Monday, June 28, 2010

Mindfulness and Acceptance Workbook for Anxiety

Last week I attended the Association for Contextual Behavioral Science (ACBS) World Conference in Reno, NV. During the lunch hour for a pre-conference weekend training with Dr. John Forsyth from the University at Albany, SUNY , we had the option of sitting in on a presentation of some unpublished research John and his lab had collected about his recent self-help book, The Mindfulness and Acceptance Workbook for Anxiety, which he co-authored with Dr. Georg Eifert. I have an interest in the effectiveness of self-help books, so I was eager to see what he found.

John presented data from two studies. In the first study, he gave out free copies of his book through a website to participants who agreed to be randomly assigned to either receive his book immediately, or to receive it after being part of a 12-week waitlist condition. Participants were assessed before receiving the book, after 12-weeks, and at 3 and 6-month follow-ups. At the end of 12-weeks, compared to the waitlist, participants who used the book showed dramatic improvements in anxiety, depression, worry, social anxiety, and even PTSD. What’s especially interesting about this is that anxiety decreased even though the book’s emphasis is on improving one’s life through cultivation of mindfulness, acceptance, and compassion rather than on getting rid of anxiety (and depression is not really addressed to my recollection). Readers of the book had significant increases in mindfulness, self-compassion, and quality of life that were maintained over the 3 and 6-month follow-ups. The same pattern happened for people who used the book after getting off the waitlist. Another remarkable thing about this study is that about half the participants were currently in psychotherapy and/or taking meds, suggesting that the book contributed to improvements above and beyond individual treatment. Nearly everyone (91%) had been in therapy before.

In a second study that is still underway, John used a similar design to compare his book to The Cognitive Behavioral Workbook for Anxiety, a respected workbook by William J. Knaus. John’s lab is still collecting follow-up data, but results are showing that, although both books appear effective, people using the Mindfulness workbook are showing greater outcomes on virtually all measures.

I think these studies are great for several reasons. For one, the market is filled with self-help books but rarely are they evaluated to determine if people actually find them helpful
. Two, this is the most naturalistic study I’ve seen, as participants have no additional interaction with John’s lab except to complete the online outcome assessments. Some other studies I’ve seen involve occasional interaction with someone from the lab to help people with a book, but in these studies, people are largely left to their own devices. Lastly, this study is very brave in that John risked finding: 1.) that his book was not helpful after all; 2.) that his book was helpful, but not as helpful as the Cognitive Behavioral workbook. Instead, his commitment to science has paid off for him in a big way. This book is a great illustration of how cultivation of mindfulness, acceptance, and compassion can really improve our lives.

Thursday, June 17, 2010

Mindfulness Intervention for Child Abuse Survivors

A group of researchers at the University of Maryland School of Medicine conducted a pilot study enrolling 27 adult survivors of childhood sexual abuse in an 8-week Mindfulness-Based Stress Reduction (MBSR) program. At the end of the program, participants exhibited significant reductions in depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms. These gains remained significant when participants were tested again 2 months after the program ended.

Although I’ve talked to therapists who are using meditation-based groups for people with PTSD—and even co-led one myself on my internship—this is the first published study I’ve come across. For that reason, I was excited about this article; however, there were some major limitations to this study. For one, participants were required to also be in individual psychotherapy; consequently, results cannot be attributed to MBSR alone. Additionally, because there was no control group, the researchers cannot rule out natural decline in symptoms unrelated to the treatment, or a placebo effect.

Despite these concerns, improvements were quite large, suggesting that additional study of MBSR with trauma survivors is worthwhile. Moreover, that 85% of participants attended the final MBSR session suggests that the treatment was well tolerated and appropriate for survivors of childhood sexual abuse. Personally, I hope to see additional research on the use of mindfulness and meditation in addressing PTSD.

For the full citation:

Kimbrough, E., Magyari, T., Langenberg, P., Chesney, M., & Berman, B. (2009). Mindfulness intervention for child abuse survivors. Journal of clinical psychology, 66(1), 17-33.

Thursday, June 10, 2010

Milk Milk Milk

One of the classic Acceptance and Commitment Therapy (ACT) interventions is called Milk Milk Milk. In this exercise, the therapist asks the client to think of the all the qualities associated with the word “milk.” The therapist then asks the client to repeat the word “milk” over and over again for about 45 seconds. Most people find that the word eventually loses all associations and becomes series of meaningless sounds or vocalizations. The therapist may then do the same thing with a word that has a strong negative self-referential quality for the client (e.g., “fraud,” “ugly,” stupid,” “damaged”). Similar to the word “milk,” the negative self-referential word begins to lose it’s meaning when said repeatedly for 45 seconds.

In ACT, this is known as a cognitive defusion exercise. The purpose of defusion exercises is to reduce the literal function of private events such as thoughts by changing its context. When we say a word aloud repeatedly, for example, we are no longer experiencing the word as we typically do. Through defusion, what might be previously perceived as a threatening stimulus becomes something harmless. Defusion also helps facilitate acceptance.

Dr. Akihiko Masuda and colleagues recently published a really interesting study where they broke down components of the Milk Milk Milk exercise. Across two studies, undergraduates were asked to generate a negative self-referential thought, and to rate this thought on the level of discomfort associated with it and its believability. They were then asked to say the word repeatedly out loud for a set duration: 1, 3, 10, 20, or 30 seconds. After they stopped, they were asked to rate the emotional discomfort and believability of the word again.

The results were really interesting. Emotional discomfort of the word went down more quickly, within the 3 – 10 second ranges. Believability took longer to go down, about 20 – 30 seconds. The first conclusion the authors draw is that emotional discomfort and believability may be different constructs. Additionally, believability appears to be more related to the degree to which individuals become caught up in private events. As a consequence, the authors conclude, focusing on reducing the emotional discomfort of a word may be less important that reducing the believability of the word, which takes a little longer.

Although not mentioned in the article, the constant process of noticing thoughts and returning to the breath in meditation may serve a similar function in reducing the believability of thought.

To read the full article:

Masuda, A., Hayes, S. C., Twohig, M. P., Drossel, C., Lillis, J., & Washio, Y. (2009). A parametric study of cognitive defusion and the believability and discomfort of negative self-relevant thoughts. Behavior Modification, 33(2), 250-262.

Thursday, June 3, 2010

Influencing Psychological Flexibility to Influence Cultural Evolution

In an article published in a 2009 issue of Behavior and Social Issues, 18, Dr. Anthony Biglan of the Oregon Research Institute writes about how through Acceptance and Commitment Therapy, an empirically-supported mindfulness- and acceptance-based treatment, people can learn to be more flexible in the way they respond to things, and through that, develop a greater attitude of caring for other human beings. He argues this would help reduce prejudice towards others, curb punitive disciplinary measures, and lower consumerism, which could help promote sustainable living. There is some initial research to support Dr. Biglan’s position, although the general thrust of the paper is more theoretical than empirical.

You can download the PDF here.