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ACT therapy

Dr. Simon Moss

Overview

Acceptance commitment therapy, or ACT, encourages clients to accept unpleasant feelings, thoughts, or images, instead inviting these individuals to engage in acts that align with their values rather than attempt to suppress or to avoid these undesirable private experiences. Despite emphasizing that unpleasant feelings, thoughts, and images should be observed without judgment, not inhibited, such problems tend to dissipate during the treatment process (Hayes, 2004a, 2004b). ACT has been shown to be effective in treating anxiety, depression, psychotic behavior, addictions, prejudice, and many other issues.

Description of the practice

Rationale

ACT, pronounced as one word, entails a set of six, interrelated processes, such as learning to accept unpleasant feelings or thoughts. These processes are intended to discourage individuals from avoiding, suppressing, or neglecting these undesirable events, because these tendencies are purported to exacerbate, not curtail, the problem. Metaphors are used, paradoxes are demonstrated, exercises are completed, and language is analyzed to fulfill these purposes.

According to the rationale that underpins ACT, many psychological problems are ascribed to this tendency to avoid or suppress unpleasant events (Hayes, Wilson, Gifford, Follette & Strosahl, 1996). For example, alcohol consumption, intended to circumvent social anxiety, often provokes other problems, such as job loss, which ultimately exacerbates the problems these individuals attempted to preclude. Parents who do not want to impose regulations on their children, merely to alleviate their fears of parental incompetence, tend to foster dysfunctional behavior in these children, again magnifying the very problem they attempted to circumvent. .

Process 1. Acceptance: The futility of control

The first process that practitioners introduce is called acceptance. The principal aim of this process is to highlight that unpleasant thoughts and feelings-anxiety, depression, prejudice, and so forth--cannot be controlled, suppressed, or stymied effectively. Indeed, attempts to control these thoughts or feelings amplify, not solve, the problem. Instead, individuals learn to accept some level of anxiety, depression, or some other unpleasant thought, feeling, or memory.

Typically, practitioners first discuss the problem with clients, utilizing these experiences to highlight the futility of controlling emotions and avoiding stress. Practitioners might ask clients how they attempt to redress their problem. Perhaps the clients shun public speaking, for example, to avoid anxiety. Practitioners then ask clients the extent to which these strategies were successful, ultimately attempting to show that most attempts to avoid or suppress anxiety are initially successful but eventually ineffective.

Practitioners might then highlight the futility of controlling emotions and thoughts, often referring to metaphors that highlight this assertion. They might, for example, refer to the "man in the hole metaphor", as depicted by Hayes, Strosahl, and Wilson (1999). Clients are asked to imagine falling into a hole or crater on some planet, representing the problem, and have access to a shovel to escape, representing the activities they undertake to solve the issue. Attempts to dig and escape, however, merely magnify the hole, reminiscent of the common experience that striving to control or reduce emotions often exacerbate the problem. The metaphor challenges the objective to reduce the emotion, such as anxiety or depression.

In addition to metaphors, exercises are sometimes introduced to highlight the futility of controlling emotions and thoughts. Clients, for example, are asked not to refrain from thinking about a warm chocolate cake as this dessert emerges from the oven (Hayes, Strosahl, & Wilson, 1999). Alternatively, they might be asked to pretend they are connected to a polygraph and have been instructed to avoid anxiety, depression, or other feelings and thoughts they cannot readily control.

Rather than metaphors or exercises, logical arguments can be proposed. In particular, people perceive anxiety as a feeling that must be avoided. As a consequence, they avoid any experiences that could provoke anxiety. Because they attempt to shun these experiences, such as public speaking, they perceive these settings as especially distressing-merely amplifying their anxiety in response to similar contexts

These exercises are intended to highlight the distinction between events that can be controlled-actions and behaviors-and events that cannot be readily controlled-thoughts, feelings, and images. For instance, in the context of obsessive-compulsive disorder, these activities demonstrate the distinction between compulsive behaviors, which can be controlled, and obsessive thoughts, which are more difficult to curb.

Acceptance: Willingness to experience

Once clients recognize the futility of controlling thoughts, feelings, and images, they are encouraged to accept, not suppress, disregard, avoid, or deride, these private events. Sometimes, they are asked to imagine a dial on their right shoulder, ranging from 1 to 10, representing the extent to which they experience the problem, such as anxiety, distress, or prejudice (Hayes, Strosahl, & Wilson, 1999). They are reminded they cannot reduce this dial& attempts to alleviate anxiety, for example, are often futile and even damaging. Next, they are asked to imagine a dial on their left shoulder, also ranging from 1 to 10, representing the level of anxiety, distress, and so forth they are willing to accept. As this dial rises, openness towards the unpleasant feeling increases.

Clients should be encouraged to raise this willingness. They are informed that raising willingness to accept the emotion might not alleviate the problem, but reducing willingness tends to amplify the problem. To develop this willingness, they should be encouraged to practice accepting the problem, exposing themselves to distressing events, and refraining from changing or judging the ensuing emotions.

Process 2: Defusion

The second process that practitioners institute is called defusion. Clients are asked to consider that thoughts and feelings are not always valid, but can be conceptualized as only mental events. As part of this process, the practitioner might often question the reasons that clients offer to justify dysfunctional behavior. For example, clients might express statements like "I wanted to attend the party but I was very anxious". The practitioner might challenge this reasoning, asking whether anxiety must dissipate before the client attends the party. The practitioner could argue the term "but" could be replaced with "and": "I wanted to attend the party and I was very anxious" (Hayes, Strosahl, & Wilson, 1999).

Second, practitioners could demonstrate that most individuals assume that thoughts are representations of reality. To illustrate, they could be asked to identify all their associations with the term "anxiety"-perhaps they form images of angry authorities, recall bodily symptoms, remember occasions in which anxiety compromised their performance, and so forth. They can then be asked to undertake an unusual exercise, which is to repeat the term "anxiety" many times, over 30 seconds. Suddenly, associations with the word anxiety seem to change. Rather than associate this term or feeling with all the other events, anxiety is merely perceived as a strange sound

Likewise, in the context of obsessive-compulsive disorder, practitioners could distinguish between obsessions-which are thoughts or worries-from compulsions-which are behaviors and fundamentally distinct. Individuals can experience obsessions, such as the belief their hands must be cleansed repeatedly, without engaging in the compulsion to align with this belief.

In the context of discrimination, individuals might learn that prejudicial feelings and thoughts are common, if not inevitable. However, these feelings and thoughts do not necessarily need to govern behavior (Lillis & Hayes, 2007) .

Process 3: Self as context

The third process that practitioners apply is called self as context. Practitioners encourage clients to refrain from defining or identifying themselves by their thoughts and feelings. Thoughts and feelings are merely private, transient events, not permanent features.

The chessboard metaphor is often used to demonstrate this proposition (Hayes, Strosahl, & Wilson, 1999). Clients are asked to imagine a chessboard in which the black pieces represent the undesirable thoughts or feelings, whereas the white pieces represent the desirable thoughts or feelings. Clients would clearly prefer the white pieces to prevail. However, their efforts to energize the white pieces also invigorate the black pieces and, as a consequence, this goal is never realized. Finally, practitioners ask the client "If you are not the pieces, then who are you?" Hopefully, the clients will perceive themselves as the chessboard-an entity that persists even as the pieces annihilate one another. In other words, they endure regardless of their thoughts, feelings, and memories.

Process 4: Contact with the present moment

In addition, practitioners invite clients to engage in the present moment, observing the world directly, not be biased by preconceptions, expectations, or linguistic practices. Clients might be encouraged to focus on their breath or attend to bodily feelings, gradually progressing from the toes to the head. In addition, they learn to merely observe unpleasant events rather than strive to modify or stifle these feelings and thoughts.

Process 5: Values

Fifth, clients are encouraged to clarify their values, reflecting upon their idealized goals and desires. Clients might be encouraged to complete the Valued Living Questionnaire (Hayes, Strosahl, & Wilson, 1999), which characterizes their values in several domains, such as family, friends, career, growth, spirituality, wellbeing, and recreational facets of life. Subsequently, they are asked to consider the importance of each domain and the extent to which they have fulfilled these values.

After this exercise, clients are asked to consider how suitable actions-exposure to stressful events, abstention from compulsive behaviors, completion of tedious work and so forth-facilitate the achievement of these values. The clients begin to recognize how avoidance of stressful contexts or engagement in compulsive behaviors might have obstructed these core values.

Process 6: Committed action

The final process is to commit-genuinely commit-to the behaviors they plan to enact, ultimately to pursue these values. In other words, clients should focus on overt behaviors that align with their values not feelings or thoughts that disrupt this pursuit. Practitioners might ask "Are you willing to do everything to engage in this act, prepared to accommodate some of the unpleasant feelings and thoughts that might coincide with this behavior?" Practitioners are discouraged from suggesting these activities will necessarily alleviate the problem: the anxiety, the obsession, and so forth.

Typical sessions

During the first session, practitioners attempt to characterize the problem the client is experiencing, before outlining the rationale and processes that underpin ACT. In every subsequent session, clients are encouraged to describe the principal events that transpired since the previous session, including the review of any homework that was assigned. Information that was presented in the previous session is summarized and additional material, together with more homework and commitments, are imparted.

Empirical support

Many studies have uncovered evidence that corroborates the efficacy of ACT and substantiate the rationale of this approach. ACT, for example, has been used to curb anxiety disorders, including obsessive-compulsive disorder (Hayes, 1987), social anxiety (Block & Wulfert, 2000), as well as panic disorder (Carrascoso, 1999& Eifert & Heffner, 2003& Levitt, Brown, Orsillo, & Barlow, 2004) and to reduce the likelihood of psychotic patients returning to hospital (Bach & Hayes, 2002& see also Gaudiano & Herbert, 2006). In addition, ACT can facilitate the capacity of individuals to desist from smoking (Gifford, Kohlenberg, Hayes, Antonuccio, Piasecki, Rasmussen-Hall, M. L., et al., 2004). Only a portion of past studies, however, have compared ACT with other established paradigms.

Affective disorders

Two randomized controlled studies, conducted by Zettle and Hayes (1986) and Zettle and Rains (1989), have shown that ACT was more effective in alleviating depression that was cognitive therapy. In addition, research conducted by Forman, Herbert, Moitra, Yeomans, and Geller (2007) showed the benefits of ACT, relative to cognitive therapy alone, in the treatment of anxiety disorders as well.

ACT has also been shown to curb trichotillomania, a tendency of some individuals to repeatedly pull their hair, intended to relieve tension, ultimately both provoking hair loss and impairing wellbeing. In particular, ACT, when coupled with habit reversal in which individuals learn to engage in alternative behaviors in response to the usual antecedents of pulling hair, has been shown to be effective (Twohig & Woods, 2004), and this effect typically coincides with a reduction in avoiding distressing events (Woods, Wetterneck, & Flessner, 2006). The benefits tended to persist for at least 3 months (Twohig & Woods, 2004).

Presumably, if acceptance is limited, individuals will often experience a discrepancy between their actual and desired affective states. Kampfe and Mitte (2009) showed that such discrepancy was, indeed, negatively related to life satisfaction. Furthermore, this discrepancy was inversely related to the self efficacy of individuals in regulating emotions.

Physical disorders

Several studies have shown ACT improves the wellbeing of patients who experience chronic pain (Hayes, Bissett, Korn, Zettle, Rosenfarb, Cooper, et al., 1999& McCracken & Eccleston, 2006& Torch & Follette, 2006)

Workplace settings

Research has seldom explored the impact of ACT in a work environment (but see Bond & Hayes, 2002& Bond, Hayes, & Barnes-Holmes, 2006). Research has seldom explored the impact of ACT in a work environment. Nevertheless, individuals who demonstrate a disposition to accept, rather than disregard or suppress, unpleasant thoughts, feelings, or images--as well as feel confident they can pursue their goals regardless of these experiences-are less inclined to commit errors at work (Bond & Bunce, 2003). That is, attempting to disregard or suppress unpleasant thoughts, feelings, and memories distracts attention from the ongoing, core values and goals of individuals. This distraction can compromise their concentration, increasing the likelihood of errors. Furthermore, because attention is distracted, they are less inclined to recognize opportunities, and therefore fail to utilize the benefits that autonomy can afford. As a consequence the positive relationship between job control and wellbeing diminishes in employees who suppress or avoid unpleasant feelings and thoughts (Bond & Bunce, 2003).

When is the practice suitable

ACT is suitable in a vast range of settings. The benefits, however, are especially pronounced in individuals who tend to avoid distressing or upsetting events, as shown by Zettle (2003) in a study that examined whether ACT can curb anxiety towards mathematics.

Acceptance rather than suppression is also especially beneficial in people who exhibit a susceptibility to anxiety. To illustrate, Keough, Timpano, Riccardi, and Schmidt (2010) conducted a study in which participants completed the White Bear Suppression Inventory, intended to measure the extent to which people strive to suppress, instead of accept, negative thoughts and feelings. Furthermore, sensitivity to anxiety was assessed, reflecting the degree to which participants fear anxiety symptoms. To illustrate, some people feel that a racing heart might translate into a heart attack. Finally, measures of panic attacks and obsessive-compulsive disorder were administered.

In general, anxiety sensitivity was positively associated with panic attacks and obsessive-compulsive disorder. This relationship, however, was especially pronounced if participants strive to suppress, instead of accept, their negative states. Presumably, anxiety sensitivity elicits negative states and thoughts. Suppression then further magnifies these negative states and thoughts.

Neglect of threatening information

As Nestler and Egloff (2010) showed, if individuals demonstrate cognitive avoidance rather than acceptance, they tend to neglect threatening information. For example, they are not as likely to change their behavior to prevent some health risk. In particular, they do not like to embrace the uncertainty and anxiety that change can evoke. They will, therefore, trivialize the importance of these changes.

For example, in a study that was conducted by Nestler and Egloff (2010), participants read a brochure about the potential dangers of excessive caffeine. Some participants were informed that caffeine could increase the likelihood of cancer, evoking a sense of threat. Other participants were not exposed to this information but were instead informed the problems that caffeine can provoke do not correspond to their age group, evoking a limited sense of threat. Participants who reported elevated levels of cognitive avoidance, such as denial, intended to change their behavior, but only if exposed to a limited sense of threat. In contrast, participants who reported limited levels of cognitive avoidance, coinciding with acceptance, intended to change their behavior, especially if they were exposed to threatening information.

Examples of the practice

Smoking

ACT has been applied successfully to facilitate abstention from cigarettes (Gifford, Kohlenberg, Hayes, Antonuccio, Piasecki, Rasmussen-Hall, et al., 2004). In particular, to curb the urge to smoke, individuals should be encouraged to recognize the thoughts, feelings, and urges that elicit their need to smoke-perhaps a feeling of unease or a need to relax. Then, they should be informed that most attempts to curb these experiences, such as suppressing their anxiety or disregarding their urges, merely amplify the problem. Third, they should be asked to consider the values they would like to pursue, the goals they would like to achieve, and some possible barriers to these endeavors, including intense urges or irritability. Next, they should learn to accept these thoughts, feelings, and urges, recognizing these experiences themselves are not inappropriate--only their response to these experiences are sometimes dysfunctional. Instead, they should learn to observe these feelings and urges, without judgment. Subs quently, they should attempt to expose themselves to various levels of these feelings and urges, gradually increasing the duration of refraining from cigarettes. They should practice a broad range of different techniques, such as observing many features of the environment, engaging in enjoyable tasks, watching TV, singing, and so forth, in response to these urges and feelings.

In addition to the benefits of acceptance, studies have also demonstrated the drawbacks of thought suppression on smoking. Erskine, Georgiou, and Kvavilashvili (2010) reported a study in which participants recorded their levels of stress and cigarette intake over a three week period. Furthermore, during the second week, some participants were asked to suppress thoughts about smoking. That is, they were instructed not to think about smoking and to suppress any thoughts that do emerge. Other participants, in contrast, were encouraged to think about smoking as frequently as they could.

Suppression of thoughts actually increased cigarette intake. That is, participants who were told not to think about smoking one week were more inclined to smoke the next week. Furthermore, this study showed that individuals who often strive to suppress unpleasant thoughts attempt, unsuccessfully, to quit smoking more often. Suppression might increase the subsequent intensity of thoughts about smoking (see ironic rebound)--which increased stress and exacerbated smoking.

Schizophrenia

As O'Connor (2009) argues, schizophrenia might emanate not from unusual, intruding thoughts, but from the disinclination to accept these thoughts. Specifically, according to O'Connor (2009), many individuals report anomalous experiences. Indeed, as research shows, many individuals in nonclinical populations adopt unusual and implausible thoughts to explain various phenomenon (e.g., Blakemore, Oakley, & Frith, 2003): They might, for example, sometimes feel their body is controlled by an external source or alien. Over 60% of individuals have experienced some level of dissociation, for example (Fewtrell & O'Connor 1995).

However, the individuals who eventually progress to schizophrenia seem to extend and appraise these thoughts differently. They might, for example, be especially concerned about these experiences. This concern can amplify these thoughts and ultimately compromise their wellbeing.

O'Connor (2009) delineated several processes that can translate an anomalous experience into clinical manifestations of schizophrenia. First, rather than conceptualize these anomalous experiences as unexplained events, some individuals might begin to form entrenched beliefs to explicate these phenomena. To illustrate, when problems arise, they might, for example, tend to blame other people or entities. They might thus ascribe any deficiencies to external agents (e.g., Bentall & Kaney, 1996). Popular myths and other social trends could also facilitate the formation of these beliefs.

Likewise, these individuals might be especially unwilling to accept ambiguity. Hence, to curb this ambiguity or uncertainty, they might form unsubstantiated beliefs that can generate specific predictions about future events. Indeed, a tendency to form conclusions rapidly (see also need for closure) and a discomfort with ambiguity (for a related concept, see preference of consistency) are associated with the formation of delusions (Freeman, Dunn, Garety, et al., 2005). Similarly, elevated anxiety and uncertainty is also associated with delusional beliefs (Guillem, Pampoulova, & Stip et al., 2005).

These entrenched beliefs might not, however, escalate into demonstrable problems unless amplified by other processes. Some individuals, for example, might become especially concerned about these beliefs. They might feel they are experiencing insanity. They feel especially threatened by these thoughts. These attributions are likely to magnify the salience, and thus frequency, of these anomalous experiences and beliefs.

Many factors can increase the likelihood of these attributions. For example, these individuals might demonstrate a powerful confirmation bias, in which they read only information that conforms to their beliefs. Indeed, confirmation bias tends to be pronounced in patients with schizophrenia, whereas a disconfirmation bias tends to be pronounced in patients with obsessive compulsive disorder (e.g., Fear & Healy, 1997).

Consistent with this perspective, many researchers advocate treatments that encourage individuals to accept anomalous experiences, curbing the likelihood these sensations and cognitions will be amplified unduly. Some researchers argue that individuals should engage with the voices they hear, attempting to initiate helpful conversations. Similarly, training in mindfulness has also been shown to curb psychosis. That is, when individuals are encouraged to observe, rather than judge, intrusive thoughts, wellbeing in people who reported psychosis improved significantly (Chadwick, Newman Taylor, & Abba, 2005).

Likewise, attempts to normalize anomalous experiences can also be constructive. Individuals do not feel as concerned about these experiences: A few experiences are thus less likely to escalate into entrenched delusions (Alford & Beck, 1994).

Related practices

Several approaches similar to ACT have evolved since the 1990s, all of which focus on changing the function of unpleasant thoughts or feelings rather than directly attempting to alleviate or eradicate these private experiences. Examples include certain forms of humanistic and experiential therapy (Greenberg, 1994), dialectical behavior therapy (Linehan, 1993), and integrative behavioral couple therapy (Wheeler, Christensen, & Jacobson, 2001).

Measures

Acceptance and action questionnaire: AAQ

Many researchers use the acceptance and action questionnaire, or AAQ. The questionnaire assesses the extent to which individuals accept and embrace, rather than avoid or suppress, negative thoughts, emotions, sensations, or inclinations.

Several versions have been developed. The AAQ-2, for example, comprises 10 items, such as "I worry about not being able to control my worries and feelings", "My painful memories prevent me from having a fulfilling life", and "Emotions cause problems in my life". The AAQ-Revised, in contrast, comprises 19 items, such as "I try to suppress thoughts and feelings that I don't like by just not thinking about them" and "Anxiety is bad". Finally, the original AAQ comprised 49 items. For all versions, participants specify the extent to which these items are true, on a 7 point scale.

Only a few studies have explored the psychometric properties of the AAQ (e.g., Bond & Bunce, 2003& Hayes, Strosahl, Wilson, Bissett, Pistorello, Toarmino, et al., 2004). Furthermore, the AAQ is currently under development and the questions are continually being refined and modified.

In the meantime, researchers can instead use the White bear suppression inventory (Wegner & Zanakos, 1994), which comprises 15 items. The inventory measures the degree to which individuals feel motivated to suppress negative thoughts and emotions. Participants specify the extent to which they agree or disagree with various statements, such as: "There are things I prefer not to think about", "I have thoughts that I try to avoid", and "I always try to put problems out of mind".

Internal consistency approaches .90 (see Wegner & Zanakos, 1994). Test-retest reliability is .92 over 1 week and .69 over 3 weeks. This measure correlates with the BDI measure of depression, as well as the Maudsley Obsessive-Compulsive Inventory and the State-Trait Anxiety Inventor. Nevertheless, the items revolve around the suppression of unpleasant thoughts rather than unpleasant emotions.

Related measures

Meta-emotions

Meta-emotions could be conceptualized as a broader variant of acceptance. Specifically, acceptance represents positive feelings towards negative emotions, thoughts, urges, and sensations. Meta-emotions, in contrast, represent other feelings or responses to these mental states.

To illustrate, Mitmansgruber, Beck, Hofer, and Schubler (2009).developed a measure of meta-emotion, comprising six distinct subscales, as uncovered by factor analysis:

The internal consistency of these six subscales was .86, .82, .85, .77, .83, and .76 respectively in one of the studies (Mitmansgruber, Beck, Hofer, & Schubler, 2009). Anger as well as contempt towards emotions, as well as suppression, were inversely related to psychological wellbeing, as represented by autonomy, mastery, growth, relationships, purpose, and acceptance of self. Compassion and interest were positively associated with psychological wellbeing (Mitmansgruber, Beck, Hofer, & Schubler, 2009).

Accommodation

Another form of acceptance, called accommodation, enables individuals to withstand contexts or situations in which the source of problems is uncertain. To illustrate, individuals often experience a sense of causal uncertainty: That is, they cannot readily explain the causes of undesirable events in their life. They frequently feel surprised, confused, and bewildered (e.g., Weary & Edwards, 1994& Weary, Jacobson, Edwards, & Tobin, 2001). They do not, therefore, feel a sense of control in the future (Edwards & Weary, 1998). Because their sense of control does not match their desires, negative emotions tend to escalate (e.g., Jacobson, Weary, & Edwards, 1999).

Nevertheless, some individuals, despite this sense of causal uncertainty, do not experience strong negative emotions, like depression (Tobin & Weary, 2008). In particular, they accept undesirable states, such as limited control, as well as adjust their behavior accordingly. In essence, they diminish their standards or expectations. Limited control does not compromise these standards. Because their expectations are fulfilled, they are not as likely to experience negative emotions (cf., self discrepancy theory).

Tobin and Weary (2008) conducted a pair of studies that illustrate this possibility. First, participants completed a measure of causal uncertainty, epitomized by items like "I do not understand what causes most of the good things that happen to me" and "When someone I know receives a poor grade, I often cannot determine if they could have done anything to prevent it". In addition, they completed the Harmony Control Scale, representing the degree to which participants accept unforeseen events, ascribing these occurrences to luck or other forces. A sample item is "I accept the present because I know it's the will of some higher power". Finally, participants completed the Beck Depression Inventory.

As hypothesized, causal uncertainty was positively associated with depression. However, if participants accepted unforeseen events, this deleterious effect of causal uncertainty diminished. Admittedly, this finding could be ascribed to compensatory control (for a discussion of this topic, see system justification theory).

A subsequent study was similar, except positive and negative affect was assessed in lieu of depression, and the flexible goal adjustment scale was administered. This scale assesses the degree to which individuals are willing to adjust their goals and plans in response to obstacles and setbacks, another form of accommodation. Both acceptance of unforeseen events as well as this willingness to adjust goals curbed the positive association between causal uncertainty and negative affect (Tobin & Weary, 2008).

Alternative therapies: Cognitive behavioral therapy

Cognitive behavior therapy is often applied to redress psychological difficulties and to improve wellbeing. This form of therapy has been shown to alleviate many mood disorders, such as anxiety (see Butler, Chapman, Forman, & Beck, 2006& Price & Couper, 2000).

Cognitive behavior therapy can sometimes be conducted in a group setting. In these settings, the therapy cannot be customized to the needs and concerns of each individual (de Vente, Kamphuis, Emmelkamp, Blonk, 2008). Nevertheless, the group format does afford participants with several benefits: Their problems do not seem as unique& they experience a sense of social support from other individuals& and they can develop their interpersonal skills (de Vente, Kamphuis, Emmelkamp, Blonk, 2008).

Cognitive behavioral interventions to curb stress at work

Many practitioners apply cognitive behavioral interventions to curb the stress that employees experience at work (Ivancevich, Matteson, Freedman, & Philips, 1990& Jones & Johnston, 2000). These interventions comprise a set of activities, such as cognitive restructuring as well as relaxation training, skill development, and education. Cognitive structuring, for example, represents an attempt to identity automatic thoughts, appraise the problem differently, challenge distorted cognitions, and highlight the potential benefits, such as learning, from demanding environments (Beck, 1979).

Preliminary studies have shown that cognitive behavioral interventions can be applied effectively to curb stress at work. After these interventions were applied, wellbeing improved both immediately (Rowe, 2000& van der Klink, Blonk, Schene, & van Dijk, 2001& van Dierendonck, Schaufeli, & Buunk, 1998) and after some delay (e.g., de Jong & Emmelkamp, 2000).

Nevertheless, some limitations to these interventions have been recognized. Cognitive behavioral interventions, for example, did not curb absenteeism (e.g., de Jong & Emmelkamp, 2000). Second, most of these interventions were directed at employees who were not afflicted with clinical levels of work stress. When the participants do experience clinical levels of work stress, evaluations of these interventions have generated mixed results (see Blonk, Brenninkmeijer, Lagerveld, & Houtman, 2006). Similarly, studies indicate that prolonged exposure to stressful environments can impede the efficacy of interventions (e.g., Maslach, Schaufeli, & Leiter, 2001& McEwen & Wingfield, 2003).

To explore these issues, de Vente, Kamphuis, Emmelkamp, Blonk (2008) examined the efficacy of cognitive-behavioral interventions, implemented to redress elevated levels of work stress. In this study, all 82 patients reported pronounced levels of neurasthenia--that is, prolonged states of mental or physical fatigue--as well as two or more other manifestations of stress, such as dizziness, digestive difficulties, tension headaches, irritability, and sleep disturbances. Furthermore, these symptoms, as reported by both the participants and a clinician, primarily emanated from difficulties at work. None of these patients reported other psychological disorders, such as social phobia, panic disorder, substance abuse, or psychotic disorders.

Participants were randomly divided into three conditions: no additional intervention, individual cognitive-behavioral intervention, and group cognitive-behavioral intervention (for a description of the intervention, see Kamphuis, de Vente, & Emmelkamp, 2001& de Vente, Kamphuis, & Emmelkamp, 2001). In short, the intervention involved cognitive restructuring, relaxation techniques such as progressive muscle relaxation (Bernstein & Borkovec, 1973), goal setting, time management, assertiveness skills, including conflict management, self assessment of lifestyle, and relapse prevention. Participants were encouraged to identify, and then to curb, one destructive habit, such as alcohol consumption. The homework that participants were assigned spanned about an hour a day. Participants attended 12 sessions.

The individual and group sessions were similar, apart from a few disparities. First, the groups comprised seven individuals. Second, the group sessions lasted 2 hours, twice as long as individual sessions. Third, to be included in the analysis, each group participant only needed to attend at least eight of the twelve sessions. Participants in the control condition could seek the support they would usually received but could not attend more than five treatment sessions with a psychologist or social worker.

Most of the outcomes were measured immediately before and after the treatment, as well as 3 months and 6 months after the intervention was completed. In particular, burnout, fatigue, depression, anxiety, and stress complaints were assessed at these times. Absenteeism was also assessed. Finally, satisfaction with the treatment and the perceived efficacy of interventions were also evaluated.

Overall, the results were not encouraging. Relative to the control condition, the cognitive behavioral intervention did not consistency curb burnout, depression, anxiety, stress, or absenteeism over the 10 months in which the study was conducted. Nevertheless, in the participants who reported lower levels of depression, the intervention was more likely than no intervention to reduce burnout (de Vente, Kamphuis, Emmelkamp, Blonk, 2008).

Over time, however, the symptoms tended to diminish. Thus natural recovery in these participants might have been pronounced, which can obscure the potential benefits of cognitive behavioral therapy. However, levels of complaints, such as burnout and stress, remained high, even 10 months after the intervention began. For example, 28% of participants had not resumed work in that time.

CBT and hypnosis

According to recent meta-analyses, CBT is even more effective if combined with hypnosis (e.g., Kirsch, 1996). Some research has examined the interrelationships between the mechanisms that underpin CBT and the mechanisms that underpin hypnosis (Visla, Cristea, Tatar, & David, 2013).

Specifically, CBT practitioners often attempt to modify the effect of two categories of beliefs: core beliefs, such as "I am a worthless person", and specific automatic beliefs, emanating from core beliefs but pertinent to the context, such as "They will laugh at me". Whether practitioners should target core beliefs or specific beliefs remains controversial, given that core beliefs are more consequential but perhaps not as amenable to change. In contrast, hypnosis often changes response expectancies (Kirsch, 1996)--equivalent to the emotions or consequences of some event, such as public speaking, that individuals expect to experience. Yet, the relationship between core beliefs, specific beliefs, and response expectancies has not been studied extensively.

Visla, Cristea, Tatar, and David (2013) undertook a study that was intended to redress this shortcoming in the context of public speaking. Participants completed measures that assess irrational core beliefs, specific beliefs about public speaking, and the degree to which they expect to feel anxious speaking publicly as well as feelings of anxiety before presenting a speech. As predicted, core irrational beliefs, such as "I am worthless", were positively associated with anxiety before speeches This relationship was mediated by both specific beliefs and response expectancies.

References

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