A Meta-analytic Review of Acceptance-Based Behavioral Interventions for the Treatment of Anxiety

The relative popularity of acceptance and commitment therapy (ACT) has grown in recent years, and inspired the development of contemporary acceptance-based treatment approaches. Acceptance-based therapies differ from traditional cognitive- behavior therapy (CBT) on pragmatic grounds, the import of which implicates the purpose of therapy. CBT utilizes exposure and cognitive change techniques primarily in service of symptom change outcomes; whereas, ACT utilizes exposure and acceptance for purposes of promoting psychological flexibility in the pursuit of personal values. The purpose of this meta-analytic study was to determine the relative efficacy of acceptance- based versus symptom-change behavioral approaches with anxiety disorders and to quantify this impact. A comprehensive literature search turned up 18 studies that met inclusion criteria for this analysis. An effect size was calculated using the standardized mean gain procedure for both the acceptance-based and symptom-change approaches, along with the waitlist control groups. The results demonstrate a large effect size for the acceptance-based approach (Weighted mean ES = .83) and a medium effect size for symptom-change approach (Weighted mean ES = .60). The waitlist control groups demonstrated a small effect size (Weighted mean ES = .24). Based on this review, it is suggested that graduate and internship programs in Clinical Psychology should promote evidence-based training in the use of acceptance-inspired behavioral therapies.

Guérir avec l'EMDR : preuves et controverses

L'EMDR est une thérapie qui a été développée pour traiter les souvenirs traumatiques, puis proposée pour traiter une variété de troubles psychologiques. Ce texte est le premier à recenser en français les études qui ont évalué l'efficacité de cette forme de thérapie. L'efficacité de l'EMDR est d'abord démontrée à l'aide d'études de cas qui comportent des limites importantes. Les études de cas basées sur un protocole expérimental donnent des résultats plus mitigés. Les études contrôlées qui examinent l'efficacité de l'EMDR sont ensuite décrites en fonction du type de contrôle exercé et du type de trouble traité. L'EMDR est aussi efficace que la thérapie cognitivocomportementale pour traiter le trouble de stress posttraumatique, mais pas pour le traitement de la phobie spécifique ni du trouble panique. De plus, les études montrent de façon répétée que l'absence des mouvements oculaires ne modifie pas l'efficacité de l'EMDR. Une analyse des différences et des similitudes entre l'EMDR et l'approche cognitivo-comportementale est présentée. Les caractéristiques pseudo-scientifiques qui ont marquées le développement et la diffusion de l'EMDR sont aussi abordées.

Guérir avec l'EMDR : preuves et controverses

L'EMDR est une thérapie qui a été développée pour traiter les souvenirs traumatiques, puis proposée pour traiter une variété de troubles psychologiques. Ce texte est le premier à recenser en français les études qui ont évalué l'efficacité de cette forme de thérapie. L'efficacité de l'EMDR est d'abord démontrée à l'aide d'études de cas qui comportent des limites importantes. Les études de cas basées sur un protocole expérimental donnent des résultats plus mitigés. Les études contrôlées qui examinent l'efficacité de l'EMDR sont ensuite décrites en fonction du type de contrôle exercé et du type de trouble traité. L'EMDR est aussi efficace que la thérapie cognitivocomportementale pour traiter le trouble de stress posttraumatique, mais pas pour le traitement de la phobie spécifique ni du trouble panique. De plus, les études montrent de façon répétée que l'absence des mouvements oculaires ne modifie pas l'efficacité de l'EMDR. Une analyse des différences et des similitudes entre l'EMDR et l'approche cognitivo-comportementale est présentée. Les caractéristiques pseudo-scientifiques qui ont marquées le développement et la diffusion de l'EMDR sont aussi abordées.

Improving family functioning and child outcome in methadone maintained families: the Parents Under Pressure programme

Twelve families responded to posters displayed in a methadone clinic for inclusion in a pilot study assessing the viability and potential utility of an intensive, multi-component family-focused intervention, the Parents Under Pressure programme. The programme was designed to improve child behaviour, decrease parental stress and improve family functioning in methadone-maintained families by targeting affect regulation, mood, views of self as a parent, drug use and parenting skills. Nine of the families completed the programme delivered in their homes; eight were recontacted at 3 months. Each family reported significant improvements in three domains: parental functioning, parent - child relationship and parental substance use and risk behaviour. In addition to the changes in family functioning, the majority of families reported a decrease in concurrent alcohol use, HIV risk-taking behaviour and maintenance dose of methadone. The families reported high levels of satisfaction with the programme. It is recommended that future studies include independent measures (e.g. behavioural observations) of child outcome and parental functioning. The results were optimistic and provided the impetus to evaluate the treatment programme using a randomized controlled trial.

The burden of major depression avoidable by longer-term treatment strategies

Background: Major depression is the largest single cause of nonfatal disease burden in Australia. Effective drug and psychological treatments exist, yet are underused. Objective: To quantify the burden of disease currently averted in people seeking care for major depression and the amount of disease burden that could be averted in these people under optimal episodic and maintenance treatment strategies. Design: Modeling impact of current and optimal treatment strategies based on secondary analysis of mental health survey data, studies of the natural history of major depression, and meta-analyses of effectiveness data. Monte Carlo simulation of uncertainty in the model. Setting: The cohort of Australian adults experiencing an episode of major depression in 2000 are modeled through "what if" scenarios of no treatment, current treatment, and optimal treatment strategies with cognitive behavioral therapy or antidepressant drug treatment. Main Outcome Measure: Disability-Adjusted Life Year. Results: Current episodic treatment averts 9% (95% uncertainty interval, 6%-12%) of the disease burden of major depression in Australian adults. Optimal episodic treatment with cognitive behavioral therapy could avert 28% (95% uncertainty interval, 19%-39%) of this disease burden, and with drugs 24% (95% uncertainty interval, 19%-30%) could be averted. During the 5 years after an episode of major depression, current episodic treatment patterns would avert 13% (95% uncertainty interval, 10%-17%) of Disability-Adjusted Life Years, whereas maintenance drug treatment could avert 50% (95% uncertainty interval, 40%-60%) and maintenance cognitive behavioral therapy could avert 52% (95% uncertainty interval, 42%-64%), even if adherence of around 60% is taken into account. Conclusions: Longer-term maintenance drug or psychological treatment strategies are required to make significant inroads into the large disease burden associated with major depression in the Australian population.

Beating the urge: Implications of research into substance-related desires

Despite the advent of improved pharmacological treatments to alleviate substance-related desires, psychological approaches will continue to be required. However, the current psychological treatment that most specifically focuses on desires and their management-cue exposure (CE)-has not lived up to its original promise. This paper argues that current psychological approaches to desire do not adequately incorporate our knowledge about the factors that trigger, maintain, and terminate episodes of desire. It asserts that the instigation and maintenance of desires involve both associative and elaborative processes. Understanding the processes triggering the initiation of intrusive thoughts may assist in preventing some episodes, but occasional intrusions will be inevitable. A demonstration of the ineffectiveness of thought suppression may discourage its use as a coping strategy for desire-related intrusions, and mindfulness meditation plus cognitive therapy may help in accepting their occurrence and letting them go. Competing tasks may be used to reduce elaboration of desires, and competing sensory images may have particular utility. The application of these procedures during episodes that are elicited in the clinic may allow the acquisition of more effective strategies to address desires in the natural environment. (C) 2004 Elsevier Ltd. All rights reserved.

Integrated versus non-integrated management and care for clients with co-occurring mental health and substance use disorders: a qualitative systematic review of randomised controlled trials

The purpose of this paper is to conduct a qualitative review of randomised controlled trials in relation to the treatment of adults with co-occurring mental health and substance use disorder (MH/SUD). In particular, integrated approaches are compared with non-integrated approaches to treatment. Ten articles were identified for inclusion in the review. The findings are equivocal with regard to the superior efficacy of integrated approaches to treatment, although the many limitations of the studies need to be considered in our understanding of this finding. Clearly, this is an extremely challenging client group to engage and maintain in intervention research, and the complexity and variability of the problems render control particularly difficult. The lack of available evidence to support the superiority of integration is discussed in relation to these challenges. Much remains to be investigated with regard to integrated management and care for people with co-occurring and MH/SUD, particularly for specific combinations of dual diagnosis and giving consideration to the level of inter-relatedness between the disorders. (C) 2004 Elsevier Ltd. All rights reserved.

Autobiographical memory specificity in response to verbal and pictorial cues in clinical depression

Background Depressed individuals have been consistently shown to exhibit problems in accessing specific memories of events from their past and instead tend to retrieve categorical summaries of events. The majority of studies examining autobiographical memory changes associated with psychopathology have tended to use word cues, but only one study to date has used images (with PTSD patients). Objective to determine if using images to cue autobiographical memories would reduce the memory specificity deficit exhibited by patients with depression in comparison to healthy controls. Methods Twenty-five clinically depressed patients and twenty-five healthy controls were assessed on two versions of the autobiographical memory test; cued with emotional words and images. Results Depressed patients retrieved significantly fewer specific memories, and a greater number of categorical, than did the controls. Controls retrieved a greater proportion of specific memories to images compared to words, whereas depressed patients retrieved a similar proportion of specific memories to both images and words. Limitations no information about the presence and severity of past trauma was collected. Conclusions results suggest that the overgeneral memory style in depression generalises from verbal to pictorial cues. This is important because retrieval to images may provide a more ecologically valid test of everyday memory experiences than word-cued retrieval.

Misophonia:current perspectives

Misophonia is characterized by a negative reaction to a sound with a specific pattern and meaning to a given individual. In this paper, we review the clinical features of this relatively common yet underinvestigated condition, with focus on co-occurring neurodevelopmental disorders. Currently available data on the putative pathophysiology of the condition can inform our understanding and guide the diagnostic process and treatment approach. Tinnitus retraining therapy and cognitive behavior therapy have been proposed as the most effective treatment strategies for reducing symptoms; however, current treatment algorithms should be validated in large population studies. At the present stage, competing paradigms see misophonia as a physiological state potentially inducible in any subject, an idiopathic condition (which can present with comorbid psychiatric disorders), or a symptomatic manifestation of an underlying psychiatric disorder. Agreement on the use of standardized diagnostic criteria would be an important step forward in terms of both clinical practice and scientific inquiry. Areas for future research include phenomenology, epidemiology, modulating factors, neurophysiological underpinnings, and treatment trials.

Intentional forgetting in dysphoria:investigating the inhibitory effects of thought substitution using independent cues

Background Individuals with clinical and subclinical depression (dysphoria) exhibit problems intentionally forgetting unwanted memories on the think/no-think (TNT) paradigm (Anderson & Green, 2001). However, providing substitute words to think about instead of the to-be-forgotten targets can improve forgetting in depressed patients. Objectives To determine if thought substitution can enhance forgetting in dysphoric participants and to examine the potential mechanisms (blocking or inhibition) that might underpin successful forgetting. Methods Thirty-six dysphoric and 36 non-dysphoric participants learned neutral word-pairs and then practiced responding with the targets to some cues (think trials) and suppressing responses to others (no think trials). Half the participants were provided with substitute words to recall instead of the original targets (aided suppression) and half were simply told to avoid thinking about the targets (unaided suppression). Finally, participants completed two recall tests for the targets; one cued with the original probes and one with independent probes. Results Regardless of suppression condition (aided or unaided), dysphoric participants exhibited impaired forgetting, relative to their non-dysphoric counterparts, but only when cued with the original probes. Furthermore, higher depression scores were associated with poorer forgetting. In the aided condition, successful forgetting was observed on both the original and independent probe tasks, which supports the inhibitory account of thought substitution. Limitations Non-clinical status of the dysphoric participants was not confirmed using a validated measure. Conclusions Findings do not support the utility of thought substitution as a method of improving the forgetting in depressed participants, but do support the inhibition account of thought substitution.

Acceptance of relapse fears in breast cancer patients: effects of an act-based abridged intervention

Objective: Relapse fear is a common psychological scar in cancer survivors. The aim of this study is to assess the effects of an abridged version of Acceptance and Commitment Therapy (ACT) in breast cancer patients.Method: An open trial was developed with 12 non-metastatic breast cancer patients assigned to 2 conditions, ACT and waiting list. Interventions were applied in just one session and focused on the acceptance of relapse fears through a ‘defusion’ exercise. Interference and intensity of fear measured through subjective scales were collected after each intervention and again 3 months later. Distress, hypochondria and ‘anxious preocupation’ were also evaluated through standardized questionnaires.Results: The analysis revealed that ‘defusion’ contributed to decrease the interference of the fear of recurrence, and these changes were maintained three months after intervention in most subjects. 87% of participants showed clinically significant decreases in interference at follow-up sessions whereas no patient in the waiting list showed such changes. Statistical analysis revealed that the changes in interference were significant when comparing pre, post and follow-up treatment, and also when comparing ACT and waiting list groups. Changes in intensity of fear, distress, anxious preoccupation and hypochondria were also observed.Conclusions: Exposure through ‘defusion’ techniques might be considered a useful option for treatment of persistent fears in cancer patients. This study provides evidence for therapies focusing on psychological acceptance in cancer patients through short, simple and feasible therapeutic methods.

Intervención cognitivo-conductual para el control de ansiedad ante la biopsia insicional en pacientes con cáncer de mama

Oncological patients are submitted to invasive exams in order to obtain an accurate diagnosis; these procedures may cause maladaptative reactions (fear, anxiety and pain). Particularly in breast cancer, the most common diagnose technique is the incisional biopsy. Most of the patients are unaware about the procedure and for that reason they may focus their thoughts on possible events such as pain, bleeding, the anesthesia, or the later surgical wound care. Anxiety and pain may provoke physiological, behavioral and emotional complications, and because of this reason, the Behavioral Medicine trained psychologist takes an active role before and after the biopsy. The aim of this study was to evaluate the effect of a cognitive-behavioral program to reduce anxiety in women submitted to incisional biopsy for the first time. There were 10 participants from the Hospital Juárez de México, Oncology service; all of them were treated as external patients. The intervention program focused in psycho-education and passive relaxation training using videos, tape-recorded instructions and pamphlets. Anxiety measures were performed using the IDARE-State inventory, and a visual-analogue scale of anxiety (EEF-A), and the measurement of blood pressure and heart rate). Data were analyzed both intrasubject and intersubject using the Wilcoxon test (p≤0.05). The results show a reduction in anxiety (as in punctuation as in ranges) besides, a reduction in the EEF-A.

Signalling changes to individuals who show resistance to change can reduce challenging behaviour

Background & objectives Several neurodevelopmental disorders are associated with resistance to change and challenging behaviours – including temper outbursts – that ensue following changes to routines, plans or expectations (here, collectively: expectations). Here, a change signalling intervention was tested for proof of concept and potential practical effectiveness. Methods Twelve individuals with Prader-Willi syndrome participated in researcher- and caregiver-led pairing of a distinctive visual-verbal signal with subsequent changes to expectations. Specific expectations for a planned subset of five participants were systematically observed in minimally manipulated natural environments. Nine caregivers completed a temper outburst diary during a four week baseline period and a two week signalling evaluation period. Results Participants demonstrated consistently less temper outburst behaviour in the systematic observations when changes imposed to expectations were signalled, compared to when changes were not signalled. Four of the nine participants whose caregivers completed the behaviour diary demonstrated reliable reductions in temper outbursts between baseline and signalling evaluation. Limitations An active control group for the present initial evaluation of the signalling strategy using evidence from caregiver behaviour diaries was outside the scope of the present pilot study. Thus, findings cannot support the clinical efficacy of the present signalling approach. Conclusions Proof of concept evidence that reliable pairing of a distinctive cue with a subsequent change to expectation can reduce associated challenging behaviour is provided. Data provide additional support for the importance of specific practical steps in further evaluations of the change signalling approach.

The Relationship between Materialistic Aspirations and Distinct Aspects of Psychological Well-being in a UK sample

The purpose of this research is to gain a deeper understanding of how materialistic aspirations are related to distinct aspects of psychological well-being. Research has consistently found a negative relationship between materialistic goals and well-being, but a review of the literature identified that the measures of well- being used in the majority of studies were measures of what Keyes (2002) describes as “subjective well-being” or “hedonic happiness”. Criticisms of these types of measures are that they fixate too much on the momentary experience of pleasure and don’t take into account what is meaningful and or what contributes to long lasting fulfilment. Very little research was found investigating the impact of materialism on “eudaimonic” well-being, which is found through doing what is worthwhile and realising ones potential and has been found to have a longer lasting impact on overall well-being (Huta & Ryan, 2010). To address this gap in the literature, a convenience sample of 113 adult subjects in the UK were recruited through Facebook and asked to respond to the Aspiration Index and the Psychological wellbeing scale. The relative importance placed on extrinsic (materialistic) and intrinsic aspirations was compared to the six dimensions of psychological well-being. In line with previous research, higher importance placed on materialistic aspirations for wealth, status and image were found to be negatively correlated with all aspects of psychological well-being. However, the strongest and only statistically significant negative correlation was between extrinsic aspirations and positive relations with others (r = -.256, p< 0.01). Positive relationships with other people form a central component of many theories of well- being and so this negative relationship may help to explain why materialistic aspirations are so consistently found to be negatively correlated to a variety of measures of well-being. Further research is needed to explore this relationship as no causation could be inferred.