Michael E. Levin

Acceptance and Commitment Therapy for Anxiety and OCD Spectrum Disorders: An Empirical Review

A fair amount of research exists on acceptance and commitment therapy (ACT) as a model and a treatment for anxiety disorders and OCD spectrum disorders; this paper offers a quantitative account of this research. A meta-analysis is presented examining the relationship between psychological flexibility, measured by versions of the Acceptance and Action Questionnaire (AAQ and AAQ-II) and measures of anxiety. Meta-analytic results showed positive and significant relationships between the AAQ and general measures of anxiety as well as disorder specific measures. Additionally, all outcome data to date on ACT for anxiety and OCD spectrum disorders are reviewed, as are data on mediation and moderation within ACT. Preliminary meta-analytic results show that ACT is equally effective as manualized treatments such as cognitive behavioral therapy. Future directions and limitations of the research are discussed.

Feasibility of a Prototype Web-Based Acceptance and Commitment Therapy Prevention Program for College Students

Abstract Objective: This study examined the feasibility of a prototype Web-based acceptance and commitment therapy (ACT) program for preventing mental health problems among college students. Participants: Undergraduate first-year students (N = 76) participated between May and November 2011. Methods: Participants were randomized to ACT or a waitlist, with assessments conducted at baseline, posttherapy, and 3-week follow-up. Waitlist participants accessed the program after the second assessment. Results: Program usability/usage data indicated high program acceptability. Significant improvements were found for ACT knowledge, education values, and depression with ACT relative to waitlist. Subgroup analyses indicated that ACT decreased depression and anxiety relative to waitlist among students with at least minimal distress. Within the ACT condition, significant improvements were observed from baseline to 3-week follow-up on all outcome and process measures. Conclusions: Results provide preliminary support for the feasibility of a Web-based ACT prevention program.

An initial meta-analysis of Acceptance and Commitment Therapy for treating substance use disorders

BACKGROUND In the past decade, multiple studies have examined the effectiveness of Acceptance and Commitment Therapy (ACT) for substance use disorders relative to other active treatments. The current meta-analysis examined the aggregate effect size when comparing ACT to other treatments (e.g., CBT, pharmacotherapy, 12-step, treatment as usual) specifically on substance use outcomes. METHOD A total of 10 randomized controlled trials were identified through systematic searches. RESULTS A significant small to medium effect size was found favoring ACT relative to active treatment comparisons following treatment. Effect sizes were comparable across studies for smoking cessation (k=5) and for other drug use disorders (k=5). CONCLUSIONS Based on these findings, ACT appears to be a promising intervention for substance use disorders. Limitations and future directions are discussed.

Examining psychological inflexibility as a transdiagnostic process across psychological disorders

The current cross-sectional study examined psychological inflexibility, a process in which behavior is rigidly guided by psychological reactions rather than direct contingencies or personal values, as a transdiagnostic process relevant to a range of depressive, anxiety, substance use and eating disorders. A sample of 972 first-year college students between 17 and 20 years of age completed self-report measures of psychological inflexibility and psychological distress as well as a structured diagnostic interview. Psychological inflexibility was significantly higher across a range of current and lifetime depressive and anxiety disorders as well as lifetime history of eating disorders, relative to students with no disorder, even after controlling for general psychological distress. Findings were mixed for substance use disorders, with a more consistent pattern for lifetime history than for current disorders. Psychological inflexibility was also related to having comorbid depressive, anxiety, and substance use disorders relative to only having one of these diagnoses. Results are discussed in relation to research on psychological inflexibility as a transdiagnostic pathological process and target for interventions.

Dropout rates in exposure with response prevention for obsessive-compulsive disorder: What do the data really say?

The purposes of this review were to: 1) determine the attrition rates for exposure with response prevention (ERP) for obsessive-compulsive disorder (OCD), 2) compare them to those in other treatments for OCD, and 3) identify predictors of ERP attrition. A systematic literature search of randomized controlled trials for ERP for OCD yielded 21 studies, representing 1400 participants. Attrition data were extracted for individual treatment conditions. The weighted mean dropout rate for ERP was 14.7% (95% CI [11.4%, 18.4%]). This figure was not statistically different from that of comparison conditions (e.g., cognitive therapy; OR=0.67-2.22, all ps>0.15). Only two studies reported refusal rates for ERP (weighted mean=4.0%; 95% CI [0.7%, 9.2%]), which precluded calculation of a reliable refusal rate for ERP. Based on these figures, we estimated an overall attrition rate of 18.7% for ERP. Treatment experience, therapist qualification, and number of treatment sessions did not significantly predict dropout rate. Our review indicates that ERP may have treatment dropout rates similar to other treatments for OCD.

Decoupling as a mechanism of change in mindfulness and acceptance: a literature review.

A growing body of research within the acceptance and mindfulness-based therapies suggests that these treatments may function in part by reducing or eliminating (i.e., decoupling) the normative relationships between internal experiences and other internal/overt behavior. Examples of decoupling effects found in this review include reduced relationships between urges to smoke and smoking behavior, between dysphoric mood and depressive cognitions, and between pain intensity and persistence in a painful task. A literature review identified 44 studies on acceptance and mindfulness that demonstrated decoupling effects. Overall, preliminary evidence for decoupling effects were found across a broad range of problem areas, including substance abuse, depression, eating disorders, overeating, chronic pain, anxiety, relationships, anger, avoidance behavior, and self-harm, with the strongest evidence currently available in the area of substance abuse. However, the review also notes a general lack of replication studies on decoupling effects and the need for more well-powered and controlled research testing specific decoupling hypotheses.

Web-Based Acceptance and Commitment Therapy for Mental Health Problems in College Students A Randomized Controlled Trial

There are significant challenges in addressing the mental health needs of college students. The current study tested an acceptance and commitment therapy (ACT), web-based self-help program to treat a broad range of psychological problems students struggle with. A sample of 79 college students was randomized to web-based ACT or a waitlist condition, with assessments at baseline and posttreatment. Results indicated adequate acceptability and program engagement for the ACT website. Relative to waitlist, participants receiving ACT improved on overall distress, general anxiety, social anxiety, depression, academic concerns, and positive mental health. There were no between-group effects on eating concerns, alcohol use, or hostility, or on some key ACT process of change measures. ACT participants improved more on mindful acceptance and obstruction to valued living, both of which mediated treatment outcomes. Results are discussed in the context of lessons learned with the website prototype, and areas for further research are presented.

Feasibility of an Acceptance and Commitment Therapy adjunctive web-based program for counseling centers

Web-based adjunctive tools provide a promising method for addressing the challenges college counseling centers face in meeting the mental health needs of students. The current study tested an initial adjunctive prototype based on acceptance and commitment therapy (ACT) in a pre-post open trial with 30 counselors and 82 student clients across 4 counseling centers. Results indicated high ratings of program satisfaction and usability with counselors and students. The majority of students completed at least part of the program. Significant improvements were found across almost all outcome and ACT process measures with student clients. Improvements in student outcomes were predicted by both changes in psychological inflexibility and how often counselors discussed the program with students. Results are discussed in relation to support for and future development of a flexible, adjunctive ACT program for counseling centers.

Web-Based Self-Help for Preventing Mental Health Problems in Universities: Comparing Acceptance and Commitment Training to Mental Health Education.

OBJECTIVE This study sought to test the feasibility of a web-based Acceptance and Commitment Training (ACT) prototype prevention program called ACT on College Life (ACT-CL). METHOD A sample of 234 university students was randomized to either the ACT-CL website or a mental health education (MHE) website. RESULTS Findings indicated a lower level of user engagement and satisfaction ratings with the prototype of ACT-CL than the MHE website. There were no significant differences between conditions on outcome measures at post or follow-up. However, statistical trends suggested the MHE condition actually led to greater remission of severe symptoms than the ACT-CL condition among those with severe symptoms at baseline. There were no differences between conditions on ACT process of change measures. Changes in psychological flexibility were predictive of changes in mental health across conditions, but relations dissipated over time. Furthermore, greater engagement in some components of ACT-CL predicted improvements in psychological flexibility, though not on mental health outcomes. CONCLUSIONS The effects of the ACT-CL program on mental health outcomes and ACT process measures were largely equivalent to those of an education website, although there was a lower level of program engagement with ACT-CL. Findings are discussed in the context of feasibility issues and lessons learned for program revisions.

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 and basic science of cognition. This article reviews the core features of ACTs theoretic model of psychopathology and treatment and its therapeutic approach. It provides a systematic review of randomized controlled trials (RCTs) evaluating ACT for depression and anxiety disorders. Summarizing 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 indicates that ACT treatment outcomes are mediated through increases in psychological flexibility, its theorized process of change.