Acceptance and commitment therapy as a treatment for anxiety and depression: A review.

Acceptance and commitment therapy (ACT) is a modern form of cognitive behavioral therapy based on a distinct philosophy (functional contextualism) and basic science of cognition (relational frame theory). This article reviews the core features of ACT’s theoretical model of psychopathology and treatment as well as its therapeutic approach. It then provides a systematic review of randomized controlled trials (RCTs) evaluating ACT for depression and anxiety disorders. Summarizing across a total of 36 RCTs, ACT appears to be more efficacious than waitlist conditions and treatment-as-usual, with largely equivalent effects relative to traditional cognitive behavioral therapy. Evidence from several trials also indicate that ACT treatment outcomes are mediated through increases in psychological flexibility, its theorized process of change. Acceptance and commitment therapy (ACT)1 is part of a larger research approach called Contextual Behavioral Sciences (CBS). Those with a CBS focus to their work generally adhere to a behavior-analytic theoretical orientation, and as such have a strong interest in the basic science that informs the techniques used in therapy. Behavior analysis traditionally focused on the use or contingency management procedures to modify overt actions, and did not have a conceptualization of the role of cognition other than it being another form of behavior that was reinforced by the verbal community.2 This differs from CBS in that, the most active line of basic research is a behavioral account of language and cognition called relational frame theory (RFT).3 RFT has been an active line of research since the 1970’s when it was called stimulus equivalence.4 Since that time, RFT research has expanded and provides a method to study language and cognition, and inform behavioral interventions. To put it simply, ACT as described in this paper, is modern behavior analysis applied to clinical issues including anxiety and depression. This manuscript will review the foundations of ACT, its theoretical model of psychopathology and treatment, and the empirical evidence for ACT as a treatment of anxiety and depressive disorders

Examining Processes of Change in an Online Acceptance and Commitment Therapy Dismantling Trial with Distressed College Students

This secondary analysis examined the processes of change from a randomized dismantling trial evaluating the Open (i.e., cognitive defusion, acceptance) and Engaged (i.e., values, committed action) components of acceptance and commitment therapy (ACT). Analyses were conducted with 161 distressed college students randomly assigned to a full online ACT program (Full n=40), online ACT targeting the Open components (Open n=41) or targeting the Engaged components (Engaged n=39), or a waitlist condition (Waitlist n=41). The intervention occurred over six weeks followed by a post-treatment assessment with mental health symptoms as the primary outcome. Consistent with predictions, pre- to post-treatment improvements in global psychological inflexibility, cognitive fusion, acceptance, values, and committed action all predicted pre- to post-treatment improvements in mental health, with most processes continuing to independently predict improvements when included in a single model. The relations between changes in psychological flexibility and mental health were generally equivalent between conditions. Each psychological flexibility process separately mediated improvements in mental health for Engaged versus waitlist and Full versus waitlist conditions. However, global inflexibility, committed action, and values progress did not mediate effects for Open versus waitlist. Overall, results indicate a range of acceptance, defusion, values, and committed action processes are functionally relevant for outcomes with the Engaged components of ACT and Full ACT, but values, committed action, and global psychological inflexibility processes may be more weakly related to the effects of the Open components of ACT alone

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

Background: Self-help resources such as books may help meet critical mental health needs in college students, but there is insufficient evidence on whether and how such books work. This randomized trial compared acceptance and commitment therapy (ACT) and traditional cognitive behavior therapy (tCBT) self-help books for social anxiety, a common concern with notable barriers to treatment seeking. Methods: A sample of college students (n = 102) with social anxiety was randomly assigned to use one of the two self-help books over eight weeks. Results: Improvements were observed in both conditions across all outcomes (social anxiety, general well-being, and social functioning) as well as potential processes of change (cognitive fusion, appraisals of social concerns, and progress toward personal values). Few differences were observed between conditions. Changes in general cognitive fusion consistently predicted outcomes at posttreatment, and anxiety-specific cognitive fusion and concern about negative social interactions also predicted some later outcomes. Conclusions: Use of self-help books to address social anxiety in college students is promising, and addressing cognitive fusion appears to be important

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

Beyond Acceptance and Commitment Therapy: Process-Based Therapy

This article describes process-based therapy (PBT) as a natural evolution toward more effective and efficient mental healthcare. Using acceptance and commitment therapy as an example of an early prototype of PBT, this paper explicates the broader features of PBT and the shift in mindset researchers and clinicians will need to take to fully embrace PBT with respect to assessment, conceptualization, and intervention. In addition, the paper enumerates challenges to implementing the PBT model and proposes recommendations for circumventing these challenges in the areas of theory development, research methodology, and clinical practice. Finally, we make the argument shifting to PBT is the logical next step for our field

Evaluating the Effects of Guided Coaching Calls on Engagement and Outcomes for Online Acceptance and Commitment Therapy

Previous research indicates mixed results for guided support with interventions. The current secondary analysis evaluated the effects of phone coaching from a dismantling trial of online acceptance and commitment therapy (ACT) in a sample of 136 distressed college students randomized to one of three versions of an ACT website. Participants were randomized to receive email prompts alone (non-coaching condition) or email plus phone coaching (coaching condition). Results indicated no differences between the coaching and non-coaching conditions on program engagement, program satisfaction, mental health outcomes, and almost all psychological flexibility processes. However, participants in the coaching condition reported stronger pre- to posttreatment improvements in psychological inflexibility than the non-coaching condition. This effect was moderated by ACT component condition, with larger pre- to posttreatment effects from coaching on psychological inflexibility in the values/committed action condition and weaker improvements from coaching in the acceptance/defusion condition. Overall, results indicate online self-guided ACT interventions with email prompts are sufficient for addressing college student mental health and that phone coaching provided minimal additional benefit

Comparing Cognitive Defusion and Cognitive Restructuring Delivered Through a Mobile App for Individuals High in Self-Criticism

There are ongoing questions regarding the similarities and differences in the clinical impact and processes of change for cognitive restructuring and cognitive defusion. This clinical component test compared 87 adults high in self-criticism randomized to a cognitive defusion mobile app, restructuring app, or waitlist condition for two weeks. Equivalent improvements were found from the defusion and restructuring apps relative to the waitlist in self-criticism and distress as well as decentering, self-compassion, and dysfunctional attitudes. However, the defusion condition had a more consistent pattern of improvements relative to waitlist. Improvements in cognitive decentering, self-compassion, and dysfunctional attitudes mediated effects for cognitive defusion relative to waitlist. These mediators were inconsistent for cognitive restructuring. Improvements in self-compassion and cognitive decentering correlated with improvements in outcomes in the defusion condition, but not the restructuring condition. Overall, these results suggest mobile apps providing cognitive defusion and cognitive restructuring strategies are equally effective, but work through distinct processes of change

Does a Brief Mindfulness Training Enhance Heartfulness in Students? Results of a Pilot Study

(1) Background: There is robust evidence that mindfulness trainings enhance mindfulness as operationalized in Western psychology, but evidence about their effect on aspects of heartfulness is sparse. This study seeks to test whether a brief mindfulness training enhances heart qualities, including self-compassion, gratitude, and the generation of feelings of happiness. (2) Methods: Eighteen students enrolled in a mindfulness training that was offered as part of an interdisciplinary class. The training consisted of five training sessions and four booster sessions of 45 minutes each over the course of nine weeks. Mindfulness was measured with the Five Facet Mindfulness Questionnaire-Short Form (FFMQ-SF) and self-compassion was measured with the Self-Compassion Scale Short Form (SCS-SF). In addition, two items were drawn from the Caring for Bliss Scale (CBS) measuring gratitude and the generation of feelings of happiness in the present moment. Assessments were conducted before the training (pre), after the training (post), and four weeks after the training (follow-up). (3) Results: Results showed that mindfulness, general self-compassion, and generating feelings of happiness increased from pre to post, whereas self-critical attitudes decreased and that these changes were maintained at follow-up. Gratitude increased from pre to post and then decreased from post to follow-up. (4) Conclusions: A brief mindfulness training seems to be beneficial for students to improve mindfulness and aspects of heartfulness, but further research is needed to investigate the effectiveness of the training relative to a cohort or active control group

Psychological inflexibility and stigma: A meta-analytic review

Stigma is known to have major impacts on the physical and psychological health of many groups. Psychological inflexibility is a psychological process that may help explain the impact of stigma on both self and others. Accordingly, acceptance and commitment therapy (ACT), which targets psychological inflexibility, has been researched as a potential treatment for stigma. In order to provide a comprehensive overview of these issues, this paper offers a systematic review and meta-analysis of the association between psychological inflexibility and stigma, as well as a systematic review of ACT interventions for stigma. The results of the meta-analysis showed a positive, medium-to-large association between psychological inflexibility and stigma measures aggregating across 16 studies. The systematic review of interventions identified 15 studies on ACT interventions for stigma. Initial findings indicate consistent reductions in stigma following ACT interventions, as well as improved outcomes relative to active controls. Data on mediation and moderation, as well as long-term outcomes, are also presented. Implications for conceptualizing and treating stigma, and limitations of the research, are discussed

An Examination of The Transdiagnostic Role of Delay Discounting in Psychological Inflexibility and Mental Health Problems

Delay discounting is a basic behavioral process that has been found to predict addictive behaviors, and more recently, other mental health problems. Acceptance and Commitment Therapy (ACT), is a transdiagnostic treatment that appears to alter delay discounting, possibly through reducing psychological inflexibility. The current study sought to further bridge research on delay discounting and ACT by examining the relation of delay discounting to a broad range of selfreported mental health problems and measures of psychological inflexibility. A cross sectional online survey was conducted with 389 college students. Small negative correlations ranging between .09 and .15 were statistically significant between delay discounting and self-reported depression, anxiety, eating concerns, hostility, academic distress, and student functioning (only general social functioning and social anxiety were non-significant). Similar negative correlations were also found between delay discounting and measures of psychological inflexibility. Psychological inflexibility statistically mediated all of the relations between delay discounting and mental health problems such that delay discounting was no longer related to mental health problems when including the mediator. Overall, these results suggest that delay discounting is a transdiagnostic process relevant to a range of mental health problems, potentially through its impact on psychological inflexibility