Testing an Acceptance and Commitment Therapy Website for Hoarding: A Randomized Waitlist-Controlled Trial

Hoarding disorder is relatively common and seriously affects those who experience it. However, it is difficult to access hoarding treatment, due to barriers such as availability and stigma. Moreover, only one treatment is well-established for hoarding (CBT), and it does not directly address important processes such as mindfulness and acceptance. Therefore, in order to make treatment more useful and easy to access, this study tested a self-help program that focused on teaching mindfulness and acceptance as related to hoarding. The self-help program was compared to a waitlist condition; participants were randomly assigned to use the website or wait 12 weeks. The website was structured as 16 self-help modules tailored for hoarding. The program was implemented as an 8-week treatment with a 4-week follow-up period, and supportive coaching was provided during the 8-week treatment period. The sample included 73 individuals with problematic hoarding symptoms; as is common in hoarding treatment studies, participants were mostly white and female. These participants were slightly less white and somewhat younger compared to participants in studies on traditional therapy. Overall, results suggested that the program was helpful and participants found it satisfactory. Those who used the website improved significantly more than the waitlist on overall hoarding symptoms, overall difficulties in functioning, self-stigma, and progress toward personal values. Many participants did not finish the program, and many still had a problematic level of hoarding symptoms after treatment, which suggests room for improvement. Participants overall found the website satisfactory and easy to use, and perceived it as likely to be helpful. It is unclear what processes led to improvement in the treatment condition, although increasing mindful awareness and reducing rigid responses to thoughts and feelings about acquiring belongings may have contributed. Future studies should test this treatment in more diverse participants and compare it to other types of treatment options. However, these results suggest that a self-help website teaching mindfulness and acceptance skills is likely to be useful for people with hoarding problems

Using Ecological Momentary Assessment to Clarify the Function of Hoarding

Experts have argued that hoarding disorder occurs in part because hoarding behaviors help individuals avoid distress and feel positive emotions in the moment. For example, when people who hoard choose to save something rather than discard it, they may avoid feelings of anxiety, and when people who hoard acquire something new, they may feel excited. However, no previous studies have examined whether or not these changes actually occur in the moment. These processes could also potentially be altered by how individuals respond to their emotions in the moment. For example, individuals who hoard may have stronger emotional reactions, distinguish less between different emotions, tend to avoid their emotions more, or tend to be inattentive of their experience, which could change how their emotions in the moment affect their behavior. Therefore, this study examined whether or not the anticipated effects of hoarding behaviors on mood occurred, and whether or not there were differences between those with higher and lower hoarding scores on how they respond to their emotions, in a sample of 61 college students. Participants completed two online surveys one week apart, and responded to questions on their mobile phone throughout the week. As expected, the students with higher hoarding scores had stronger emotional reactions to stress, avoided their emotions more often, and were less attentive to their ongoing experience. Both those with higher hoarding scores and lower hoarding scores vi reported that they acquired new items primarily to feel good. However, acquiring, discarding, working with items, and looking for items did not change either group’s mood in the moment. Overall, these findings suggest that people who hoard do have differences in how they respond to their emotions, which could mean that treatments that target these responses may be useful for these people. They also show the importance of understanding why working to put yourself in a good mood through acquiring is problematic for some people and not others, and suggest that there may be a difference between how these behaviors are intended to perform and their actual results

Does the Cognitive Fusion Questionnaire Measure More than Frequency of Negative Thoughts?

Cognitive fusion is a psychopathological process that appears to be relevant to a wide range of disorders. This process is frequently measured with the Cognitive Fusion Questionnaire (CFQ). However, the construct validity of similar measures has been criticized for substantial overlap with distress. It is possible the CFQ may excessively measure the presence of unwanted thoughts, rather than fusion per se. Therefore, this study examined the discriminant validity of the CFQ relative to a measure of automatic negative thoughts (the Automatic Thoughts Questionnaire) in a college student sample (n = 389). While the two measures were highly correlated (ρ = .74), exploratory factor analysis demonstrated that they consistently loaded onto separate factors. The CFQ also demonstrated incremental validity in predicting distress and anxiety over four weeks when controlling for baseline automatic negative thoughts. Overall findings are consistent with the CFQ measuring its intended construct, rather than the mere presence of negative thoughts. Major limitations to generalizability include the use of a college student sample with minimal racial and ethnic diversity, and the lack of additional comparator measures

The Interaction of Mindful Awareness and Acceptance in Couples Satisfaction

Past studies indicate that the awareness and acceptance facets of trait mindfulness both independently predict relationship satisfaction. However, this study hypothesized that the combination of awareness and acceptance might be a stronger contributor to relationship functioning than either in isolation. Regression analyses were used to test whether mindful awareness and acceptance interact in predicting couples satisfaction in a sample of dating or married college students (n = 138). Acceptance was positively associated with couples satisfaction, while awareness was unrelated. These two mindfulness facets interacted such that greater awareness was related to poorer satisfaction when acceptance was low, but was unrelated when acceptance was high. Conversely, greater acceptance was only related to greater satisfaction when awareness was moderate or high. These results suggest the combination of high awareness and low acceptance can be problematic for relationships, while at least moderate mindful awareness is needed for acceptance to be beneficial

Comparing Cognitive Fusion and Cognitive Reappraisal as Predictors of College Student Mental Health

Transdiagnostic cognitive behavioral interventions target different cognitive processes to promote mental health, including cognitive fusion and cognitive reappraisal. Determining the relative impact of cognitive fusion and reappraisal on a range of student mental health concerns could help interventions target psychopathological cognitive processes more effectively. Therefore, this study examined the longitudinal impact of cognitive fusion and reappraisal on mental health and functioning outcomes. A series of hierarchical regression models tested the effects of cognitive fusion and reappraisal in a sample of college students (n = 339). When controlling for reappraisal and baseline symptoms, fusion predicted distress, depression, generalized anxiety, social anxiety, hostility, academic distress, and student role problems 1 month later. Reappraisal predicted only student role problems longitudinally when controlling for fusion. These results suggest that cognitive fusion is a stronger predictor than reappraisal for a range of student mental health concerns and may be a particularly important target for improving student mental health

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

Pilot Evaluation of the Stop, Breathe & Think Mindfulness App for Student Clients on a College Counseling Center Waitlist

Objectives: College counseling centers face significant challenges meeting the mental health needs of their students and waitlists are common. Mobile apps offer a promising solution to increase access to resources while students wait for services. Methods: This pilot randomized controlled trial evaluated the feasibility and acceptability of a publicly available mindfulness app. Students on a counseling center waitlist (n=23) were randomized to use the app or not, with assessments completed over four weeks. Results: Recruitment over three semesters was slow, leading to an underpowered trial. Participants reported high satisfaction and moderate app usage. Very preliminary support was found for potential app efficacy relative to the control condition, particularly for depression, anxiety, and overall distress. Weaker, mixed effects were found for mindfulness and values processes. Conclusions: Overall, these results provide mixed findings suggesting the potential benefits, but also challenges in using a mindfulness app for students waiting to receive counseling services

Effects of Cognitive Restructuring and Defusion for Coping with Difficult Thoughts in a Predominantly White Female College Student Sample

Background: Understanding how cognitive processes are naturally used by untrained individuals in the moment to cope with difficult thoughts may help inform effective and efficient interventions. Methods: This study investigated self-reported naturalistic use of two evidence-based processes, cognitive restructuring and cognitive defusion, in an untrained, predominantly White female college student sample (n = 194) through ecological momentary assessments over seven days. Results: Cognitive restructuring and defusion had a large positive relationship. Both processes were also positively associated with increased momentary use of suppression and distraction. Only momentary defusion was associated with decreased rumination and negative affect at the same timepoint, while both defusion and restructuring were associated with positive affect and increased values progress at the same timepoint. Momentary defusion predicted later values progress, but only among those with low distress. Conclusions: Overall, results suggest that both cognitive restructuring and cognitive defusion are used in a nonclinical, untrained population, that both processes are overall beneficial when used in the moment, and that defusion may be particularly relevant to certain aims such as lower rumination or values progress across time points. Replication among clinical and more diverse populations is needed

A Pilot Randomized Controlled Trial of Acceptance and Commitment Therapy Guided Self-Help for Overweight and Obese Adults High in Weight Self-Stigma

Weight self-stigma, in which individuals internalize stigmatizing messages about weight, is a prevalent problem that contributes to poor quality of life and health. This pilot randomized controlled trial evaluated acceptance and commitment therapy (ACT) guided self-help using The Diet Trap (Lillis, Dahl, & Weineland, 2014) for 55 overweight/obese adults high in weight self-stigma. Participants were randomized to the ACT self-help book plus phone coaching (GSH-P; n=17), self-help book plus email prompts only (GSH-E; n=20), or a waitlist condition (n=18), with online self-report assessments at baseline and posttreatment (8 weeks later). Participants reported high satisfaction ratings and engagement with the ACT self-help book, with no differences between GSH-P and GSH-E. Both GSH-P and GSH-E improved weight self-stigma relative to waitlist with large effect sizes. There were mixed findings for health outcomes. The GSH-P condition improved more on healthy eating behaviors and general physical activity, but neither ACT condition improved more than waitlist on self-reported body mass index, emotional eating, and a second measure of physical activity. Results suggest an ACT self-help book with email prompts can reduce weight self-stigma and potentially improve some health behavior outcomes. Phone coaching may provide additional benefits for generalizing ACT to diet and physical activity