Wednesday, October 27, 2010

Acceptance and Commitment Therapy Vs. Cognitive Therapy for the Treatment of Comorbid Eating Pathology

Recently, a group of researchers at Drexel University--including Dr. James Herbert, who we interviewed about mindfulness over the summer--conducted a study comparing Acceptance and Commitment Therapy (ACT) and Cognitive Therapy (CT) for disordered eating. Juarascio and colleagues looked at people in treatment with "subclinical eating pathology"--meaning that most people identified problematic eating behavior but didn't qualify for an official eating disorder diagnosis.

Although CBT is considered the gold-standard for eating disorder treatment, some research indicates only 30-50% of people completely stop binging and purging, according to research cited by the authors. Consequently, there seems to be some room for improvement.

This study appears to have been culled from the leftovers from a previous study of ACT and CT treatment for anxiety and depression (Foreman et al., 2007), that it was pulled from the same data set. It looks like the authors found that a number of participants (N = 55) from the data set reported eating disordered behavior and ran additional analyses on these individuals.

This study is what is known as an effectiveness study. It doesn't have the control of an efficacy study, but it plays out closer to what happens in real life. This makes it more naturalistic. (Click here for a quick explanation of efficacy vs. effectiveness.)

Participants agreed to the study and were randomly assigned to either an ACT or a CT therapist. These were students at a post-baccalaureate institution who received treatment from one of 23 doctoral students trained in both ACT and CT. Therapy was not conducted through a manual or protocol, as would happen in an efficacy study.

The researchers predicted people who received ACT would show greater improvements than those who received CT, and analyses supported this hypothesis. Although CT lead to small improvements in eating disorder behavior, ACT led to very large improvements.

Because treatment wasn't manualized, we don't know exactly what components of CT and ACT were drawn upon in therapy. In addition, CT participants didn't necessarily receive gold-standard CT protocols for eating disordered behavior. In fact, as they note, the researchers are not certain if  eating disordered behavior was a focus. And, as was noted, the eating disordered problems were generally subclinical. For these reasons, this study cannot be considered a test of a gold-standard cognitive behavioral treatment for eating disorders against ACT.

That said, this study has wonderful real world validity. If someone with eating disordered problems walked into a CT or an ACT therapist's office, this is the kind of treatment he or she may be likely to receive. Fewer clinicians use the kind of manualized treatments that are used in more controlled studies (e.g., RCT's), although knowledge of manualized treatments can be very useful in real world practice.

This study provides pretty good evidence for the effectiveness of ACT in addressing eating disordered behavior. ACT promotes greater mindfulness, acceptance, and movement towards valued directions; by contrast, CT focuses on changing the content of one's thinking. Results suggest ACT processes of change may be more appropriate for individuals with eating disordered problems than CT processes.

Drs. Forman and Herbert have large collection of their research available as PDF's on their Drexel research lab page. Click here to download a copy of the article.

For the full citation:

Juarascio, A. S., Forman, E. M., & Herbert, J. D. (2010). Acceptance and Commitment Therapy versus Cognitive Therapy for the treatment of comorbid eating pathology. Behavior Modification, 34(2), 175-190.

Thursday, October 21, 2010

Differential Effects of Mindful Breathing, Progressive Muscle Relaxation, and Loving-Kindness Meditation on Decentering and Negative Reactions to Repetitive Thoughts

"Decentering" is a term used to describe a process in which individuals learn to take a step back and observe a thought more objectively as content, rather than perceiving thoughts as accurate reflections of reality. For example, a non-decentered stance might be something like, "I'm too anxious to attend thw party," believing the thought, and canceling plans to attend, even though one would like to go. A more decentered stance is, "I'm having the thought, 'I'm too anxious to attend the party,'" and attending anyway. Decentering came out of the Mindfulness-Based Cognitive Therapy camp (Click here for other SM MBCT posts), and is similar to "defusion" in Acceptance and Commitment Therapy (Click here for other SM ACT posts).

In a recent study published in Behaviour Research and Therapy, Dr. Greg Feldman of Simmons College and colleagues examined the impact of a 15 minute intervention on decentering, as measured by the Toronto Mindfulness Scale.

As Simmons College is an all girls' school, all participants were female. They were randomly assigned to one of three 15 minute guided exercises: 1.) mindful breathing, adapted from a MBCT script; 2.) a Buddhist loving-kindness meditation, adapted from Insight Meditation by Buddhist teachers Sharon Salzburg and Joseph Goldstein; and 3.) progressive muscle relaxation, a decades old relaxation practice that is just like it sounds.

Mindful breathing was related to greater scores on decentering compared to loving-kindness and progressive muscle relaxation. Also, even though people who practiced mindful breathing endorsed greater repetitive thoughts (e.g., worrying, making mental lists), mindful breathing was associated with a weaker relationship between negative affect and repetitive thoughts. This finding adds to a growing body of literature suggesting that mindfulness shift the way people respond to negative thoughts and feelings, making them less aversive. (Similarly, the MBRP study we recently wrote about had a similar finding with depression and relapse.)

Several years ago, I never would have thought we could find signficant changes from only 15 minutes of mindfulness, but there is a growing body of research using similarly short interventions. We still need to be careful of other confounds, such as demand characteristics (e.g., people responding a certain way because they feel expected to), but the research is very promising.

For the abstract, click here. For the full citation:

Feldman, G., Greeson, J., & Senville, J. (2010). Differential Effects of Mindful Breathing, Progressive Muscle Relaxation, and Loving-Kindness Meditation on Decentering and Negative Reactions to Repetitive Thoughts. Behaviour Research and Therapy, 48, 1002-1011.

Friday, October 15, 2010

A RCT of Acceptance and Commitment Therapy vs. Progressive Relaxation Training for Obsessive-Compulsive Disorder

In a previous post about the use of Acceptance and Commitment Therapy (ACT) for problematic pornography viewing, I mentioned researcher Dr. Michael Twohig’s work with ACT for obsessive-compulsive disorder (Twohig, Hayes, &; Masuda, 2006; Twohig, 2009; Twohig &; Whittal, 2009). Well, it looks like Dr. Twohig is on a hot streak as Journal of Consulting and Clinical Psychology (JCCP) has just published another study by Dr. Twohig: the first randomized controlled trial (RCT) of ACT for OCD.

OCD is a condition characterized by frequent, unwanted thoughts (obsessions) and/or reliance on repetitive or ritualized behavior (compulsions) in order to get rid of obsessions and reduce anxiety. The gold standard of treatment is what’s called Exposure with Ritual Prevention (ERP; sometimes called Exposure and Response Prevention), which is often used in the context of cognitive behavioral treatment. ERP involves having people sit for extended periods of time with distressing stimuli related to obsessions without engaging in the compulsions they typically use to alleviate distress. For example, someone with a fear of germs who compulsively hand washes might be asked to smear dirt on his hands and spend a half hour sitting with dirty hands without washing them. For someone who spends hours a day compulsively washing his hands even when they are not observably dirty, this can be extremely stressful. Perhaps because of this, there is a high drop out rate for people using ERP—about 25% according to the article. Also, even though ERP is the most effective treatment for OCD, most clinicians are reluctant to use it. (Clinicians can be uncomfortable sitting with distress, too!)

Although exposure can be and often is incorporated into ACT treatment, Dr. Twohig specifically did not include ERP in his ACT protocol. This move is shrewd yet bold. Given the widespread research support for the use of ERP in OCD treatment, adding it to ACT would leave the study vulnerable to serious questions about whether ACT contributes anything new to OCD treatment.

It’s worth noting, however, that the study does not directly compare ACT to ERP. Instead ACT is compared to progressive relaxation training (PRT), in which people are systematically taught ways of relaxing, beginning with their muscles. PRT has some support in OCD treatment but is considered less effective than ERP. I’ll address the researchers' reasons for using PRT over ERP at the end of this blog.

Approximately 80 people were randomly assigned to receive either 8-weeks of ACT or 8-weeks of PRT delivered in 1-hour sessions. The protocol is striking in its brevity--eight 1-hour sessions is not a lot of time. Participants were assessed 1 week before treatment, 1 week, after treatment, and 3-months later.

Instead of ERP, ACT treatment focused on typical ACT processes. Participants learned to notice how attempts at controlling obsessions made them worse over time, respond to obsessions more flexibly, and make behavioral commitment to things that were important to them. The behavioral commitments may resemble in vivo or real-world exposure exercises often found in ERP treatments. However, emphasis was placed less on deliberate exposure as in traditional ERP. Instead, the emphasis was placed on moving towards something important and responding to any distress that showed up.

Results indicted greater improvement in OCD symptoms at the end of treatment and at follow-up for ACT participants compared to those assigned to PRT. Participants rated the acceptability of ACT very highly—more so than PRT. Additionally, dropout rates were lower for ACT than is common for ERP.

This study provides evidence that ACT is a useful treatment for OCD worth further study. ACT has several things going for it: 1.) ACT was well-tolerated by participants, which is extremely important given the high dropout rate associated with ERP; 2.) The ACT protocol was remarkably brief—eight 1-hour sessions—which is much shorter than average for ERP treatments; 3.) Although not directly compared, reductions in OCD were similar to those indicated in a review of ERP treatment for OCD.

The researchers caution that they believe the ACT protocol for OCD would benefit from more tinkering before it is compared to ERP. However, I expect we’ll see a direct comparison in the near future. ACT has the potential to be a treatment that is better tolerated but as effective as ERP, or it may be a treatment for people who cannot tolerate direct exposure as emphasized in ERP. Regardless, it’s off to a promising start.

For members of the Association for Contextual Behavioral Science, the article may be downloaded here. For full citation:

Twohig, M.P., Hayes, S.C., Plumb, J.C., Pruitt, L.D., Collins, A.B., et al. (2010). A Randomized Controlled Trial of Acceptance and Commitment Therapy vs. Progressive Relaxation Training for Obsessive-Compulsive Disorder. Journal of Consulting and Clinical Psychology, 78(5), 705-716.

Wednesday, October 6, 2010

MBCT for Individuals Whose Lives Have Been Affected by Cancer: A RCT

A recent issue of the well-respected Journal of Consulting and Clinical Psychology has an article on the use of Mindfulness-Based Cognitive Therapy (MBCT) for people with cancer. MBCT is an adaptation of Mindfulness-Based Stress Reduction (MBSR) and was developed to reduce depressive relapse. MBSR has already been used with good results in people with cancer across several studies (Carlson et al, 2003; Tacon et al., 2004), including one randomized controlled trial (RCT; Speca et al., 2000). Although it's not the first study employing a mindfulness-based treatment with an oncology population, this new study is the first controlled study of MBCT for people with cancer.

The authors of this study, a group of Australian researchers lead by Dr. Elizabeth Foley, call MBCT a “refinement” of MBSR twice in the article, which I found a strange choice of words. It could imply that MBCT may be better suited to addressing the needs of cancer patients; however, the authors don’t actually say this and the design of the study doesn’t allow for these conclusion to be drawn. Instead, the authors suggest that because depression and anxiety are common in cancer patients, and because MBSR has been shown to be helpful in people with cancer, using MBCT may also be beneficial.

The sample consisted of 115 patients across a range of cancer types. They were randomly assigned to either MBCT or a wait-list condition. The wait-list group received MBCT after the data was collected.

MBCT involves 8 weekly 2-hour sessions in groups of 8-12 people. MBCT was modified in several ways for these participants. Didactic information focused on common problems associated with cancer, including depression, anxiety, and pain. One change that particularly struck me was the body scan. The body scan involves mindfully moving your attention from your toes to the crown of your head. Apparently this was very difficult for many participants, for whom bringing awareness to the cancerous part of the body was very painful and difficult. Consequently, participants had the option of a “graded practice,” which might begin with awareness of the sensation of one’s clothing in the cancerous area. Sensitivity was paid to the physical difficulties of practice and to fatigue. Lastly, 32% of participants had people who cared for them also participate in MBCT per invitation by the researchers. Overall, I was really impressed by the sensitivity in adapting this treatment for cancer patients.

The results of the study indicated that, compared to the wait-list group, people who participated in MBCT showed improvements in anxiety, depression, and distress. These improvements were maintained at a 3-month follow-up. One thing I found impressive is that at 3 months, 62% reported regular meditation practice and 31% reported occasional practice. This means that over 90% found value in continued mindfulness practice.

Given that MBSR has already been used successfully with cancer patients in previous studies, I personally think comparing MBCT to MBSR (as opposed to a wait-list) would have been much more interesting. The authors note that the impact of treatment is comparable to the MBSR RCT by Speca et al. (2000). Consequently, I don’t think this study is particularly groundbreaking. That said, it’s always interesting to encounter a RCT for a mindfulness-based treatment, and the study adds to the growing literature in the use of mindfulness-based interventions for cancer patients.

Full citation for the MCBT study:

Foley, E., Baillie, A., Huxter, M., Price, M., & Sinclair, E. (2010). Mindfulness-Based Cognitive Therapy for individuals whose lives have been affected by cancer: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 78(1), 72-79.

Citations for studies of MBSR with cancer patients (links are included to free PDF's of articles ):

Tacón, A. M., Caldera, Y. M., & Ronaghan, C. (2004). Mindfulness-based stress reduction in women with breast cancer. Families, Systems, & Health, 22(2), 193-203.

Friday, October 1, 2010

Prickles and Goo

Today I'm offering something on the lighter side.

This video provides a cute illustration of some of the tensions that can build between those approaching mindfulness from an empirical standpoint and those who approach it more traditionally. That said, I think there's a little bit of prickles and a little bit of goo in all of us.

The narration is a clip of Alan Watts. Watts had a profound impact on the West in making Buddhism, particularly Zen, accessible to the English-speaking world. Watts published The Spirit of Zen in 1936 and continued to speak and publish until his death in 1973. The animation is by South Park creators Trey Parker and Matt Stone.