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Acceptance-Based Behavioral Therapy for Generalized Anxiety Disorder

Acceptance-Based Behavioral Therapy (ABBT) for Generalized Anxiety Disorder (GAD) is a form of psychotherapy for adults who have a principal diagnosis of GAD. The treatment is designed to decrease symptoms of worry and stress, so clients no longer meet DSM-IV criteria for GAD or they experience a reduction in GAD symptoms and comorbid depression or mood-related symptoms. The model on which ABBT for GAD operates theorizes that GAD is caused and maintained by a restricted and self-critical position toward one's own internal experiences of thoughts, emotions, memories, and physical sensations, resulting in a behavioral repertoire of rigid and habitual efforts to control or avoid the unwanted internal experiences rather than engaging in valued activities. By integrating clinical methods and strategies from cognitive behavioral therapy with acceptance, mindfulness, and values practices, the intervention aims to help each client cultivate a curious, compassionate position toward one's internal experiences; increase acceptance of these internal experiences without behavioral efforts to avoid them; and increase the client's engagement in valued activities.

A therapist works one-on-one with a client over an 18-week period, delivering ABBT for GAD through 14 weekly and 2 biweekly sessions that include (1) psychoeducation regarding the nature of worry, anxiety, emotion, and experiential avoidance; (2) practice developing mindfulness and acceptance as an alternative response to internal experiences; and (3) identification of valued directions and actions, recognition of obstacles to these actions, and practice engaging in chosen valued actions nonetheless. The therapist focuses on helping the client make choices to act in value-consistent ways rather than in ways that are motivated by avoidance of anxiety. Each session begins with a mindfulness practice, involves the review of activities in identified valued directions between treatment sessions, and concludes with the assignment of out-of-session work. The first eight sessions include both psychoeducational and experiential components with a focus on helping the client develop skills, which are applied through practice during the final eight sessions. The last two sessions also include a focus on relapse prevention.

ABBT for GAD is one of several mindful acceptance-based and values-oriented behavioral therapies, which include Acceptance and Commitment Therapy, Dialectical Behavior Therapy, and Mindfulness-Based Cognitive Therapy (each of which was reviewed by NREPP separately).

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: September 2013
1: Generalized anxiety disorder diagnosis and severity
2: Worry and stress symptoms
3: Depression symptoms
Outcome Categories Mental health
Ages 18-25 (Young adult)
26-55 (Adult)
Genders Male
Female
Races/Ethnicities Asian
Black or African American
Hispanic or Latino
White
Settings Outpatient
Geographic Locations Urban
Suburban
Implementation History ABBT for GAD was developed in 2002, and since then, the intervention has been implemented with approximately 5,000 clients in 30 States and territories, as well as internationally in Australia, Brazil, Canada, Denmark, Iran, Israel, New Zealand, Singapore, Spain, Sweden, Switzerland, and the United Kingdom.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: No
Adaptations ABBT for GAD has been adapted for delivery in a group format in an outpatient setting. The treatment manual has been translated into Spanish, and the program has been culturally adapted for use in Puerto Rico. Two program books have been translated into other languages: Mindfulness and Acceptance-Based Behavioral Therapies in Practice has been translated into Portuguese, and The Mindful Way Through Anxiety: Break Free From Chronic Worry and Reclaim Your Life has been translated into Finnish and German.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: September 2013

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder: Evaluation in a randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(6), 1083-1089.  Pub Med icon

Supplementary Materials

Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment, 10(2), 176-181.

Brown, T. A., Antony, M. M., & Barlow, D. H. (1992). Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample. Behaviour Research and Therapy, 30(1), 33-37.  Pub Med icon

Brown, T. A., Chorpita, B. F., Korotitsch, W., & Barlow, D. H. (1997). Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behaviour Research and Therapy, 35(1), 79-89.  Pub Med icon

Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). Reliability of DSM-IV anxiety and mood disorders: Implications for the classification of emotional disorders. Journal of Abnormal Psychology, 110(1), 49-58.  Pub Med icon

Hayes, S. A., Orsillo, S. M., & Roemer, L. (2010). Changes in proposed mechanisms of action during an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder. Behaviour Research and Therapy, 48(3), 238-245.  Pub Med icon

Hayes-Skelton, S. A., Roemer, L., & Orsillo, S. M. (2013). A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 81(5), 761-773.  Pub Med icon

Michelson, S. E., Lee, J. K., Orsillo, S. M., & Roemer, L. (2011). The role of values-consistent behavior in generalized anxiety disorder. Depression and Anxiety, 28(5), 358-366.  Pub Med icon

Roemer, L., & Orsillo, S. M. (2007). An open trial of an Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder. Behavior Therapy, 38(1), 72-85.  Pub Med icon

Outcomes

Outcome 1: Generalized anxiety disorder diagnosis and severity
Description of Measures GAD diagnosis and severity were assessed using the Anxiety Disorders Interview Schedule for DSM-IV: Lifetime Version (ADIS-IV-L), which determines current and lifetime DSM-IV diagnostic status for GAD and provides a clinical severity rating (CSR) for each GAD diagnosis. The CSR ranges from 0 to 8, with higher numeric ratings indicating a greater severity of GAD.
Key Findings In a randomized clinical trial, adults who met DSM-IV criteria for GAD and sought treatment at an outpatient center for anxiety and related disorders were randomly assigned to the intervention group or the wait-list control group. All participants were assessed by trained doctoral students before (pretreatment) and after treatment (posttreatment), at least 14 weeks after study entry. Participants in the wait-list control group were offered ABBT for GAD after the posttreatment assessment, and all participants who received the intervention were assessed at 3- and 9-month posttreatment follow-ups. Findings included the following:

  • From pre- to posttreatment assessments, participants in the intervention group had a larger reduction in the CSR for GAD compared with participants in the wait-list control group (p < .001). This group difference was associated with a large effect size (Cohen's d = 1.32).
  • From the posttreatment assessment to the 3- and 9-month posttreatment follow-ups with all participants who received the intervention (including former wait-list participants), there was no significant change in the CSR for GAD.
  • At the posttreatment assessment, the percentage of participants who no longer had a DSM-IV diagnosis for GAD was larger for the intervention group relative to the wait-list control group (76.92% vs. 16.67%; p < .01).
  • From the posttreatment assessment to the 3- and 9-month posttreatment follow-ups with all participants who received the intervention (including former wait-list participants), there was no significant change in the percentage who no longer had a DSM-IV diagnosis for GAD (78.26% at the posttreatment assessment and 84.21% and 76.47% at the 3- and 9-month posttreatment follow-ups, respectively).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.1 (0.0-4.0 scale)
Outcome 2: Worry and stress symptoms
Description of Measures Worry and stress symptoms were measured using the following:

  • The Penn State Worry Questionnaire (PSWQ), a 16-item measure of trait levels of excessive worry. Using a scale ranging from 1 ("not at all typical of me") to 5 ("very typical of me"), participants respond to each item (e.g., "My worries overwhelm me," "I do not tend to worry about things," "Many situations make me worry"). Higher scores indicate a greater number of worry symptoms.
  • The 7-item Stress subscale of the 21-item Depression Anxiety Stress Scales (DASS-21). The DASS-21 includes Depression, Anxiety, and Stress subscales, and the Stress subscale approximates symptoms associated with GAD. Using a scale ranging from 0 ("did not apply to me at all") to 4 ("applied to me very much, or most of the time"), participants respond to items related to tension, agitation, and negative affect (e.g., "I felt I was rather touchy," "I found it difficult to relax," "I found myself getting agitated"). Higher scores indicate a greater number of stress symptoms.
Key Findings In a randomized clinical trial, adults who met DSM-IV criteria for GAD and sought treatment at an outpatient center for anxiety and related disorders were randomly assigned to the intervention group or the wait-list control group. All participants were assessed by trained doctoral students before (pretreatment) and after treatment (posttreatment), at least 14 weeks after study entry. Participants in the wait-list control group were offered ABBT for GAD after the posttreatment assessment, and all participants who received the intervention were assessed at 3- and 9-month posttreatment follow-ups. Findings included the following:

  • From pre- to posttreatment assessments, compared with participants in the wait-list control group, those in the intervention group had larger reductions in worry symptoms (p = .001) and in stress symptoms (p = .002). These group differences were associated with large effect sizes (Cohen's d = 1.02 and 0.92, respectively).
  • From the posttreatment assessment to the 3- and 9-month posttreatment follow-ups with all participants who received the intervention (including former wait-list participants), there were no significant changes in worry or stress symptoms.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.7 (0.0-4.0 scale)
Outcome 3: Depression symptoms
Description of Measures Depression symptoms were measured using the Beck Depression Inventory (BDI), a 21-item self-report instrument that assesses the severity of depression symptoms over the past 2 weeks. Using a scale ranging from 0 to 3, participants respond to each item. Total scores range from 0 to 63, with higher scores indicating more severe depression symptoms.
Key Findings In a randomized clinical trial, adults who met DSM-IV criteria for GAD and sought treatment at an outpatient center for anxiety and related disorders were randomly assigned to the intervention group or the wait-list control group. All participants were assessed by trained doctoral students before (pretreatment) and after treatment (posttreatment), at least 14 weeks after study entry. Participants in the wait-list control group were offered ABBT for GAD after the posttreatment assessment, and all participants who received the intervention were assessed at 3- and 9-month posttreatment follow-ups. Findings included the following:

  • From pre- to posttreatment assessments, compared with participants in the wait-list control group, those in the intervention group had a larger decrease in the severity of depression symptoms (p = .001). This group difference was associated with a large effect size (Cohen's d = 1.06).
  • From the posttreatment assessment to the 3- and 9-month posttreatment follow-ups with all participants (including former wait-list participants), there was no significant change in the severity of depression symptoms.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.8 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 18-25 (Young adult)
26-55 (Adult)
71% Female
29% Male
87.1% White
6.5% Hispanic or Latino
3.2% Asian
3.2% Black or African American

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Generalized anxiety disorder diagnosis and severity 2.3 1.8 1.8 1.8 2.0 3.0 2.1
2: Worry and stress symptoms 3.9 4.0 1.8 1.8 2.0 3.0 2.7
3: Depression symptoms 4.0 4.0 1.8 1.8 2.0 3.0 2.8

Study Strengths

Reliability was high (kappa = .72) for the ADIS-IV-L CSR across trained doctoral students who conducted the assessments; construct and face validity for this measure also were present. Internal reliability for the PSWQ was moderate (Cronbach's alpha = .79) with the study sample and high (Cronbach's alpha = .86) with subsamples with GAD in an independent clinical sample. Reliability for the DASS-21 Stress subscale was high (Cronbach's alpha = .87) with the study sample, as was internal consistency (Cronbach's alpha = .91) with an independent study sample. The BDI is very well known in the mental health field and has strong psychometric properties, including high internal consistency and test-retest reliability and construct, convergent, and discriminant validity (among depression subtypes and between depression and anxiety); reliability for the BDI was high (Cronbach's alpha = .87) with the study sample. The PSWQ has construct (for one factor, worry), criterion, and convergent validity with a subsample with GAD. The DASS-21 Stress subscale has construct validity (for stress, anxiety, and depression factors), with concurrent and discriminant validity (among different anxiety groups). The intervention is manual driven and was delivered by six doctoral students under the direct supervision of the investigators/intervention developers. Two sessions with each client were randomly selected and rated for treatment adherence using a 17-item checklist, with 25% of the randomly selected sessions double rated for interrater reliability, which was moderate across the two doctoral student raters (kappa = .70). Random assignment controlled for many potential confounding variables. The analytic strategy used an intent-to-treat approach and sophisticated statistical modeling with prospective power analyses and effect size calculations to detect between-group differences in the outcomes.

Study Weaknesses

For the GAD diagnosis from the ADIS-IV-L, interrater reliability across raters was low during the study (kappa = .56), despite training, experience, certification, and ongoing consensus meetings with a supervising doctoral-level psychologist. The validity of the GAD diagnosis was complicated by the comorbid presence of mood disorders, which were allowed in the study population, and the fact that GAD diagnostic disagreements frequently involved incomplete separation between GAD and mood disorders. The 17-item adherence checklist was described as a listing of 12 "allowed" and 5 "forbidden" strategies, but the strategies were not linked to critical stages or steps to be carried out in a treatment session, and no psychometric properties were presented for the checklist. The number of sessions rated with the adherence checklist was low across the study and inadequate to establish psychometrics for a fidelity instrument. There was no comparison of completers and noncompleters on pretreatment demographic variables, despite a small sample size and attrition rates of 13% in the intervention group and 25% in the wait-list control group at the posttreatment assessment. For the 3- and 9-month follow-ups, the attrition rates were much higher (38.7% and 45.2%, respectively), and again, there was no comparison of completers and noncompleters on pretreatment demographic variables. Potential confounding variables include the absence of an attention control group, the absence of substantiated reliability of the GAD diagnosis at posttreatment and follow-up assessments, the inability to confirm that raters were blind to condition, and the absence of independent fidelity competency ratings of the therapists delivering the intervention. The sophisticated statistical modeling used requires a minimum sample size per group and more than two groups, requirements that were not met in the study.

Readiness for Dissemination
Review Date: September 2013

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Orsillo, S. M. (n.d.). An Acceptance-Based Behavior Therapy for Generalized Anxiety Disorder [PowerPoint slides]. Boston, MA: Author.

Orsillo, S. M., & Roemer, L. (2011). The mindful way through anxiety: Break free from chronic worry and reclaim your life. New York, NY: Guilford Press.

Orsillo, S. M., & Roemer, L. (n.d.). Mindfulness and acceptance-based behavioral therapies in practice [PowerPoint slides]. Boston, MA: Author.

Program Web site, http://mindfulwaythroughanxietybook.com

Roemer, L., & Orsillo, S. M. (2009). An Acceptance-Based Behavior Therapy for GAD (a work in progress). Boston, MA: Author.

Roemer, L., & Orsillo, S. M. (2009). Mindfulness- and acceptance-based behavioral therapies in practice. New York, NY: Guilford Press.

Roemer, L., & Orsillo, S. M. (n.d.). Mindfulness and acceptance-based behavioral therapy for anxiety disorders [PowerPoint slides]. Boston, MA: Author.

Other program materials:

  • ABBT for GAD Adherence Checklist
  • ABBT for GAD Weekly Competence Form
  • ABBT Group Adaptation Materials
  • ABBT Helpful Responses Worksheet and Answers
  • ABBT Medication Monitoring Forms
  • ABBT Mindfulness Exercises
  • ABBT Treatment Handouts
  • ABBT Treatment Monitoring Forms
  • ABBT Treatment Values Assignments
  • List of Potential Measures

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
4.0 3.3 3.5 3.6

Dissemination Strengths

The program materials are comprehensive and clearly describe therapeutic techniques of the intervention and the implementation of individual psychotherapeutic sessions. Although training is not required, a training workshop is offered to address variation in implementer skill and includes a range of detail on the model. Ongoing consultation and support are available. Tools for assessing client progress in treatment, client satisfaction with treatment, and observer ratings of therapist fidelity to the model and skills used in treatment sessions are available to support quality assurance. Guidance is provided on selecting and administering assessment tools for use with various client populations.

Dissemination Weaknesses

Little guidance is provided for the interpretation and use of data collected from quality assurance tools. Supervision and comprehensive fidelity monitoring are not emphasized as an integral part of program delivery.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Mindfulness- and Acceptance-Based Behavioral Therapies in Practice (book) $28 each Yes
The Mindful Way Through Anxiety: Break Free From Chronic Worry and Reclaim Your Life (book) $16.95 each Yes
Acceptance and Commitment Therapy (book) $37.78 each No
Mindfulness-Based Cognitive Therapy (book) $55 each No
Skills Training Manual for Treating Borderline Personality Disorder $36.87 each No
An Acceptance-Based Behavior Therapy for GAD (manual) Free No
ABBT Treatment Handouts Free No
On-site ABBT training workshop Varies, depending on site needs, length of training, and location No
Implementation consultation by phone or email or in person $150 per hour, plus travel expenses if necessary No
ABBT for GAD Weekly Competence Form Free No
ABBT for GAD Adherence Checklist Free No
Contact Information

To learn more about implementation, contact:
Susan M. Orsillo, Ph.D.
(617) 305-1924
sorsillo@suffolk.edu

To learn more about research, contact:
Lizabeth Roemer, Ph.D.
(617) 287-6358
lizabeth.roemer@umb.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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