Experiential avoidance as a mechanism of change across cognitive-behavioral therapy in a sample of participants with heterogeneous anxiety disorders

Despite the substantial evidence that supports the efficacy of cognitive-behavioral therapy for the treatment of anxiety and related disorders, our understanding of mechanisms of change throughout treatment remains limited. The goal of the current study was to examine changes in experiential avoidance across treatment in a sample of participants (N = 179) with heterogeneous anxiety disorders receiving various cognitive-behavioral therapy protocols. Univariate latent growth curve models were conducted to examine change in experiential avoidance across treatment, followed by parallel process latent growth curve models to examine the relationship between change in experiential avoidance and change in anxiety symptoms. Finally, bivariate latent difference score models were conducted to examine the temporal precedence of change in experiential avoidance and change in anxiety. Results indicated that there were significant reductions in experiential avoidance across cognitive-behavioral treatment, and that change in experiential avoidance was significantly associated with change in anxiety. Results from the latent difference score models indicated that change in experiential avoidance preceded and predicted subsequent changes in anxiety, whereas change in anxiety did not precede and predict subsequent changes in experiential avoidance. Taken together, these results provide additional support for reductions in experiential avoidance as a transdiagnostic mechanism in cognitive-behavioral therapy.First author draf

Trajectories of change in well-being during cognitive-behavior therapies for anxiety disorders: quantifying the impact and covariation with improvements in anxiety

Despite substantial evidence supporting the efficacy of cognitive behavioral therapy for reducing many forms of mental illness, less is known about whether CBT also promotes mental health or well being. We will discuss results of a recent study (Gallagher et al., 2019) examining changes in well being d uring different CBT treatments for anxiety disorders and how these changes relate to anxiety. In that study, 223 adults (55.6% female, Mage=31.1 yrs) were randomized to one of five CBT protocols for anxiety disorders at an outpatient clinic. Effect sizes w ere calculated to examine the timing and magnitude of changes in well being as a result of CBT. Further, parallel process latent growth curve models were conducted to examine the extent to which trajectories of changes in well being correlated with the tra jectories of change in both clinician rated and self reported anxiety during active treatment. Results indicated that there were moderate to large increases in overall well being and the three components of subjective, psychological, and social well being, mainly during the second half of CBT, and these increases were maintained at a 6 month follow up. Further, trajectories of change in well being across treatment were strongly correlated with trajectories of change in clinician rated and self reported anxi ety. Together, these findings suggest that different CBT protocols for anxiety consistently produce robust and lasting changes in different domains of positive mental health and increases in well being are strongly linked to changes in anxiety during treatment.Published versio

Effectiveness of the internet-based Unified Protocol transdiagnostic intervention for the treatment of depression, anxiety and related disorders in a primary care setting: a randomized controlled trial

Background Research has shown that internet-based cognitive behavioural therapy (iCBT) can be a very promising solution to increase access to and the dissemination of evidence-based treatments to all of the population in need. However, iCBT is still underutilized in clinical contexts, such as primary care. In order to achieve the effective implementation of these protocols, more studies in ecological settings are needed. The Unified Protocol (UP) is a transdiagnostic CBT protocol for the treatment of emotional disorders, which includes depression, anxiety and related disorders, that has shown its efficacy across different contexts and populations. An internet-based UP (iUP) programme has recently been developed as an emerging internet-based treatment for emotional disorders. However, the internet-delivered version of the UP (iUP) has not yet been examined empirically. The current project seeks to analyse the effectiveness of the iUP as a treatment for depression, anxiety and related emotional disorders in a primary care public health setting. Methods The current study will employ a parallel-group, randomized controlled trial design. Participants will be randomly assigned to (a) the internet-based Unified Protocol (iUP), or (b) enhanced waiting list control (eWLC). Randomization will follow a 2:1 allocation ratio, with sample size calculations suggesting a required sample of 120 (iUP=80; eWLC=40). The Mini-International Neuropsychiatric Interview (M.I.N.I.) will be used for assessing potential participants. The Overall Anxiety Severity and Impairment Scale (OASIS) and the Overall Depression Severity and Impairment Scale (ODSIS) as well as other standardized questionnaires will be used for assessments at baseline, 4 weeks, 8 weeks and 12 weeks from baseline and for the iUP condition during the follow-up. Discussion Combining the advantages of a transdiagnostic treatment with an online delivery format may have the potential to significantly lower the burden of emotional disorders in public health primary care setting. Anxiety and depression, often comorbid, are the most prevalent psychological disorders in primary care. Because the iUP allows for the treatment of different disorders and comorbidity, this treatment could represent an adequate choice for patients that demand mental health care in a primary care setting

“Surviving and Thriving During Stress”: Bridging the Gap with Technology, a Web-Based Acceptance-Based Behavioral Therapy Program for University Students

The high rates of anxiety in college students and the many barriers to accessing evidence-based care in communities and on campuses indicate a clear need to explore ways to provide effective evidence-based treatments to more people. Web-based interventions and preventions are one way to bridge this gap, and hold the potential to decrease suffering and mental health disparities. The current randomized control trial examined the acceptability and efficacy of a three-session web-based therapist assisted acceptance-based behavioral intervention targeting anxiety (Surviving and Thriving During Stress, SATDS) for college students versus a waitlist (WL) control condition, in a sample of diverse college students. Overall, participants rated the program as helpful and acceptable. Mixed-model repeated-measures (MMRM) models were run in SPSS to examine the effects of time, condition, and condition x time on outcomes and mechanisms. Results indicated there were significant condition x time interactions for general anxiety, depression, and quality of life (QOL); indicating SATDS participants reported significantly greater changes on these outcomes from pre- to post- treatment vs. WL. MMRM models examining hypothesized mechanisms of change indicated there were significant condition x time interactions for experiential avoidance and decentering, and a marginally significant interaction for valued living. Bivariate correlations between residualized gain scores on both outcomes and mechanisms affected by the intervention indicated that change in mechanisms was generally associated with change in outcomes. All significant gains were maintained at one-month follow-up, with the exception of QOL. Results contribute to the growing literature on the acceptability and efficacy of web-based approaches, and suggest that these approaches can be effective for diverse college students, and may provide a unique platform to increase access to evidence-based care

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 of change that occur throughout treatment (Kazdin, 2007). Identifying these mechanisms would help to 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), which refers to attempts to control or eliminate distressing internal experiences, regardless of behavioral consequences, in participants with a principal diagnosis of Generalized Anxiety Disorder (GAD) receiving either Acceptance-based Behavior Therapy (ABBT) or Applied Relaxation (AR). Reductions in EA have been hypothesized to be a mechanism of change in mindfulness and acceptance-based interventions, and may also be relevant in more broadly defined Cognitive Behavioral Therapies (CBTs). Participants scores across treatment on the Acceptance and Action Questionnaire (AAQ), which measures EA, were used to calculate a slope and intercept value for each participant, which were used as predictors in a series of linear regressions examining the impact of reductions in EA over the course of treatment on symptom and quality of life outcomes. Results indicated that steeper slope in EA across treatment significantly predicted worry (PSWQ), anxious arousal (DASS-Stress), and quality of life (QOLI) at post-treatment across both treatment conditions. AAQ intercept, or where participants started in terms of EA also significantly predicted all outcomes at post-treatment. Given recent discussions about the definition and measurement of EA, we re-ran all analyses with a more narrow definition of experiential avoidance focused only on attempts to avoid or control internal experiences. These exploratory analyses indicated this AAQ slope was still a significant predictor for all three outcomes across both treatment conditions. However, AAQ intercept was no longer a significant predictor for any of the outcomes. These results contribute to a growing body of literature on common mechanisms of change across traditional CBTs and mindfulness and acceptance-based approaches. Future research is needed to further clarify the definition and measurement of EA. Given that EA appears to be an important treatment target across CBTs broadly, future research should examine ways to disseminate and implement approaches that foster reductions in EA in diverse contexts