Evaluating posttraumatic stress in young adult cancer survivors: Implications of revised DSM-5 traumatic event criteria.

OBJECTIVE: The Diagnostic and Statistical Manual for Psychiatric Diagnoses (DSM-5) significantly narrowed conditions under which life-threatening illnesses meet qualifying traumatic event (QTE) criteria for posttraumatic stress disorder (PTSD). To investigate the impact of this change on identification of PTSD in young adult cancer survivors (YACS), we compared prevalence of QTE exposure using DSM-5 and earlier DSM-IV criteria. METHODS: The Structured Clinical Interview for the DSM-5 (SCID-5) was customized for study goals and administered to a convenience sample of 250 YACS ages 18-40 followed at a single cancer center. RESULTS: The SCID-5 was well-tolerated by participants and estimated duration was brief (33 min; range 12-75). Only 35 interviews (14%) presented complex scoring questions. 168 participants (67.2%) identified cancer as their "most stressful or traumatic experience." Applying DSM-IV criteria, 227 YACS (90.8%) reported any QTEs; prevalence was significantly reduced following more restrictive DSM-5 QTE criteria, with only 124 YACS (49.6%) reporting ≥1 QTE (z = -9.68, p < 0.001). CONCLUSIONS: The SCID-5 can be successfully adapted to assess QTEs in YACS following both DSM-IV and DSM-5 criteria. DSM-5 criteria significantly limit prevalence of QTE exposures compared with DSM-IV. As the majority of YACS identify cancer as their most stressful life event, it is critically important to investigate its impact on their psychological functioning. Until more is known about how PTSD symptoms may arise after cancer, clinicians and researchers should adapt PTSD assessments to systematically evaluate the role of cancer as a traumatic event that may lead to PTSD symptoms in YACS.

Learning gains from a one-day training in acceptance-based behavior therapy.

The primary method of training for individual licensed mental health professionals is continuing education (CE). Despite the promise of CE as a vehicle for training clinicians in evidence-based practices, only a handful of studies have examined the efficacy of trainings delivered in the CE context. Moreover, these studies have focused on a few very specific therapeutic approaches. There is a growing body of evidence supporting Acceptance-based Behavior Therapy (ABBT) as a treatment for generalized anxiety disorder (GAD) and related disorders. Training workshops aimed at disseminating ABBT are regularly conducted across and outside the United States, yet the effectiveness of these trainings is unknown. The goal of this study was to examine learning outcomes among licensed mental health professionals following a six-hour CE training in ABBT. Data were collected at baseline, post-training, and at three-month follow-up. Participants demonstrated a statistically significant increase in learning on an ABBT Knowledge Questionnaire and in their coded responses to client scenarios from baseline to follow-up, although there was a significant decline in knowledge between post and follow-up. Beyond baseline ABBT knowledge, attitude towards evidence-based practice was the only predictor of change in knowledge over time.

A randomized controlled pilot study evaluating Worry Less, Live More: The Mindful Way Through Anxiety Workbook.

Effective interventions for generalized anxiety exist, but barriers to treatment prevent their broad dissemination. Commercially available self-help materials may help bridge this gap, but few have been empirically evaluated. This study compared self-reported change in generalized anxiety symptomology and associated problems between community members with excessive worry who were randomly assigned to receive the Worry Less, Live More: The Mindful Way through Anxiety Workbook (n = 35) and those in a delayed condition (n = 29). Participants in the workbook condition reported significantly greater reductions between baseline and 11-week follow-up in self-reported worry (η2 =.15), general anxiety/tension (η2 =.13), and anxiety (η2 =.24) than those in the delayed condition, although no statistically significant differences across condition on changes in depression, functional impairment or acceptance were detected. This pilot study provides support for continued research examining the efficacy of acceptance-based behavioral therapy delivered in a self-help format.

The relationship between substance use, experiential avoidance, and personally meaningful experiences.

Background: High rates of substance use among college students have been associated with a wide range of detrimental consequences. Psychological inflexibility, characterized by both experiential avoidance and a disconnection with personally meaningful values, is proposed to contribute to the development and maintenance of substance misuse. Objectives: This study explored the unique contribution of experiential avoidance and four different values dimensions (i.e., importance, consistency, effort, and intrinsic motivation) on substance use and related problems accounting for the known predictors of gender and drinking motives. Method: Zero-inflated regression was used to analyze predictors of substance use and related problems among 233 college students. Results: Controlling for gender and drinking motives, stronger values importance was predictive of lower rates of alcohol use problems. Less behavioral consistency with values predicted marijuana abstinence, less frequent use of marijuana, and less frequent use of illicit drugs. Although there was little evidence for a unique association between experiential avoidance and substance use or substance-related problems in this sample, coping and enhancement motives predicted alcohol use problems and illicit drug use. Conclusion/Importance: These findings offer preliminary support for prevention and intervention efforts aimed at enhancing engagement in values activities and reducing substance use as a form of affect regulation in this population.

The relationship between personal growth and psychological functioning in individuals treated in a partial hospital setting.

OBJECTIVES: We examined whether current level of personal growth and changes in personal growth predicted treatment response among participants in a partial hospital setting. METHOD: Patients (N = 269; aged 18-70 years, M = 33.6; 52.4% female) completed measures of personal growth initiative (PGI), valuing personal growth (VPG), and psychological functioning measures at treatment admission and discharge from a partial hospital. RESULTS: PGI and VPG were negatively associated with depression and positively associated with psychological well-being. Baseline PGI and VPG did not predict changes in psychological functioning at discharge. PGI and VPG significantly increased following treatment, and increases were associated with decreases in depression and increases in well-being over and above previously established predictors. CONCLUSIONS: Valuing personal growth for intrinsic reasons and active engagement in the personal growth process may be important characteristics to cultivate in psychotherapy as they are malleable and negatively related to depression.

Acceptance and Body Dissatisfaction: Examining the Efficacy of a Brief Acceptance Based Intervention for Body Dissatisfaction in College Women.

BACKGROUND: Body dissatisfaction among college women is concerning given its high prevalence and associated negative consequences. While cognitive-behavioral approaches to reducing body dissatisfaction have considerable support, it may be beneficial to target the problematic relationship that some individuals have with their internal experiences. AIMS: To examine the relative efficacy of an acceptance-based compared to a cognitive restructuring approach to targeting body dissatisfaction. METHOD: College women were randomly assigned to an acceptance (n = 21), cognitive restructuring (n = 21) or a neutral comparison condition (n = 24). Participants completed a body dissatisfaction challenge postintervention and their dissatisfaction, distress about body-related thoughts and emotions, and the extent they felt defined by their outward appearance were measured. RESULTS: Both approaches provided a protective effect against decreases in body satisfaction and related feelings. CONCLUSION: Acceptance and CBT approaches to treating body dissatisfaction are worthy of future investigation.

Interpersonal Problems, Mindfulness, and Therapy Outcome in an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder.

OBJECTIVE: To better understand the role interpersonal problems play in response to two treatments for generalized anxiety disorder (GAD); an acceptance-based behavior therapy (ABBT) and applied relaxation (AR), and to examine how the development of mindfulness may be related to change in interpersonal problems over treatment and at follow-up. METHOD: Eighty-one individuals diagnosed with GAD (65.4% female, 80.2% identified as white, average age 32.92) were randomized to receive 16 sessions of either ABBT or AR. GAD severity, interpersonal problems, and mindfulness were measured at pre-treatment, post-treatment, 6-month follow-up, and 12-month follow-up. RESULTS: Mixed effect regression models did not reveal any significant effects of pre-treatment interpersonal problems on GAD severity over treatment. After controlling for post-treatment GAD severity, remaining post-treatment interpersonal problems predicted 6- but not 12-month GAD severity. Participants in both conditions experienced a large decrease in interpersonal problems over treatment. Increases in mindfulness over treatment and through follow-up were associated with decreases in interpersonal problems, even when accounting for reductions in overall GAD severity. CONCLUSIONS: Interpersonal problems may be an important target of treatment in GAD, even if pre-treatment interpersonal problems are not predictive of outcome. Developing mindfulness in individuals with GAD may help ameliorate interpersonal difficulties among this population.

Mindfulness and acceptance-based behavioral therapies for anxiety disorders.

This article presents a brief conceptual overview of acceptance-based behavioral therapies (ABBTs) for anxiety disorders, followed by a review and summary of the recent efficacy studies of ABBTs for anxiety and comorbid disorders. We discuss clinical implications, including the importance of targeting reactivity and experiential avoidance in interventions for anxiety disorders through the use of mindfulness and other acceptance-based strategies, as well the encouragement of engagement in meaningful activities or valued action. We also address future directions for research, such as expanding research to include more randomized control trials comparing ABBTs for specific anxiety disorders to other active treatments, examining mechanisms of change, exploring adaptations in different care-delivery contexts, as well as determining the applicability of these approaches to clients from marginalized or non-dominant statuses.

A contemporary view of applied relaxation for generalized anxiety disorder.

Applied relaxation (AR), originally developed by Lars-Göran Öst, is a long-standing, efficacious treatment for generalized anxiety disorder (GAD). While newer treatments are continuing to be developed, AR remains one of the most efficacious treatments for GAD. However, AR has received less in-depth attention more recently, particularly in terms of potential mechanisms of action. This article is written to honor the development and history of AR and to highlight the ways that it has continued to be adapted. In this article, AR treatment strategies are presented, which include: noticing early signs of anxiety, learning relaxation skills, and applying relaxation at the first sign of anxiety. Then, additional adaptations to AR are presented along with recommendations of how AR may be enhanced by understanding potential mechanisms of change. Finally, recommendations are made for the continued evolution of AR as a powerful and efficacious treatment for GAD.

An Acceptance-Based Behavioral Therapy for Individuals with Generalized Anxiety Disorder.

In response to clinical observations and research findings that individuals with Generalized Anxiety Disorder are reactive to their internal experiences, avoid and suppress painful emotions, thoughts, and sensations, and limit their involvement in meaningful activities, an Acceptance Based Behavioral Therapy (ABBT) was developed to specifically target these responses. ABBT incorporates acceptance and mindfulness strategies with more traditional behavior therapy techniques. Specifically, ABBT uses mindfulness and acceptance approaches as an alternate response to the rigid, avoidant responses characteristic of GAD. Likewise, therapy focuses on identifying and enacting behaviors that are congruent with what is personally meaningful to the client rather than engaging in actions that are motivated by avoidance of anxiety. This article provides a case conceptualization from an ABBT perspective for "William," the composite client presented in Robichaud (this issue). The article goes on to demonstrate how an ABBT approach to treatment may unfold session-by-session for "William."

Using Mindfulness- and Acceptance-Based Treatments With Clients From Nondominant Cultural and/or Marginalized Backgrounds: Clinical Considerations, Meta-Analysis Findings, and Introduction to the Special Series.

A growing body of research suggests that mindfulness- and acceptance-based principles can increase efforts aimed at reducing human suffering and increasing quality of life. A critical step in the development and evaluation of these new approaches to treatment is to determine the acceptability and efficacy of these treatments for clients from nondominant cultural and/or marginalized backgrounds. This special series brings together the wisdom of clinicians and researchers who are currently engaged in clinical practice and treatment research with populations who are historically underrepresented in the treatment literature. As an introduction to the series, this paper presents a theoretical background and research context for the papers in the series, highlights the elements of mindfulness- and acceptance-based treatments that may be congruent with culturally responsive treatment, and briefly outlines the general principles of cultural competence and responsive treatment. Additionally, the results of a meta-analysis of mindfulness- and acceptance-based treatments with clients from nondominant cultural and/or marginalized backgrounds are presented. Our search yielded 32 studies totaling 2,198 clients. Results suggest small (Hedges' g=.38, 95% CI=.11 - .64) to large (Hedges' g=1.32, 95% CI=.61 - 2.02) effect sizes for mindfulness- and acceptance-based treatments, which varied by study design.

A Fresh Look at Potential Mechanisms of Change in Applied Relaxation for Generalized Anxiety Disorder: A Case Series.

Applied Relaxation (AR), which involves noticing early signs of anxiety and responding with a relaxation response, is an empirically supported treatment for Generalized Anxiety Disorder (GAD). However, research on hypothesized mechanisms of AR (e.g., reduced muscle tension) has been mixed, making it likely that additional mechanisms are contributing to the efficacy of AR. Stemming from more recent conceptualizations of GAD, it is hypothesized that mindfulness, decentering, and acceptance may be potential mechanisms of change in AR. Outcome, mechanism data, and case descriptions from three individuals diagnosed with GAD who received 16 weeks of AR as part of a larger randomized controlled trial are presented to demonstrate the ways that AR may lead to clinical improvement through mindfulness, decentering, and acceptance.

The role of values-consistent behavior in generalized anxiety disorder.

BACKGROUND: Theory and research suggest that generalized anxiety disorder (GAD) is associated with diminished quality of life and restriction in valued action. The purpose of this study was to examine the relevance of values-consistent behavior (valued action) in understanding the impairment in quality of life in GAD. METHOD: Treatment-seeking clients with a principal diagnosis of GAD (n = 30) were compared with demographically matched nonanxious controls (n = 30) using self-report measures. RESULTS: Participants with GAD reported significantly less valued action compared with controls, and within the GAD group, diminished valued action was not fully explained by depression comorbidity. Valued action was significantly correlated with measures of experiential avoidance, distress about emotions, and quality of life. Further, consistent with a theoretical model of GAD, restrictions in valued action contributed unique variance to diminished quality of life over and above the contributions of gender, GAD severity, experiential avoidance, distress about emotions, and depression comorbidity. Finally, an acceptance-based behavioral therapy significantly improved self-reports of valued action for GAD clients with 40% achieving clinically significant change in this domain. CONCLUSION: The findings provide preliminary support for the relevance of valued action in understanding the functional impairment associated with GAD, and the beneficial effects of an acceptance-based behavior therapy in increasing valued action.

Acceptance-based behavioral therapy for GAD: effects on outcomes from three theoretical models.

BACKGROUND: Although cognitive-behavioral therapy (CBT) is efficacious in the treatment of generalized anxiety disorder (GAD), many individuals remain symptomatic following treatment, indicating a need for further treatment development. As a result, many researchers have developed unique cognitive-behavioral therapies that highlight specific targets for intervention. METHODS: The current study examined the effect of an acceptance-based behavioral therapy for GAD on the proposed targets for intervention highlighted in several theoretical models: emotion regulation difficulties, intolerance of uncertainty, and low perceptions of control. Clients were randomly assigned to immediate (n=15) or delayed (n=16) treatment. RESULTS: Individuals treated with the acceptance-based behavioral therapy reported significantly fewer difficulties in emotion regulation and fear of emotional responses, as well as greater tolerance of uncertainty and perceived control over anxiety than individuals in the waitlist control condition. In addition, these effects were maintained at 3- and 9-month follow-up assessments. CONCLUSIONS: The present study provides promising evidence that an acceptance-based behavioral therapy for GAD has significant effects on the unique targets of intervention highlighted in several prominent theoretical models of GAD.

The effect of values affirmation on psychological stress.

There is growing evidence for the efficacy of acceptance-based behavioral therapies, which aim to increase acceptance of internal experiences and values-consistent action. Further, experimental studies have demonstrated that acceptance decreases distress and increases willingness to engage in challenging tasks (e.g. Levitt, Brown, Orsillo, & Barlow, 2004). However, research demonstrating the positive effects of values articulation on psychological functioning is needed. The goal of the present study was to evaluate the efficacy of a brief intervention in reducing anxiety related to a stressful speech task. Contrary to predictions, engagement in values writing did not reduce anticipatory or posttask anxiety relative to engagement in a neutral writing task. However, self-esteem significantly predicted anxious response to the task. Experiential avoidance and valued living were also associated with anxious response to the task, although the contribution of these predictors was not statistically significant.

The development of a brief acceptance and mindfulness-based program aimed at reducing sexual revictimization among college women with a history of childhood sexual abuse.

Women with a history of childhood sexual assault (CSA) are more likely to be revictimized; however, most existing programs aimed at reducing sexual victimization do not expressly address the issue of revictimization. The present study examined the efficacy of a brief mindfulness-based program in reducing rates of sexual assault and revictimization in college women over the course of an academic semester. Although the results were not statistically significant, a large-magnitude effect was noted, whereby women with a history of CSA who participated in the program were less likely to be sexually assaulted and raped at 2-month follow-up.

Distress and avoidance in generalized anxiety disorder: exploring the relationships with intolerance of uncertainty and worry.

Theory and research suggest that treatments targeting experiential avoidance may enhance outcomes for patients with generalized anxiety disorder (GAD). The present study examined the role of experiential avoidance and distress about emotions in a treatment-seeking sample with a principal diagnosis of GAD compared with demographically matched nonanxious controls and sought to explore their shared relationship with two putative psychopathological processes in GAD: intolerance of uncertainty and worry. Patients with GAD reported significantly higher levels of experiential avoidance and distress about emotions compared with nonclinical controls while controlling for depressive symptoms, and measures of these constructs significantly predicted GAD status. Additionally, experiential avoidance and distress about anxious, positive, and angry emotions shared unique variance with intolerance of uncertainty when negative affect was partialed out, whereas only experiential avoidance and distress about anxious emotions shared unique variance with worry. Discussion focuses on implications for treatment as well as future directions for research.

Psychophysiological and self-reported emotional responding in alcohol-dependent college students: the impact of brief acceptance/mindfulness instruction.

Drinking motivated by the desire to cope with painful emotions has been shown to be strongly related to alcohol dependence; the resulting maladaptive pattern of substance use can, therefore, be conceptualized as a form of experiential avoidance (an attempt to decrease contact with unpleasant internal states). Acceptance-based interventions, which specifically address experiential avoidance, are multifaceted, and the mechanisms of action are only beginning to be understood. Using a treatment analogue design to look at the underlying components of acceptance-based interventions, the authors tested the effects of brief mindfulness instructions on the emotional responding of alcohol-dependent college students and compared these results with those from a sample of nondependent students. Multidimensional self-reported and psychophysiological emotional responses to pleasant, unpleasant, and neutral pictorial stimuli did not differ between alcohol-dependent and nondependent participants or between the alcohol-dependent participants receiving the mindfulness versus neutral condition. Alcohol-dependent participants' severity of alcohol dependence was found to be related to both self-reported and psychophysiological responses to the unpleasant pictures; these results support the notion that alcohol-dependent participants may use alcohol to cope with unpleasant emotions.

Surviving and Thriving During Stress: A Randomized Clinical Trial Comparing a Brief Web-Based Therapist-Assisted Acceptance-Based Behavioral Intervention Versus Waitlist Control for College 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 increase access to evidence-based treatments. Web-based interventions and preventions are one way to bridge this gap; they hold the potential to decrease mental health disparities and enhance student functioning. The current RCT examined the acceptability and efficacy of a 3-session web-based therapist-assisted acceptance-based behavioral intervention targeting anxiety (Surviving and Thriving During Stress) for college students versus a waitlist (WL) control condition, in a sample of racially and ethnically diverse college students. Overall, participants rated the program as helpful and acceptable. Mixed-effects regression models (MRMs) were run in SPSS to examine the effects of time, condition, and Condition × Time on outcomes and hypothesized mechanisms. Significant Condition × Time interactions for general anxiety, depression, and quality of life (QOL) emerged, suggesting that SATDS participants reported significantly greater changes on these outcomes from pre- to posttreatment versus WL. However, interaction effects were nonsignificant for anxious arousal and social anxiety. MRMs examining hypothesized mechanisms revealed significant Condition × Time interactions for experiential avoidance, decentering, and values-based living. However, interaction effects were nonsignificant for mindfulness. All significant gains were maintained at 1-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 these approaches can be effective for diverse college students, and may provide a unique platform to increase access to evidence-based care.

An open trial of an acceptance-based behavior therapy for generalized anxiety disorder.

Research suggests that experiential avoidance may play an important role in generalized anxiety disorder (GAD); see . Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9, 54-68, for a review). Therefore, a treatment that emphasizes experiential acceptance, as well as intentional action, may lead to both reduced symptomatology and improved quality of life and functioning for individuals with this chronic disorder. In an open trial of a newly developed acceptance-based behavior therapy for GAD, 16 treated clients demonstrated significant reductions in clinician-rated severity of GAD and reports of anxiety and depressive symptoms and fear and avoidance of their internal experience, as well as significant improvements in reports of quality of life, at both posttreatment and 3-month follow-up. Directions for future treatment development and research are discussed.