ACCEPTANCE-RELATED RESEARCH: OVERVIEW
Dialectical behavior therapy (DBT), mindfulness-based cognitive therapy (MBCT), acceptance-based behavior therapy (ABBT), and Acceptance and Commitment Therapy (ACT) are all recent extensions of traditional cognitive-behavioral therapies grouped under the rubric of acceptance-based psychotherapies. These therapies focus on increased awareness and acceptance of one’s internal experiences (thoughts, feelings and sensations) to gain greater psychological distance from internal experiences, achieve greater clarity as to one’s core life values, and most importantly, to behave in ways that are consistent with these values. These interests drive several interrelated research projects, and our lab is currently developing and evaluating acceptance-based therapies for treatment of a variety of clinical problems.
ACCEPTANCE-RELATED RESEARCH: ANXIETY DISORDERS
VARIATIONS OF COGNITIVE BEHAVIOR THERAPY FOR SOCIAL ANXIETY DISORDER
This study compares the effectiveness of two forms of cognitive behavioral therapy (CBT) for social anxiety disorder: cognitive therapy (also known as traditional CBT), and a newer model of CBT known as acceptance and commitment therapy (ACT). Both models share the core components of CBT, such as systematic and gradual exposure to feared situations, social skills training, and homework assignments. They differ primarily in the way in which they address anxiety-related thoughts and feelings, as described below. Cognitive therapy (CT) highlights the identification and reappraisal of distorted or dysfunctional cognitions in the treatment of psychopathology. Acceptance and Commitment Therapy (ACT) stresses mindful awareness of distressing thoughts and feelings, in the context of moving toward important values.
A secondary aim of this study is to explore mechanisms of treatment action for the two treatments.
INTERNET SELF-HELP PROGRAM FOR SOCIAL ANXIETY DISORDER
We recently developed a self-help Internet program for scial anxiety based on acceptance-based principles. It was adapted from our in-person manual. As part of the program, participants also received brief therapist support via videoconferencing. Our pilot study had very promising results. Participants were highly satisfied with the program and demonstrated significant treatment gains. We are currently conducting a second study that assesses the efficacy of this program in a larger sample in a randomized trial, with and without therapist support.
BRIEF INTERVENTION FOR PUBLIC SPEAKING ANXIETY
This study involves a comparative trial of two types of exposure-based individual treatments for public speaking anxiety in a clinical population. Study participation includes one 90-minute anxiety-management session and two study assessments over four hours. All study participants will receive an intervention for this type of anxiety. Individuals may be compensated for participation. This study will be running through Spring 2014.
FRONTAL ASYMMETRY IN SOCIAL ANXIETY USING FUNCTIONAL NEAR-INFRARED SPECTROSCOPY
Our lab recently collaborated with Drexel’s School of Biomedical Engineering to explore the use of functional near-infrared spectroscopy (fNIRS), a new imaging technique that collects data on cerebrovascular activity during in vivo tasks. The increased portability of this innovative procedure allows us to examine prefrontal hemispheric brain activity in a larger variety of social situations. Because fNIRS has not been used in anxiety research, our lab aims to explore and develop the utility of fNIRS to provide useful data regarding frontal brain activity in social anxiety.
REMOTE TREATMENT (TELETHERAPY) OF SOCIAL ANXIETY DISORDER
Two pilot studies assessed the feasibility, acceptability, and initial efficacy of our acceptance-based CBT intervention to treat adults with generalized SAD. Despite solid empirical support for the effectiveness of various exposure-based CBT programs for SAD, over 80% of people with SAD do not receive any type of treatment whatsoever. Individuals living in non-metropolitan areas of the country have limited access to CBT therapists competent in the treatment of SAD. Also, due to the nature of social anxiety, a significant number of socially anxious adults are unwilling or reluctant to seek treatment in person. One study utilized Second Life, a free online virtual world that potentially holds great promise in the widespread delivery of CBT to individuals who are unable or unwilling to obtain in-person treatment. Using this platform, avatars representing therapists and patients meet in a virtual therapy room and communicate using verbally using VOIP technology. In a second study, treatment was delivered using Skype videoconferencing.
TREATMENT OF OBSESSIVE COMPULSIVE DISORDER IN SKYPE
Obsessive Compulsive Disorder (OCD) is a relatively common anxiety disorder characterized by upsetting and unwanted intrusive thoughts and repetitive behaviors the person feels compelled to perform. This randomized controlled trial sought to compare the efficacy, feasibility, and acceptability of two variations of exposure and ritual prevention (a specific type of cognitive behavior therapy for OCD) delivered via videoconferencing. Exposure and ritual prevention is the current, gold standard treatment for OCD. This study sought to determine if supplementing exposure and ritual prevention with acceptance and commitment therapy (1) enhances outcome, and (2) increases treatment adherence.
TESTING AN ALTERNATIVE HYPOTHESIS FOR COGNITIVE BIAS MODIFICATION FOR PUBLIC SPEAKING ANXIETY
Anxious and depressed individuals tend to show biases in cognitions and implicit attitudes when presented with affectively-laden stimuli relevant to their specific mood state. Cognitive Bias Modification (CBM) is a relatively new area of research based on the notion that these biases can be changed relatively quickly and easily, resulting in symptom reduction. CBM attempts to modify maladaptive behaviors and cognitions by training individuals to attend to more desirable stimuli rather than the stimuli that are consistent with the individuals’ cognitive bias. In some cases, CBM requires as little as a single computer-based intervention. Several recent studies (e.g., Amir, Beard, Burns, & Bomyea, 2009; Amir, Beard, Taylor et al., 2009; Amir, Weber, Beard, Bomyea, & Taylor, 2008; Li, Tan, Qian, & Liu, 2008; Schmidt, Richey, Buckner, & Timpano, 2009) have demonstrated that computer-based CBM treatments, compared with control groups, reduce social anxiety in both clinical and non-clinical samples. However, the design of these studies leaves open the possibility that simple attentional training, rather than bias modification per se, is responsible for the treatment effects. The current study attempted to replicate a one-session CBM study for public speaking (Amir et al., 2008) to verify this phenomenon, as well as test this alternative hypothesis by implementing a second control group undergoing simple attentional training.
This study involves a comparative trial of two types of exposure-based group treatment (one using a standard habituation context and the other using a framework of psychological acceptance) for public speaking anxiety in a clinical population. Treatment consists of 6 weekly group sessions. Behavioral, diagnostic, and self-report data are currently being collected and analyzed.
ACCEPTANCE AND COMMITMENT THERAPY VERSUS COGNITIVE THERAPY FOR THE TREATMENT OF TEST ANXIETY
This study examined ACT as a treatment method for test anxiety, using all of the essential components (such as role-plays and completing homework assignments) that have made ACT successful in other treatment areas. A previously-presented (Brown, Forman, Herbert, 2008) pilot study had suggested participants in the ACT intervention would perform better on their final exams than participants in the CT group. This study aimed to replicate and extend the pilot study by randomly assigning a sample of undergraduate students with moderate-to-high test anxiety (as measured by the Test Anxiety Inventory) to either a CT- or an ACT-based intervention. Both interventions entailed weekly 1.5 hour sessions over a period of three weeks. Intervention content consisted of psychoeducation about test anxiety in conjunction with standard techniques from each respective therapeutic paradigm.
STANDARD VERSUS ACCEPTANCE-BASED VARIATIONS OF COGNITIVE-BEHAVIORAL THERAPY FOR MOOD AND ANXIETY DISORDERSS
This project compared outcomes and mechanisms of action for mood and anxiety-disordered patients randomly assigned to either standard CBT or ACT. The aim of the study was to allow a comparison between these two forms of therapy in terms of mediating mechanisms as well as their impact on symptom levels (depression, anxiety), life functioning (work, school, family, relational), and well being (quality of life, subjective well-being). Results indicated that ACT has comparable effectiveness to gold standard CBT at post-treatment, but, notably, that it is mediated through different pathways (Forman, Herbert, Moitra, Yeomans & Geller, 2007). However, follow-up analyses demonstrated better long-term outcomes for the standard CBT group in terms of both depression and general level of function (Forman, Shaw, Goetter, Herbert, Park & Yuen, 2012).
ACCEPTANCE-BASED BEHAVIOR THERAPY FOR SOCIAL ANXIETY DISORDER
This project examined the effectiveness of acceptance-based behavior therapy (ABBT) for the treatment of social anxiety disorder (SAD), as well the mechanisms of action by which it works (Dalrymple, Herbert & Forman, 2006; Dalrymple & Herbert, 2007). For this project, a comprehensive ABBT for SAD treatment manual was developed. Results provide strong support for its effectiveness.
ACCEPTANCE-RELATED RESEARCH: WEIGHT AND EATING
For information about acceptance-related weight and eating projects please see the Innovation Lab website.
ACCEPTANCE-RELATED RESEARCH: MEASUREMENT DEVELOPMENT
As acceptance-based therapies are relatively new, measures for tracking change in related constructs are in need of development and refinement. Defusion and mindfulness are considered crucial elements of acceptance-based treatment and measurement of these constructs is of vital importance. To this end, our lab has developed the Philadelphia Mindfulness Scale (Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008) and the Drexel Defusion Scale (Forman, Herbert, Juarascio, Yeomans, Zebell, Goetter, & Moitra, 2012). Both of these measures provide important data relevant to understanding therapeutic processes.
ACT/CT ADHERENCE AND COMPETENCE RATING SCALE
The Drexel University ACT/CT Adherence and Competence Rating Scale (DUACRS) represents an attempt to combine items relevant to assessing therapist practices specific to Acceptance and Commitment Therapy (ACT) and Cognitive Therapy (CT) with items focusing on more general therapist attributes within a single scale. The instrument’s psychometric characteristics (most notably, its high interrater reliability and its ability to distinguish between treatment conditions), indicate that it holds promise for research and clinical us.
ACCEPTANCE-RELATED RESEARCH: RECURRING THEMES AND OTHER PAST PROJECTS
SOCIAL ANXIETY DISORDER
Social Anxiety Disorder (SAD), or Social Phobia, is one of the most common psychiatric disorders and investigating its etiology, topology and treatment has been a long-standing focus of the lab. Recently, our lab has investigated novel treatments for SAD (e.g., ACT), the mechanisms of action at work in SAD, and the application of newer functional imaging techniques to the study of SAD.
VALIDITY OF THE CONSTRUCT OF PTSD
Although the diagnostic entity of PTSD is widely accepted, there are some indications that the construct (as currently conceived) is flawed. For instance, most notions of PTSD assume that the post-traumatic reactions are universal biological responses to profound trauma that should be equally present in people from all cultures. However, a growing body of work, including some from our lab (Yeomans, Herbert & Forman, 2008), suggests that this is not the case. In fact, there is evidence that some post-traumatic reactions may in fact be closely tied to one’s expectations of what type of symptoms one ought to experience following a trauma. This important research highlights the fact that Western-style education and intervention efforts may be creating PTSD symptoms in trauma victims where they otherwise would not have existed.
MEASURING COGNITIVE DEFUSION
Cognitive defusion is an integral but rarely researched component of Acceptance and Commitment Therapy. Our lab is currently examining the usefulness of the Implicit Relational Assessment Procedure (IRAP), a technology based on Relational Frame Theory, in assessing undergraduates' levels of defusion. Our aims are to explore the relationship between psychopathology, psychological functioning, and defusion (measured both explicitly and implicitly).
MEASURING ACCEPTANCE VERSUS CONTROL-BASED PAIN MANAGEMENT STRATEGIES USING EEG
Two competing psychological pain management strategies, an acceptance- and a control/distraction-based strategy, were assessed both behaviorally and via electroencephalography (EEG) in an analog population. Behaviorally, the two strategies were compared for their effectiveness in alleviating subjective pain and increasing pain tolerance time during induced experimental pain. Additionally, EEG was used to assess the differences that occur on a neural level when using one strategy versus the other. Results showed that although the strategies did not produce different behavioral results, there were marked differences in neural activity between the acceptance- and control-based pain management strategies.
ACCEPTANCE OF PAIN IN JUVENILE IDIOPATHIC ARTHRITIS
It has been demonstrated that acceptance of pain is associated with better functional outcomes (including decreased disability, depression, anxiety, and catastrophizing) among chronic pain patients. Our lab is examining the role of acceptance of pain in adolescents with juvenile arthritis. We are currently exploring whether acceptance of pain has moderating effects on pain intensity, disability, anxiety, and quality of life measures. Results may lend support for the use of acceptance-based treatments in conjunction with standard medical treatment for youths with arthritis.
ACCEPTANCE-BASED STRATEGIES TO PROMOTE HIV MEDICATION ADHERENCE
Despite the existence of effective pharmacological treatments, such as highly active antiretroviral therapy (HAART), a significant number of Americans with HIV do not maintain adequate adherence levels for treatment to work. It is thought that an acceptance-based intervention may be preferable to traditional cognitive behavior approaches to medication adherence because of the significant role that denial and experiential avoidance play in this population. Our lab is currently comparing treatment-as-usual to an acceptance-based intervention for increasing HAART adherence in a predominantly minority, low socio-economic status sample of uninsured adults in a Philadelphia primary care clinic.
PSYCHOTHERAPY: PROCESSES, OUTCOMES, AND DECISION-MAKING
INVESTIGATIONS OF MECHANISMS OF ACTION OF PSYCHOTHERAPY
Each psychotherapy perspective has a theory purporting to explain how it works. In the case of traditional cognitive-behavioral therapy, the theory, in part, suggests that a reduction in distorted thinking is responsible for the effects of the therapy. Acceptance-based therapies call for different mechanisms of action, e.g., increases in experiential awareness and acceptance as well as increases in the ability to “defuse” from or separate from one’s thoughts and feelings. Our group has been investigating the extent to which the two therapies operate through the mechanisms their theoretical frameworks purport. It is hoped that knowledge about such mechanisms of action will translate into the ability to create more effective and efficient therapies.
EVALUATION OF PSYCHOTHERAPY OUTCOME
Our research group is interested in questions such as: Which therapies are most effective? How should effectiveness be measured? How should therapies be labeled as “empirically-supported treatments”?
While there is a long history of clinicians making use of a complex assortment of data to aid in clinical decision-making and conceptualization, virtually no empirical support for the usefulness of such data in sound decision making exists. Our lab group is pursuing research aiming to investigate the degree to which data such as developmental, relationship, and family history demonstrably and empirically aid clinical decision-making.
SCIENCE AND PSEUDOSCIENCE
Claims about the legitimacy of mental health interventions are not necessarily grounded in acceptable scientific approaches. Our research group is interested in developing general principles that help to separate true scientific approaches from those that are better described as pseudoscientific, because their grounding principles violate core tenets of the scientific approach. In addition, our group has an interest in identifying psychotherapeutic approaches (e.g. thought field therapy) that claim a scientific grounding but are best labeled as pseudoscientific.
SUDDEN GAINS IN PSYCHOTHERAPY
Sudden gains in psychotherapy, defined as large enduring reductions in symptom intensity from one therapy session to the next, suggest that progress is not gradual, but marked by sharp discontinuities. This instability, often attributed to life events, is thought to be noise that obscures signs of gradual improvement. However, current research suggests that some sudden gains represent enduring improvements. Our research group is interested in questions such as: Do sudden gains represent transient noise or long lasting decreases in patients’ symptom severity? Do sudden gains observed in efficacy studies also exist in routine clinical settings, and are they present in all forms of psychotherapy?