Acceptance & Mindfulness-Based Behavioral Treatment for GAD

At the Anxiety Disorders SIG meeting at the 2001 AABT convention Lizabeth (whose last name I forget) & Susan Orsillio presented the work they currently have under way to develop a new approach to treating Generalized Anxiety Disorder.

While CBT is the best available treatment for GAD it isn't as effective as we'd like. Only 40-60% end up with high end-state functioning. We need to develop more effective treatments.

GAD can be seen as characterized by unsuccessful attempts to control internal experience and future events. This provides a good rationale for using acceptance and mindfulness as interventions. Worry serves to decrease physiological arousal and gives an illusory feeling of control. Worriers also sometimes say that they worry about one thing to avoid thinking about other, more upsetting topics. Intollerance of uncertainty and experiential avoidance also seem to play an important role in GAD.

Adding acceptance and mindfulness-based interventions to traditional CBT may be one way to address these issues. These interventions try to help clients take a stance of “control what you can (take behavioral steps towards desired goals despite anxiety) and accept the things you can’t control (anxiety, uncertainty, uncontrollable events)”. They try to increase the individual’s focus on present experience (rather than worry about the future) and their willingness to experience emotions and physical sensations and then choose to take steps towards desired goals (rather than trying to avoid or control their internal experiences).

The investigators are developing a treatment protocol which they will be testing empirically. Each session starts with a mindfulness exercise, use metaphor and exercises, and include homework exercises such as self-monitoring, observing the function of worry, practice in mindfulness, and taking daily actions towards goals.

Session 1: they clarify the client’s goals for treatment, find out about their previous unsuccessful attempts at change (so that they don’t discount similar components of this treatment), and help them understand the function of worry (anxiety reduction, sense of control, avoidance of other concerns,...) and recognize the cost of worry (stresst, symptoms, impairment, becoming a spectator in life). They they do diaghramatic breathing.

Session 2: Review Session 1, Progressive Relaxation Training with a mindfulness rationale, not a control rationale.

Session 3: Discuss the function of emotion, hot stove analogy (once you've been burned, it is natural to avoid hot stoves but doing makes it impossible to cook dinner. Once you've been burned you can avoid stoves completely or you can accept the risks and learn to deal with hot stoves safely anyway - you can try to avoid or control aversive experiences or you can accept the experiences but choose how to respond). Then they discuss attempts at control, experiences that reinforce attempts at control, limits of control (thought suppression, polygraph metaphor, $1M to fall in love analogy), analysis of previous attempts at control, cycle of failed attempts at control.

Session 4: Mindfulness as an alternative (mindfulness= awareness + willingness, a non-judgemental stance) Exercises - (1) body awareness/ focusing on experience (2) noticing experience without judging - watching one’s thoughts without evaluating/judging/responding (leaves on a stream). Mindfulness (be here now) vs mindless worry (thinking/worrying about lots without being present in the moment)

Session 5: Talk about worry & control efforts taking precedence over important life directions, differentiate between goals (future focused) and what I value in the moment (present-focused). Skiing metaphor - is the point to get to the bottom of the hill? Suppose a helicopter swoops down and takes you to the bottom of the hill, is that better? HW - produce a narrative about how they want to be (in the moment) in several important areas of life, identify internal and external barriers. (This can make people feel bad because people recognize the ways in which their life falls short).

Session 6: Client is asked to make a commitment to action in one of the areas. External barriers are reconceptualized as actions to take, internal barriers are examined in the context of willingness (alternatives: do nothing, attempt to control, be willing to act and accept the internal experience).

Session 7: Introduce model of responding to worry cues. Be aware of the worry. Does the worry require action? Am I allowing the worry to get in the way?

Sessions 8 & 9: Review values, actions, barriers, & committments.

Session 10: Review progress & steps that remain to be taken.

Thus far they’ve designed the protocol and have conducted a small (4 person) pre-pilot group treatment. The initial results are very encouraging, each group member made real life changes. However, there was too much content for the available time, group members wanted more individual attention, deciding how to sequence interventions was difficult, and more practice time is needed. When people come into treatment with a goal of becoming free of anxiety, it isn’t simple to sell them on the idea of accepting the anxiety and going on with life anyway. Is the eventual goal to be free of anxiety or is it to be able to live a good life no matter how I feel?

The investigators are wondering if they simply shoud use more sessions (perhaps 20), longer sessions, switch to individual therapy, or combine individual and group sessions.
They have a grant to fund refinement of the protocol and conduct a pilot study. They plan to follow up with a randomized clinical trial.

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