Analyses revealed three typical patterns: (i.) responders with a high initial impairment (N = 57), (ii.) responders with a moderate initial impairment (N = 225), and (iii.) patients with a high initial impairment and no remission (N = 75). Among other significant predicators, patient´s attachment anxiety and therapeutic alliance at session eight contributed to the prediction of change patterns.

DISCUSSION

Psychotherapy of SAD should consider patient's attachment and focus on the establishment of a solid therapeutic alliance in an early therapy stage.