Acceptance and Commitment Therapy for …

1 Acceptance and CommitmentTherapy for GeneralizedSocial Anxiety DisorderA Pilot StudyKristy L. DalrympleBrown Medical School and Rhode Island HospitalJames D. HerbertDrexel UniversityDespite the demonstrated efficacy of cognitive-behavior Therapy (CBT) forsocial anxiety disorder (SAD), many individuals do not respond to treatment ordemonstrate residual symptoms and impairment posttreatment. Preliminaryevidence indicates that Acceptance -based approaches ( , Acceptance andcommitment Therapy ; ACT) can be helpful for a variety of disorders andemphasize exposure-based strategies and processes.

2 Nineteen individualsdiagnosed with SAD participated in a 12-week program integrating exposuretherapy and ACT. Results revealed no changes across a 4-week baseline controlperiod. From pretreatment to follow-up, significant improvements occurred insocial anxiety symptoms and quality of life, yielding large effect size changes also were found in ACT-consistent process measures, andearlier changes in experiential avoidance predicted later changes in symptomseverity. Results suggest the acceptability and potential efficacy of ACT forSAD and highlight the need for future research examining both the efficacy andmechanisms of change of Acceptance -based programs for SAD.

3 Keywords: social anxiety disorder; Acceptance and Commitment Therapy ;experiential avoidanceSocial anxiety disorder (SAD) is an extreme fear of embarrassment orhumiliation in social or performance situations and is usually charac-terized by avoidance of these situations. The fear often is associated withBehavior ModificationVolume XX Number XMonth XXXX XX-XX Sage Note:We thank Brandon A. Gaudiano, PhD, for his comments regarding previousversions of the address correspondence to Kristy L.

4 Dalrymple, Department of Psychiatry, Rhode IslandHospital, 235 Plain St., Suite 501, Providence, RI 02905; e-mail: distress and impairment in several areas, including work, sociallife, and family life (Herbert & Dalrymple, 2005). The Diagnostic andStatistical Manual of Mental Disorders(4th ed., text revision; DSM-IV-TR;American Psychiatric Association [APA], 2000) recognizes two subtypesof SAD: generalized and specific. The generalized subtype includes thosewho fear multiple social situations, and the specific subtype includes thosewho fear one or two discrete social situations.

5 SAD is the fourth mostcommon psychiatric disorder in the United States (after major depression,alcohol dependence, and specific phobia), with a lifetime prevalence rate (Kessler, Berglund, Demler, Jin, & Walters, 2005). Cognitive behavioral group Therapy (CBGT; Heimberg, 1991; Heimberg& Becker, 2002) is the most extensively studied treatment program forSAD. It emphasizes the cognitive factors that maintain SAD ( , exag-gerated negative beliefs about one s performance in social situations; Clark& Wells, 1995; Rapee & Heimberg, 1997), as well as behavioral factors( , avoidance of these situations).

6 CBGT targets these maintaining fac-tors by means of cognitive restructuring in an effort to modify negativebeliefs, as well as with in vivo and simulated exposure exercises to decreaseavoidance and test dysfunctional beliefs. Several studies support the effi-cacy of CBGT ( , Heimberg et al., 1998; Hope, Herbert, & White, 1995),and it is included on the list of empirically supported treatments developedby the American Psychological Association s Committee on Science andPractice (Chambless et al.)

7 , 1996). Recently CBGT for SAD has beensuccessfully adapted to an individual format ( , Herbert, Rheingold,Gaudiano, & Myers,2004), and a meta-analysis has shown no differencebetween group and individual formats (Gould, Buckminster, Pollack, Otto,and Yap, 1997).Results from studies examining the relative efficacy of the componentsof cognitive behavior treatment (CBT) for SAD have been mixed, althoughfew studies have demonstrated the added efficacy of cognitive restructuringto exposure alone.

8 A meta-analysis by Gould et al. (1997) found that expo-sure interventions produced the largest effect sizes, either alone or in com-bination with cognitive restructuring. In addition, a dismantling study byHope, Heimberg, and Bruch (1995) found that exposure alone was at leastas effective as exposure plus cognitive restructuring. Previous studies alsohave shown that exposure Therapy alone achieved cognitive changes in thesame range as that achieved by using traditional cognitive restructuringtechniques alone (Hope et al.)

9 , 1995a; Mattia, Heimberg, & Hope, 1993;Newman, Hofmann, Trabert, Roth, & Taylor, 2004), suggesting that cogni-tions may not necessarily need to be changed directly through cognitiverestructuring for patients to engage in exposure. 2 Behavior ModificationAlthough traditional CBTs for SAD have been shown to be efficacious,most individuals continue to demonstrate residual symptoms and impair-ment after treatment, and a significant percentage do not respond to treat-ment at all (approximately 25% of patients in some studies, such as thoseof Heimberg et al.

10 , 1998, and Herbert et al., 2005). Even in those patientswho do respond to treatment, their scores often do not reach those of non-clinical populations and they continue to experience significant symptomsposttreatment. Few studies have examined the effect of traditional CBT onquality of life in SAD, but one study found that, although quality of life hadimproved by posttreatment, scores still did not approach those of nonanx-ious persons (Eng, Coles, Heimberg, & Safren, 2001). More recent researchhas shown that 12 weeks of CBT improved quality of life only in interper-sonal domains but not other ones, such as personal growth (Eng, Coles,Heimberg, & Safren, 2005).