ACT and CBT for Anxiety

ACT is more successful than CBT in anxiety group counseling

Abstract

Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) have different theoretical views. CBT targets the form and frequency of mental experiences, whereas ACT focuses on the context of thoughts and feelings. Researchers carry assumptions about the characteristics of both these therapies, and how they differ from each other. This paper examines the proposed differences between CBT and ACT for anxiety disorder. It includes aspects of treatment components, processes, and outcomes. Research was conducted on 15 high school students who were provided a five-week couseling group based on their Individual Educational Plan. Each group received a different type of therapy with one controlled group. It was hypothesized ACT would benefit the students more than CBT. The general conclusion is that ACT is more conducive to minimize anxiety.

Introduction

Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) are two major paradigms in the mental health field.  The present research reviews broad similarities and differences between both.  It is believed that a comparison between CBT and ACT is beneficial in determining which is better suited for school-based counseling. Therefore, the purpose of this study was to determine the effectiveness of CBT and ACT in an anxiety school-based counseling group. It is hypothesized that ACT is more successful than CBT in anxiety group counseling.

Literature Review

Anxiety is one of the most common disorders among young people (Roberts et al. 2009). According to the Diagnostic and Statistical Manual of Mental Disorders, 5^th Edition, generalized anxiety disorder (GAD) is a common anxiety disorder that involves experiencing constant and chronic worrying, nervousness, and tension. It becomes very difficult to control as the worry is controlling, with the student displaying in physical and psychologic symptoms which leads to significant distress or impairment.  GAD is an interruption in how the brain controls the signals it uses to identify danger and initiate action to help avoid it. However, in students who experiences GAD, this signaling mechanism doesn’t work as it should and they experience the danger signal when there is no danger. GAD is extreme anxiety and worry about everyday events that occurs over an extended period. A student with GAD worries excessively about many different things and is not able to control their worry. The anxiety causes serious emotional distress and causes problems at school. These feelings of anxiety usually also have physical components, including headaches, aches and pains, nausea, shaking and sweating. 

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Feeling anxiety in response to danger or in new situations is perfectly normal. It’s called the fight-or-flight response and helps the student survive in dangerous situations. But these typical feelings are different from GAD. A student with GAD constantly feels tense and on edge, even when there is no danger. There is no one specific cause for GAD. For a student to be diagnosed with GAD symptoms tend to be chronic, lasting at least 6 months and may affect the students everyday task like attending school. (American Psychiatric Association, 2013)

Research has been conducted on treatment outcome and the importance of considering development in intervention with young people (Cartwright-Hatton et al. 2004). Developmentally appropriate treatments for anxious adolescents are beginning to emerge. In an attempt to improve treatment approaches for students, researchers have looked into alternatives to CBT and have increased the interest in ACT. However, no randomized clinical trials for generalized anxiety has yet compared ACT to CBT.

CBT is a psychosocial intervention that is the most widely used evidenced based practice for treating mental disorders. CBT focuses on the development of personal coping strategies that target solving current problems and changing unhelpful patterns in cognitions (e.g. thoughts, beliefs and attitudes). The underlying concept behind CBT is that our thoughts and feelings play a fundamental role in our behavior.

CBT is generally short-term and focused on helping clients deal with a very specific problem. During treatment, people learn how to identify and change destructive or disturbing thought patterns that have a negative influence on behavior. When the individual  applies a more optimistic (and realistic) thought, their emotion changes (more hopeful) and their behavior changes (get out of bed and takes a walk).The goal of cognitive behavior therapy is to teach patients that while they cannot control every aspect of the world around them, they can take control of how they interpret and deal with things in their environment.

ACT is a form of psychotherapy commonly described as a form of cognitive behavioral therapy. It is an empirically based psychological intervention that uses acceptance, mindfulness strategies, commitment and behavior-change strategies, to increase psychological flexibility.

ACT differs from CBT in that rather than trying to teach people how to better control their thoughts, feelings, sensations, memories and other private events, ACT teaches them to just notice, accept and embrace their private events.

ACT is a powerful tool that can reduce suffering by helping one observe thoughts and feelings as they are, without trying to change them. ACT also emphasizes behaving in ways consistent with valued goals and life direction. ACT is proven to be effective in treating anxiety. ACT doesn’t attempt to improve or alleviate symptoms, but rather aims to help the person stop obsessing over his or her symptoms, create new lifestyle patterns, and make healthier choices. It encourages being fully conscious in the present moment and maintaining or changing behavior based on what the moment involves

Methods

Demographics

This research was conducted with a group of 15 High School students in a city in Union County, New Jersey. Their ages ranged from 15 to 18 years old.  There were 9 boys and 6 girls. These students were selected to take part in this research as they are all required to participate in a school setting group for generalized anxiety disorder. Generalized anxiety disorder was defined as persistent and excessive worry about different things. Tyrer, P., & Baldwin, D. (2006). They are required to participate in the group as it is directed in their Individual Educational Plan (IEP). The student’s qualification for an IEP was due to them being found eligible in one of the fourteen conditions under Individuals with Disabilities Education Act (IDEA). As indicated on the PRISE booklet the fourteen conditions are specific learning disability, other health impaired, Autism spectrum disorder, emotional disturbance, speech or language impairment, visual impairment, deafness, hearing impairment, deaf-blindness, orthopedic impairment, intellectual disability, traumatic brain injury, preschool child with a disability and multiple disabilities. The student classifications were as follows; 3 students emotional disturbance, 1 student speech or language impairment, 2 student Autism spectrum disorder, 2 student other health impaired, and 7 students specific learning disability.

Materials

The aim was to distribute the groups evenly according to self-report.  To obtain this measurement, participants were presented with a pre-test and post-test on a Hamilton Anxiety Rating Scale (HAM-A). The rating scale consists of 14 items the items includes anxious mood, tension, fears, insomnia, somatic complaints and behavior. This rating scale was developed to quantify the severity of anxiety symptomatology. Each item is rated by the participant on a 5-point scale, ranging from 0 (not present), 1 (mild), 2 (moderate), 3 (severe), and 4 (very severe). The participant could score from a range of 0-56, where <17 indicates mild severity, 18-24 mild to moderate severity and 25 -30 moderate to severe. The survey in its entirety is in Appendix A. 

Procedures

Students met initially for their group counseling. Students played Jenga as an icebreaker. Jenga blocks were colored in green, red, blue, yellow and purple.  Each color had a question for students to answer to introduce themselves. Questions varied from “what is your name, to I do not like….”.  Once the icebreaker was complete an HAM-A was given to each student to fill out.  Each HAM-A form was scored, and the students were split up evenly between three groups. To select which group was given which therapy style the group numbers were placed in a hat and the therapy style was placed in another box.  Once selected CBT group met on Mondays, Controlled group met on Wednesday, and ACT group met on Fridays. During the first meeting each group created their group counseling rules, a contract was typed up and each member signed it.  The groups rules were maintaining confidentiality, commitment to attendance, respect for each other, and participation.

Design/Analysis

The CBT group used thought challenging also known as cognitive restructuring.  This process is when the student challenges the negative thinking patterns that entice anxiety. Week one the students worked on identifying when they experience anxiety. They each took turns in defining what anxiety meant to them and what they are thinking when they start to feel anxious.  They were each given a notepad to write down for one week to write down when they experience anxiety and what happened before and after the anxiety episode.  They were also asked to write down that they were thinking when they were experiencing anxiety.  Week two students brought in their notepads and discussed their findings.  Everyone’s anxiety-provoking thoughts were evaluated. The thoughts and beliefs of anxiety were questioned. Every student was able to weigh in on the pros and cons on others anxiety. Each student selected what causes them the more anxiety and for homework students were asked to rate their anxiety daily based on 0 to 10 scale. Week three students evaluated the anxiety-provoking thoughts. Students needed to determine the realistic chances of what makes them anxious will happen.  For homework student continued to rate their daily rate of anxiety. Week four students worked on replacing negative thoughts with realistic thoughts. Each student worked on creating a realistic, calming statement they can say to themselves when facing or anticipating a situation that leads to anxiety. For homework students tracked how they felt when they used the positive thoughts and they rated their anxiety level. Week five was the closing session and students were able to discuss how they feel they have progressed with minimizing their anxiety.

The ACT group focused on accepting anxiety.  Week one the students worked on identifying when they experience anxiety. They each took turns in defining what anxiety meant to them and what they are thinking when they start to feel anxious. Students were introduced to cognitive distortion. It was explained to the student that they will always experience anxiety, but they would need to learn how to reduce the influence they allow anxiety to have on them. For homework students were given a notepad where they wrote what they were thinking when they experienced anxiety and how they could change the sentence to a positive sentence. Week two the students reviewed their notepads and discussed how the positive thinking made them feel and acceptance was discussed. The students learned how to accept their unpleasant thoughts and how to let them go. Each student was given a switch button and when they discussed their unpleasant thoughts they were given the switch to turn off the thoughts and say a pleasant thought about their anxiety. For homework the students were asked to write down why it is ok to experience the anxiety. Week three students were presented with mindfulness This allows the student to engage in the present moment instead of becoming lost in their thoughts. For homework the students were asked to observe themselves. They were asked to observe themselves thinking and to write down how they are in control of their thoughts and how the thoughts can’t be harmful to them.  Week four the students identified what they stand for and what is important to them. They were able to communicate how the anxiety has stopped them from doing different things and how the negativity of anxiety does not go with their values. For homework the students were asked to write a committed action. This action was to a line with their values. Week five was the closing session and students were able to discuss how they feel they have progressed with accepting anxiety.

The controlled group was a student lead group, every week was based on what the students wanted to discuss. Week one the students worked on identifying when they experience anxiety. They each took turns in defining what anxiety meant to them and what they are thinking when they start to feel anxious. No homework was given.  Week two the students discussed what worries them and how others view their worry.  Their homework was to think of the other student’s suggestions on their worries when they experience worry.  Week three the students discussed their homework and how everyone felt with their worry and if it helps calmed them down. No homework was given.  Week four the students discussed a good day without anxiety and each gave ideas on what they do or would like to do with relaxation techniques.  For homework the students were going to try the relaxation techniques.  Week five was the closing session and students were able to discuss how they have worked together to help minimize anxiety.

Run Analysis

It was determined a one-way analysis of variance (ANOVA) would be the best way to run the data. The one-way ANOVA is used to determine if there is any statistically significant difference between the mean of unrelated groups. In specific it tests the null hypothesis and weather it should be accepted or rejected. It is important to know that a one-way ANOVA is an omnibus test, which explains that at least three groups were different, but it does not explain which of the three groups were statistically significantly different.

Based on the research the independent variable, is represented by the three different types of therapy each group received. While the dependent variable is the students level of anxiety. As indicated one group received CBT for anxiety, another ACT for anxiety, and the last group was the controlled group who had a student-centered anxiety group.  Using the information given by BOOK NAME FOR REFERENCE, the students were divided into three similar levels of anxiety groups based on their scores on their pre-test on HAM-A. Chart 1 displays the 15 participants pre and post test results. To prepare for the one-way ANOVA, the results for the post-test of each of the 3 groups were separated as shown on table 3. These results allowed to run the one-way ANOVA which is displayed on table 4.

Table 1

Table 2

Table 3

Table 4

Interpretation

A one-way ANOVA was conducted to evaluate the difference between CBT and ACT for anxiety.  The independent variable was the kind of therapy the students were given.  The dependent variable was the rate of anxiety. To determine if the null hypothesis should be accepted or rejected, the results on table 4 were reviewed.  Table 4 shows the F-value is less than the F-critical value for the alpha level selected of 0.05. Therefore, the evidence accepts the null hypothesis. There is no significantly difference between CBT and ACT. Another measure for the one-way ANOVA to review is the p-value.  In order for a p-value to have significance the value must be less than 0.05. As shown in table 4 the p-value is 0.55. The p-value is more than the alpha level selected, the null hypothesis is accepted.  The alternative hypothesis must be rejected.

The one-way ANOVA results indicate that there is no statistically significant difference between CBT and ACT. It is important to note these results could be skewed because of the confounding variables. The students could have been seeing a therapist outside of school. The student’s social economic status was not considered. The therapist competency in CBT and ACT was not evaluated. Finally, there was no generalizability in the study.

Conclusion

The purpose of this study was to examine the relationship between safety and security index and human development.  Descriptive statistics allowed to determine the mean of the independent variable the different types of therapy, and the dependent variable, levels of anxiety.  A one-way ANOVA was computed to analyze the data.  The ANOVA was not significant, allowing to accept the null hypothesis, and indicating that there is no statistically significant between CBT and ACT. Overall the findings suggest that both CBT and ACT are highly viable treatment for anxiety disorders.

References:

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
• Cartwright-Hatton, S., Roberts, C., Chitabesan, P., Fothergill, C., & Harrington, R. (2004). Systematic review of efficacy of cognitive behavior therapies for childhood and adolescent anxiety disorders. British Journal of Clinical Psychology,43, 421–436.
• Roberts, R. E., Roberts, C. R., & Chan, W. (2009). One-year incidence of psychiatric disorders and associated risk factors among adolescents in the community. Journal of Child Psychology and Psychiatry,50(4), 405–415.