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Objective: Psychotherapies like Acceptance and Commitment Therapy (ACT) are thought to target multiple clinical outcomes by intervening on multiple mechanistic process variables. However, the standard mediation approach does not readily model the potentially complex associations among multiple processes and outcomes. The current study is one of the first to apply network intervention analysis to examine the putative change processes of a psychotherapy., Methods: Using data from a randomized trial of ACT versus minimally-enhanced usual care for anxious cancer survivors, we computed pre-to post-intervention (n = 113) residualized change scores on anxiety-related outcomes (general anxiety symptoms, cancer-related trauma symptoms, and fear of cancer recurrence) and putative processes of the intervention (experiential avoidance, self-compassion, and emotional approach coping). We estimated a network model with intervention condition and residualized change scores as nodes., Results: Contrary to the expectation that intervention effects would pass indirectly to outcomes via processes, network analysis indicated that two anxiety-related outcomes of the trial may have acted as primary mechanisms of the intervention on other outcome and process variables., Conclusions: Network intervention analysis facilitated flexible evaluation of ACT's change processes, and offers a new way to test whether change occurs as theorized in psychotherapies., Competing Interests: Declaration of competing interest Mr. Fishbein and Dr. Haslbeck declare no conflicts of interest. Dr. Arch receives unrelated research funding from National Comprehensive Cancer Network, AstraZeneca, and the National Institutes of Health., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: Acceptance and Commitment Therapy (ACT) is a promising psycho-oncological intervention, but its mechanisms in real-world settings are not fully understood. This study examined core theorized ACT and broader ACT-consistent target processes as mediators of ACT versus minimally-enhanced usual care within a randomized trial for anxious cancer survivors in a community oncology setting., Method: Two core theorized ACT target processes (experiential avoidance and values-aligned behavior, each measured with two instruments) and two broader ACT-consistent target processes (emotional approach coping and self-compassion) were analyzed at pre- and post-intervention as mediators of general anxiety symptoms, cancer-related trauma symptoms, and fear of cancer recurrence (N = 134)., Results: ACT led to greater increases on emotional approach coping (ps ≤ .001) and one measure of values-aligned behavior (ps ≤ .031), and marginal or greater improvement on self-compassion (ps ≤ .055), but not other core ACT target processes. Self-compassion and emotional approach coping mediated ACT's effects on cancer-related trauma symptoms (ps ≤ .037). Additionally, self-compassion, emotional approach coping, and values-aligned behavior marginally mediated fear of recurrence and general anxiety symptoms improvement (ps ≤ .088)., Conclusion: ACT reduced cancer survivors' anxiety-related symptoms, and especially cancer-related trauma symptoms, most consistently by promoting self-compassion and emotional approach coping., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: No prior studies have examined moderators of dropout between distinct treatments for anxiety disorders. This study applied a novel statistical approach for examining moderators of dropout from traditional cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT)., Method: We combined data from two randomized controlled trials (N = 208) comparing CBT and ACT for patients with DSM-IV anxiety disorders. Adapting Kraemer's method for constructing and evaluating composite moderators (2013), 26 variables were examined for individual effect sizes. Forward-stepwise regression combined with k-fold cross validation was used to identify a model to predict treatment dropout., Results: Four baseline variables comprised the final composite moderator: self-reported degree of control over internal anxiety, current psychiatric medication use, religiosity, and endurance in a voluntary hyperventilation stressor. This composite moderator predicted differential dropout from ACT vs. CBT with a medium effect size (r = 0.28), and had a significantly larger effect size than any individual moderator., Conclusions: Findings reveal that specific patient profiles predict differential dropout from ACT vs. CBT for anxiety disorders. In the first investigation of a composite moderator with a dichotomous outcome, findings also support the superiority of composite over individual moderators., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: Mindfulness-based interventions have been increasingly applied to treat eating-related problems ranging from obesity to eating disorders. Yet few studies have empirically examined the mechanisms of a mindful approach to eating. The current studies examine the potential of brief mindfulness instructions to enhance the psychological and behavioral dimensions of eating., Methods: In three experiments (total N = 319 undergraduates), we examined whether brief mindfulness instructions would enhance the positive sensory experience involved in tasting food as well as healthy eating behaviors., Results: Relative to distraction control instructions, the first two studies demonstrated that brief mindfulness instructions increased the enjoyment of a commonly pleasurable food (chocolate; Study 1), and a food with generally more mixed associations (raisins; Study 2). The third study replicated and extended these findings to show that brief mindfulness instructions also led to lower calorie consumption of unhealthy food relative to distracted or no-instruction control conditions, an effect mediated by greater eating enjoyment., Conclusions: Findings demonstrated the power of brief mindfulness instructions to positively impact both health-relevant behavior and sensory experience associated with eating food. Implications for both theory and clinical applications of mindfulness are discussed., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: Little is understood about how the public perceives exposure-based therapy (ET) for treating anxiety and trauma-related disorders or how ET rationales affect treatment credibility. Distinct approaches to framing ET are practiced, including those emphasized in traditional cognitive behavioral therapy, acceptance and commitment therapy, and the more recent inhibitory learning model. However, their relative effect on ET's credibility remains unknown., Method: A final sample of 964 U.S. adults provided baseline views of ET. Participants rated ET treatment credibility following a simple ET definition (pre-rationale) and following randomization to rationale modules addressing ET goals, fear, and cognitive strategies from distinct theoretical perspectives (post-rationale). Baseline ET views, symptoms, and sociodemographic characteristics were examined as putative moderators and predictors., Results: At baseline, the majority had never heard of ET. From pre- to post-rationale, ET treatment credibility significantly increased but the rationales' theoretical perspective had little impact. More negative baseline ET views, specific ethnic/racial minority group status, and lower education moderated or predicted greater increases in treatment credibility following the rationale., Conclusions: ET remains relatively unknown as a treatment for anxiety or trauma, supporting the need for direct-to-consumer marketing. Diverse theory-driven rationales similarly increased ET credibility, particularly among those less likely to use ET., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Cognitive behavioral therapy (CBT), particularly when it includes an exposure component, is an empirically supported psychosocial treatment for anxiety disorders that has been shown to be highly efficacious, desirable to patients, and cost-effective. However, access to and receipt of exposure-based treatment CBT anxiety remains lacking despite these benefits. The current study reviewed electronic medical records at a large public outpatient psychiatry clinic in order to clarify what usual care for anxiety disorders entails, and to determine the extent to which effective psychosocial treatment is accessible to, and implemented with anxiety disorder patients. Database queries generated from the billing and medical record system at the Los Angeles County Adult Outpatient Psychiatry Clinic identified 582 patients presenting with an anxiety disorder diagnosis in a 6-month time frame. These patients' electronic medical records were reviewed using a standardized data collection form. Findings indicated that the majority of patients received pharmacological treatment for their anxiety. The majority of the psychosocial treatment delivered was supportive therapy. Among the minority of patients who did initiate CBT, an even smaller minority received treatment that included an exposure component, and those who did receive exposure likely received a sub-optimal dose. Understanding usual care delivery patterns is an important preliminary step to identifying and addressing barriers to optimal anxiety disorder treatment in adult community mental health settings., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Relatively little is known about women's anxiety-related treatment preferences and no studies have examined potential differences between pregnant versus non-pregnant women. Treatment credibility and willingness are particularly important to understand regarding exposure-based cognitive behavioral therapy (CBT) and pharmacotherapy, the leading evidence-based treatments., Methods: A large U.S. sample of pregnant (n = 377) and matched non-pregnant (n = 399) women (total N = 776) rated overall treatment preferences and treatment credibility, concerns, and willingness to have CBT and pharmacotherapy if suffering from anxiety., Results: Women preferred anxiety-related treatment that included psychotherapy. Preference for psychotherapy alone was stronger among pregnant (74%) than non-pregnant (47%) women, p < .001. In response to treatment descriptions, both groups rated CBT more favorably than pharmacotherapy on treatment willingness, credibility, and concerns, ps < .001, with the magnitude of this preference significantly greater among pregnant than non-pregnant women, ps < .001. Pregnancy status was unrelated to CBT ratings. Treatment credibility and to a lesser extent total concerns mediated the relationship between pregnancy status and pharmacotherapy willingness., Conclusions: Non-pregnant and especially pregnant women rated exposure-based CBT for anxiety more favorably than pharmacotherapy. Pregnancy status predicted general treatment preferences and pharmacotherapy, but not CBT, ratings., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Identifying treatment moderators facilitates treatment matching and personalized medicine. No previous studies have investigated treatment moderators for a mindfulness-based versus traditional cognitive behavioral therapy (CBT) for anxiety disorders to determine for whom each is most effective. The current study examined three putative moderators of principal anxiety disorder severity outcomes for adapted mindfulness based stress reduction (MBSR) and group CBT - baseline depression symptoms, anxiety sensitivity, and diagnostic severity., Method: Seventy-one patients with a DSM-IV anxiety disorder were randomized to adapted MBSR or group CBT and assessed at baseline, post-treatment, and 3-month follow up., Results: CBT outperformed adapted MBSR among those with no to mild depressive symptoms and, at post-treatment only, among those with very high anxiety sensitivity. At follow up, adapted MBSR outperformed CBT among those with moderate to severe depressive symptoms and among those with average anxiety sensitivity (for this sample). Baseline severity affected post-treatment outcomes differently in CBT than in adapted MBSR., Conclusion: Baseline levels of depression, anxiety sensitivity, and to some extent diagnostic severity, differentially moderated outcomes in CBT and adapted MBSR for anxiety disorders. Recommendations and clinical implications are discussed., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: To compare a mindfulness-based intervention with cognitive behavioral therapy (CBT) for the group treatment of anxiety disorders., Method: One hundred five veterans (83% male, mean age=46 years, 30% minority) with one or more DSM-IV anxiety disorders began group treatment following randomization to adapted mindfulness-based stress reduction (MBSR) or CBT., Results: Both groups showed large and equivalent improvements on principal disorder severity thru 3-month follow up (ps<.001, d=-4.08 for adapted MBSR; d=-3.52 for CBT). CBT outperformed adapted MBSR on anxious arousal outcomes at follow up (p<.01, d=.49) whereas adapted MBSR reduced worry at a greater rate than CBT (p<.05, d=.64) and resulted in greater reduction of comorbid emotional disorders (p<.05, d=.49). The adapted MBSR group evidenced greater mood disorders and worry at Pre, however. Groups showed equivalent treatment credibility, therapist adherence and competency, and reliable improvement., Conclusions: CBT and adapted MBSR were both effective at reducing principal diagnosis severity and somewhat effective at reducing self-reported anxiety symptoms within a complex sample. CBT was more effective at reducing anxious arousal, whereas adapted MBSR may be more effective at reducing worry and comorbid disorders., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: To assess the relationship between session-by-session putative mediators and treatment outcomes in traditional cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for mixed anxiety disorders., Method: Session-by-session changes in anxiety sensitivity and cognitive defusion were assessed in 67 adult outpatients randomized to CBT (n = 35) or ACT (n = 32) for a DSM-IV anxiety disorder., Results: Multilevel mediation analyses revealed significant changes in the proposed mediators during both treatments (p < .001, d = .90-1.93), with ACT showing borderline greater improvements than CBT in cognitive defusion (p = .05, d = .82). Anxiety sensitivity and cognitive defusion both significantly mediated post-treatment worry; cognitive defusion more strongly predicted worry reductions in CBT than in ACT. In addition, cognitive defusion significantly mediated quality of life, behavioral avoidance, and (secondary) depression outcomes across both CBT and ACT (p < .05, R(2) change = .06-.13), whereas anxiety sensitivity did not significantly mediate other outcomes., Conclusions: Cognitive defusion represents an important source of therapeutic change across both CBT and ACT. The data offered little evidence for substantially distinct treatment-related mediation pathways., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: Mindfulness forms the basis for multiple clinical interventions and has been induced in laboratory settings. However, few studies have examined the effects of dispositional or trait mindfulness. The purpose of this study was to investigate the relationship of trait mindfulness to laboratory stressor responding across fear-based anxiety disorder and non-anxious samples. We hypothesized that trait mindfulness would be associated with diminished stressor responding above and beyond the contribution of anxiety and depression-related variables, and to a greater extent in high anxiety than low anxiety individuals., Methods: 90 participants, including 46 with anxiety disorders and 44 non-anxious controls, were assessed on hyperventilation and relaxation stressors. The relationship of trait mindfulness to stressor-related anxiety, negative affect, and duration was investigated in a hierarchical multiple regression model., Results: Trait mindfulness predicted stressor responding in over 80% of measured outcomes, and predicted to a greater extent among high anxiety individuals in 50% of outcomes., Conclusions: Trait mindfulness was associated with diminished responses to laboratory stressors in clinically anxious and non-anxious samples. Implications for emotion regulation and clinical interventions are discussed., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

This study examined naturalistic medication use and cognitive behavioral therapy (CBT) treatment outcomes in 105 patients meeting DSM-IV criteria for panic disorder (PD), assessed by structured clinical interview. The association between pre- and post-treatment use of SSRIs, benzodiazepines (BZs), and any anti-anxiety or anti-depressant (A/D) medication were investigated for three indicators of treatment outcome (PD severity, presence of agoraphobia (AG), anxiety sensitivity) at post-treatment and 6-month follow-up. Controlling for pre-treatment severity, pre-treatment SSRI use was associated with worse outcomes for AG (p=.04) and anxiety sensitivity (p=.047); post-treatment SSRI use was associated with delayed improvements in PD severity (p=.05). Pre-treatment use of A/D was associated with poorer PD severity outcomes (p=.04). Post-treatment use of A/D was associated with higher anxiety sensitivity scores across post-treatment and 6-month follow-up (p=.03). BZ use was not associated with significantly worse outcomes. However, there was a decrease in the number of patients using BZs from pre-treatment to post-treatment (p=.06) and follow-up (p=.006). In conclusion, controlling for pre-treatment severity, pre- and post-treatment use of SSRIs and A/D was associated with poorer outcomes, particularly for PD severity and anxiety sensitivity.

The current study investigated whether a 15 min recorded focused breathing induction in a normal, primarily undergraduate population would decrease the intensity and negativity of emotional responses to affectively valenced picture slides and increase willingness to remain in contact with aversive picture slides. The effects of the focused breathing induction were compared with the effects of 15 min recorded inductions of unfocused attention and worrying. The focused breathing group maintained consistent, moderately positive responses to the neutral slides before and after the induction, whereas the unfocused attention and worry groups responded significantly more negatively to the neutral slides after the induction than before it. The focusing breathing group also reported lower negative affect and overall emotional volatility in response to the post-induction slides than the worry group, and greater willingness to view highly negative slides than the unfocused attention group. The lower-reported negative and overall affect in response to the final slide blocks, and greater willingness to view optional negative slides by the focused breathing group may be viewed as more adaptive responding to negative stimuli. The results are discussed as being consistent with emotional regulatory properties of mindfulness.