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: Weight and Eating
Acceptance-based Behavior Treatment for Obesity
The Behavior Weight Loss Program investigates novel, acceptance-based behavioral approaches to weight control. The pilot study investigated an acceptance-based behavior treatment manual for weight control. This was developed and tested in an uncontrolled trial among four groups of overweight women. Results supported the effectiveness of this approach, as well as the theorized mechanisms of action (Forman, Butryn, Hoffman, Herbert and Lowe, 2008; Hoffman, Forman, Herbert, Butryn & Lowe, in preparation).
The research lab was recently awarded a grant by the NIH for a study called Mind Your Health. This NIH-funded randomized controlled trial will compare acceptance based behavioral treatment versus standard behavioral treatment will begin shortly. The study will assess whether acceptance based behavioral treatment is superior at achieving weight loss and weight loss maintenance.
Acceptance-based Treatment for Cravings
Our first study compared acceptance-based and traditional, “control”-based approaches to coping with cravings in a group of undergraduates. Results indicated that the relative efficacy of the two approaches depended on individuals’ sensitivity to the food environment (Forman, Hoffman, McGrath, Herbert, Brandsma & Lowe, 2007). More specifically, acceptance-based strategies were significantly superior in terms of both craving intensity and food consumption in those individuals who were the most sensitive to the food environment, whereas control-based strategies appeared to be advantageous for those who were less sensitive.
The second study used a similar protocol in a group of overweight women recruited from the community. Results will be available shortly.
Acceptance and Commitment Therapy for Physical Activity Promotion
This project aims to examine the effectiveness of Acceptance and Commitment Therapy in promoting physical activity behaviors among individuals who are struggling to adhere to their physical activity goals. ACT outcomes and mechanisms of action for mood and anxiety-disordered patients randomly assigned to either standard CBT or ACT targets individuals’ commitment to difficult behaviors and tolerance of distress, and as such can be theorized to be particularly successful in increasing physical activity adherence. Results indicated that ACT was superior at increasing physical activity in this population (Butryn, Forman, Hoffman, Shaw, & Juarascio, in preparation).
Food Acceptance and Awareness Questionnaire
This measure was designed to measure acceptance and awareness of food cues and cravings. Preliminary results suggest that that the measure has good internal consistency, and convergent and divergent validity. Furthermore, there is some evidence to suggest that the measure may be predictive of weight loss amongst women undergoing a behavioral weight loss program. Currently we are investigating the test-retest reliability and the measures utility in predicting cravings and sweet consumption.
Acceptance and Commitment Therapy for Eating Disorders
Current gold-standard treatments for eating disorders such as standard CBT demonstrate only limited efficacy in reducing eating pathology. However, acceptance based treatments may be more effective given their focus on values clarification, acceptance, and distress tolerance. Currently, there exists some evidence to suggest that ACT may be more effective at reducing sub-syndromal eating pathology than standard cognitive therapy (Juarascio, Forman, Herbert, in preparation), but additional research is needed to determine its efficacy at treating eating disorders. To investigate the potential utility of this treatment model for eating disorders, our pilot study is currently investing changes in ACT related concepts during standard inpatient treatment for eating disorders. The study seeks to determine whether these changes are associated with treatment outcome.
Acceptance and Commitment Therapy for Increasing Adherence to Lifestyle Recommendation in Cardiac Patients
Previous research indicates that cardiac patients have a difficult time adhering to recommended lifestyle changes such as eating a healthy diet, engaging in more physical activity, and smoking cessation. A pilot study is currently investigating whether ACT concepts are associated with diet, physical activity, and smoking status in cardiac patients. Future research will seek to determine whether ACT can increase compliance with these changes amongst current cardiac patients.
Internalization of the thin Ideal- Implicit Relational Assessment Procedure
In light of the rising rates of eating disorders and obesity, it is increasingly important to understand what might lead someone to develop disordered eating and gain weight. One potential measure that has shown predictive validity for disordered eating, weight gain, and body image dissatisfaction is internalization of the thin ideal. Two studies are currently investigating the utility of Relational Frame Theory and a thin ideal Implicit Relational Assessment Procedure (IRAP) at predicting changes in these variables. Preliminary results from a pilot study has shown that internalization of the thin ideal, as measured by the IRAP, is correlated with self-reported internalization, disordered eating, and weight, demonstrating the potential utility of this measurement tool. A longitudinal study will begin in the fall. This project will assess whether the thin ideal IRAP can predict increases in disordered eating, body image dissatisfaction and weight amongst college females during the freshman year of college.
Implicit and Explicit Attitude Discrepancy: Chocolate Study
Increasing research on implicit attitudes has suggested that eating behavior and food choice under certain situations rely heavily on implicit attitudes towards food. Though implicit attitudes have been found to be somewhat accurate predictors of eating behavior, it is still difficult to predict some maladaptive eating behaviors, such as disinhibition (overeating without explicit intent to do so). There has been some evidence to suggest that it is not implicit attitudes alone, rather the discrepancy between implicit attitudes and explicit attitudes towards food that are indicative of disinhibition. The current study makes use of the Implicit Association Test (FreeIAT) and Visual Analogue Scale (VAS), as well as a behavioral chocolate tasting component to examine the relationships between implicit attitudes, explicit attitudes, and disinhibition.
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. A secondary aim of this study is to explore mechanisms of treatment action for the two treatments.
Remote Treatment (Teletherapy) of Social Anxiety Disorder
Two pilot studies assess 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 utilizes 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 is 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 seeks 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 seeks 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 attempts 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 that undergoes simple attentional training.
Treatment of Co-occurring Severe Mental Illness and Substance Abuse
Collaborating with investigators from the University of Pennsylvania, Dartmouth Medical School, and Cheney University, as well as several colleges within Drexel, our group is currently exploring the possibility of a large-scale, multi-site study comparing cognitive therapy and acceptance and commitment therapy for the treatment of comorbid severe mental illness and substance abuse.
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
The current study examines 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 suggested those participants in the ACT intervention performed better on their final exams than those participants in the CT group. The current study aims 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 entail weekly 1.5 hour sessions over a period of three weeks. Intervention content consists of psychoeducation about test anxiety in conjunction with standard techniques from each respective therapeutic paradigm. Data collection is ongoing.
Standard Versus Acceptance-Based Variations of Cognitive-Behavioral Therapy for Mood and Anxiety Disorderss
This project compares outcomes and mechanisms of action for mood and anxiety-disordered patients randomly assigned to either standard CBT or ACT. The aim of the study is 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 thus far have indicated that ACT has comparable effectiveness to gold standard CBT, but, notably, that it is mediated through different pathways (Forman, Herbert, Moitra, Yeomans & Geller, in press).
Acceptance-based Behavior Therapy for Social Anxiety Disorder
This project examines 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 et al., in press). For this project, a comprehensive ABBT for SAD treatment manual was developed. Results provide strong support for its effectiveness.
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, in press) and the Drexel Defusion Scale. Both of these measures provide important data relevant to understanding therapeutic processes.
ACT/CT Adherence and Competence Rating Scale
ACT/CT Adherence and Competence Rating Scale—Katie McGrath 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 use.
Acceptance-Related Research: Other Projects
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 behavior results, there are marked differences in neural activity when comparing 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.
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.
Frontal Asymmetry in Social Anxiety Using Functional Near-Infrared Spectroscopy
Our lab is currently collaborating 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.
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, in press), suggests that this is not the case. In fact, there is evidence that some post-traumatic reactions may be 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.
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?