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The effectiveness of acceptance and commitment therapy for social anxiety disorder: a randomized clinical trial

Abstract

Objective

Acceptance and commitment therapy has been used to treat anxiety disorders recently. The purpose of this study was to investigate the effectiveness of acceptance and commitment therapy for psychological symptoms in students with social anxiety disorder, including difficulty in emotion regulation, psychological flexibility based on experiential avoidance, self-compassion, and external shame.

Methods

This study was a semi-experimental clinical trial. Twenty four students with social anxiety disorder were randomly divided into two groups after initial evaluations: an experimental group (12 subjects) and a control group (12 subjects). The experimental group received 12 treatment sessions based on a protocol of acceptance and commitment therapy for anxiety disorders, and the control group was put on a waiting list. Self-Compassion (SCS), Difficulty in Emotion Regulation (DERS), External Shame (ESS), Social Anxiety (SPIN), and Acceptance and Action (AAQ-II) questionnaires were used to assess participants. Data were analyzed using SPSS.

Results

Acceptance and commitment therapy was shown to be effective at the post-test and follow up stages for reducing external shame, social anxiety, and difficulty in emotion regulation and its components, and for increasing psychological flexibility and self-compassion (p < 0.05). The largest effect size of treatment was for increase of psychological flexibility and the lowest efficacy was for the components “difficulty in impulse control” and “limited access to emotional strategies” at the post-test and follow-up stages, respectively.

Conclusion

Acceptance and commitment therapy may be an appropriate psychological intervention for reducing the symptoms of students with social anxiety disorder and helping them to improve psychological flexibility. Emotion and related problems can be identified as one of the main targets of this treatment.

Clinical trial registration:

Iranian Registry of Clinical Trials, IRCT20180421039369N1.

Acceptance and commitment therapy; difficulty in emotion regulation; external shame; psychological flexibility; self-compassion; social anxiety disorder

Introduction

Social anxiety disorder is characterized by significant fear or anxiety about one or more social situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Arlington: American Psychiatric Publishing; 2013. Social anxiety disorder is one of the most common disorders among young people,22. Azadeh SM, Kazemi-Zahrani H, Besharat MA. Effectiveness of acceptance and commitment therapy on interpersonal problemsand psychological flexibility in female high school students with social anxiety disorder. Glob J Health Sci. 2016;8:131.,33. Wong QJ, Rapee RM. The aetiology and maintenance of social anxiety disorder: a synthesis of complimentary theoretical models and formulation of a new integrated model. J Affect Disord. 2016;203:84-100. affecting approximately 13% of the population.44. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU. Twelve month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. 2012;21:169-84. This disorder, in addition to isolating some patients socially55. Teo AR, Lerrigo R, Rogers MA. The role of social isolation in social anxiety disorder: A systematic review and meta-analysis. J Anxiety Disord. 2013;27:353-64. and having a destructive effect on occupation and on educational and interpersonal performance,66. Hofmann S, Otto M. Practical clinical guidebooks series. Cognitive-behavior therapy for social anxiety disorder: Evidence-based and disorder-specific treatment techniques. New York: Routledge/Taylor & Francis; 2008. can inflict huge costs on all countries’ economies every year.77. Dams J, König HH, Bleibler F, Hoyer J, Wiltink J, Beutel ME, et al. Excess costs of social anxiety disorder in Germany. J Affect Disord. 2017;213:23-9.,88. Stuhldreher N, Leibing E, Leichsenring F, Beutel ME, Herpertz S, Hoyer J, et al. The costs of social anxiety disorder: the role of symptom severity and comorbidities. J Affect Disord 2014;165:87-94. Therefore, comprehensive study of this disorder and use of evidence-based interventions are important.

Many studies have shown that people with social anxiety disorder have ineffective experiential avoidance.99. Kashdan TB, Farmer AS, Adams LM, Ferssizidis P, McKnight PE, Nezlek JB. Distinguishing healthy adults from people with social anxiety disorder: evidence for the value of experiential avoidance and positive emotions in everyday social interactions. J Abnorm Psychol. 2013;122:645.,1010. Soltani E, Bahrainian SA, Arani AM, Farhoudian A, Gachkar L. Psychometric properties of the Persian version of the Social Anxiety-Acceptance and Action Questionnaire. Iran J Psychiatry Behav Sci. 2016;10:e3753. This is related to a person’s desire for change and sensitivity to internal situations and events.1111. Hayes SC, Wilson KG, Gifford EV, Follette VM, Strosahl K. Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. J Consult Clin Psychol. 1996;64:1152. Previous studies have identified self-compassion,1212. Gill C, Watson L, Williams C, Chan SW. Social anxiety and self-compassion in adolescents. J Adolesc. 2018;69:163-74.

13. Arch JJ, Landy LN, Schneider RL, Koban L, Andrews-Hanna JR. Self-compassion induction enhances recovery from social stressors: comparing adults with social anxiety disorder and healthy controls. Anxiety Stress Coping. 2018;31:594-609.

14. Blackie RA, Kocovski NL. Examining the relationships among self-compassion, social anxiety, and post-event processing. Psychol Rep. 2018;121:669-89.
-1515. Werner KH, Jazaieri H, Goldin PR, Ziv M, Heimberg RG, Gross JJ. Self-compassion and social anxiety disorder. Anxiety Stress Coping. 2012;25:543-58. difficulty in emotion regulation,1616. Ziv M, Goldin PR, Jazaieri H, Hahn KS, Gross JJ. Emotion regulation in social anxiety disorder: behavioral and neural responses to three socio-emotional tasks. Biol Mood Anxiety Disord. 2013;3:20.

17. Farmer AS, Kashdan TB. Social anxiety and emotion regulation in daily life: spillover effects on positive and negative social events. Cogn Behav Therapy. 2012;41:152-62.
-1818. Mennin DS, McLaughlin KA, Flanagan TJ. Emotion regulation deficits in generalized anxiety disorder, social anxiety disorder, and their co-occurrence. J Anxiety Disord. 2009;23:866-71. and extreme feelings of shame1919. Hedman E, Ström P, Stünkel A, Mörtberg E. Shame and guilt in social anxiety disorder: effects of cognitive behavior therapy and association with social anxiety and depressive symptoms. PloS One. 2013;8:e61713.,2020. Matos M, Pinto Gouveia J, Gilbert P. The effect of shame and shame memories on paranoid ideation and social anxiety. Clin Psychol Psychother. 2013;20:334-49. as the most important psychological problems experienced by people with social anxiety disorder. Clinicians have used pharmacological and psychological interventions to attempt to improve the symptoms of social anxiety disorder.2121. Gilbert P. The relationship of shame, social anxiety and depression: the role of the evaluation of social rank. Clin Psychol Psychother: 2000;7:174-89.

22. Dalrymple KL, Herbert JD. Acceptance and commitment therapy for generalized social anxiety disorder: a pilot study. Behav Modif. 2007;31:543-68.

23. Twohig MP, Hayes SC, Masuda A. Increasing willingness to experience obsessions: acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behav Therapy. 2006;37:3-13.

24. Eifert GH, Forsyth JP, Arch J, Espejo E, Keller M, Langer D. Acceptance and commitment therapy for anxiety disorders: Three case studies exemplifying a unified treatment protocol. Cogn Behav Pract. 2009;16:368-85.

25. Dindo L. One-day acceptance and commitment training workshops in medical populations. Curr Opin Psychol. 2015;2:38-42.

26. Roemer L, Orsillo SM, Salters-Pedneault K. Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: evaluation in a randomized controlled trial. J Consult Clin Psychol. 2008;76:1083.

27. Twohig MP, Woidneck MR, Crosby JM. Newer generations of CBT for anxiety disorders. In: Simons G, Hoffman SG, editors. CBT for anxiety disorders: a practitioner book. Wiley-Blackwell; 2013. p. 225-50.
-2828. Hayes SC. Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behav Therapy. 2004;35:639-65. Although some psychological interventions, such as cognitive-behavioral therapy, have demonstrated efficacy for treatment of patients with social anxiety, some people did not respond to treatment or symptoms remained.2222. Dalrymple KL, Herbert JD. Acceptance and commitment therapy for generalized social anxiety disorder: a pilot study. Behav Modif. 2007;31:543-68. One treatment that has been used recently to treat anxiety disorders and has demonstrated effectiveness for reducing anxiety symptoms is acceptance and commitment therapy (ACT).2323. Twohig MP, Hayes SC, Masuda A. Increasing willingness to experience obsessions: acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behav Therapy. 2006;37:3-13.

24. Eifert GH, Forsyth JP, Arch J, Espejo E, Keller M, Langer D. Acceptance and commitment therapy for anxiety disorders: Three case studies exemplifying a unified treatment protocol. Cogn Behav Pract. 2009;16:368-85.

25. Dindo L. One-day acceptance and commitment training workshops in medical populations. Curr Opin Psychol. 2015;2:38-42.
-2626. Roemer L, Orsillo SM, Salters-Pedneault K. Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: evaluation in a randomized controlled trial. J Consult Clin Psychol. 2008;76:1083.

ACT is derived from the modern theory of cognition and language2727. Twohig MP, Woidneck MR, Crosby JM. Newer generations of CBT for anxiety disorders. In: Simons G, Hoffman SG, editors. CBT for anxiety disorders: a practitioner book. Wiley-Blackwell; 2013. p. 225-50. and is classified as a third-wave psychological treatment, in which some cognitive-behavioral therapy concepts have been changed.2828. Hayes SC. Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behav Therapy. 2004;35:639-65. The main assumption underlying ACT is that humans experience disturbing thoughts, emotions, and feelings2929. Hayes SC, Villatte M, Levin M, Hildebrandt M. Open, aware, and active: contextual approaches as an emerging trend in the behavioral and cognitive therapies. Annu Rev Clin Psychol. 2011;7:141-68. and that their attempts to change or to get rid of these experiences are ineffective, which sometimes exacerbates these disturbances and ultimately leads to avoidance.3030. Hayes SA, Orsillo SM, Roemer L. Changes in proposed mechanisms of action during an acceptance-based behavior therapy for generalized anxiety disorder. Behav Res Ther. 2010;48:238-45. The six core psychological processes employed in this treatment are Acceptance, Defusion, Self as context, Contact with the present moment, Values, and Committed action.3131. Luoma JB, Hayes SC, Walser RD. Learning ACT: an acceptance & commitment therapy skills-training manual for therapists. Oakland: New Harbinger Publications; 2007. These six processes are all implemented using metaphors, empirical exercises, and logical contradictions to escape the literal content of the language and interact more with the ongoing flow of experience at the present moment.3232. Twohig MP. Acceptance and commitment therapy: introduction. Cogn Behav Pract. 2012;19:499-507. The purpose of this treatment is to reduce experiential avoidance and increase psychological flexibility.3030. Hayes SA, Orsillo SM, Roemer L. Changes in proposed mechanisms of action during an acceptance-based behavior therapy for generalized anxiety disorder. Behav Res Ther. 2010;48:238-45. A study by Azadeh et al.22. Azadeh SM, Kazemi-Zahrani H, Besharat MA. Effectiveness of acceptance and commitment therapy on interpersonal problemsand psychological flexibility in female high school students with social anxiety disorder. Glob J Health Sci. 2016;8:131. demonstrated the efficacy of ACT for the interpersonal problems and psychological flexibility of high school girls with social anxiety disorder. In that study, only clients of one gender were selected and they were not followed-up to determine the effects of treatment over time, so the effective and lasting aspects of the intervention were not evaluated. The results of a study conducted in 2007 by Dalrymple and Herbert2222. Dalrymple KL, Herbert JD. Acceptance and commitment therapy for generalized social anxiety disorder: a pilot study. Behav Modif. 2007;31:543-68. showed that from pre-test to follow-up there was a significant decrease in symptoms experienced and improvement in the quality of life of people with social anxiety after ACT. More studies are needed to determine the effectiveness of ACT, especially in terms of cultural differences and variables related to emotion regulation.

Considering the study of research literature in this field, as well as the need to study the application of psychological treatments in different cultures and their effect on various psychological symptoms, especially emotion, the importance of further exploration is evident. The aim of this study is to evaluate the effectiveness in patients with social anxiety of ACT for psychological symptoms, including difficulty in emotion regulation, poor psychological flexibility rooted in experiential avoidance, self-compassion, and external shame.

Methods

This study was a semi-experimental clinical trial, with control and experimental groups, that was approved under code IRCT20180421039369N1 in the IRCT (Iranian Registry of Clinical Trials). Sampling was intentional, from among all students with social anxiety disorder in Kermanshah city. In two recent studies of the effectiveness of ACT, sample sizes were 19 and 30 individuals.22. Azadeh SM, Kazemi-Zahrani H, Besharat MA. Effectiveness of acceptance and commitment therapy on interpersonal problemsand psychological flexibility in female high school students with social anxiety disorder. Glob J Health Sci. 2016;8:131.,2222. Dalrymple KL, Herbert JD. Acceptance and commitment therapy for generalized social anxiety disorder: a pilot study. Behav Modif. 2007;31:543-68. A sample size of 24 was selected for the present study. In coordination with the University’s Counseling Center, posters were put up in college and dormitory environments and individuals with social anxiety symptoms were invited to attend a psychological assessment session. The diagnostic interview was based on the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV) and conducted by a clinical psychologist for all participants.

After reviewing inclusion and exclusion criteria, individuals willing to participate in the research were randomly assigned to groups using a random number generator (http://stattrek.com/statistics/random-number-generator.aspx). Inclusion criteria were as follows: 1) diagnosis of social anxiety disorder; 2) informed consent from the patient for participation in the study; 3) not receiving psychological treatment during the previous six months; 4) no psycho-pharmacotherapy during the previous six months; 5) no comorbidity with other anxiety and mood disorders; 6) absence of other psychiatric disorders and severe neurological disorders; 7) no substance abuse or alcohol abuse. Exclusion criteria included unwillingness to attend continuing treatment sessions and simultaneous enrollment on another treatment program. Members of the experimental group attended twelve 90-minute sessions based on a protocol of ACT for anxiety disorders.2424. Eifert GH, Forsyth JP, Arch J, Espejo E, Keller M, Langer D. Acceptance and commitment therapy for anxiety disorders: Three case studies exemplifying a unified treatment protocol. Cogn Behav Pract. 2009;16:368-85. Members of the control group were put on the waiting list. The control group were given treatment after the final evaluation. A total of 24 students were enrolled on the study, 22 of whom, in the experimental and control groups, completed the treatment sessions and pre-test and two-month follow-up evaluations. One person in the experimental group was excluded from the study because of unwillingness to continue attending therapy sessions and one person in the control group because of non-completion of final evaluations (Figure 1).

Figure 1
Diagram illustrating participation in pre-test, post-test, and follow-up phases.

Ethical considerations

In order to comply with ethical standards, participants were informed of the conditions of the research and received informed consent forms before the start of the study. After completing the follow-up evaluation, individuals in the control group also attended ACT sessions. After implementation of the protocol, all research participants were referred to a psychiatrist or psychologist as necessary for complementary therapies. This research was approved by the ethics committee at the Kermanshah University of Medical Sciences (IR.KUMS.REC.1397.085).

Statistical analysis

SPSS software was used to analyze findings and statistical data. Multivariate analysis of covariance was used to analyze the effectiveness of the treatment in the experimental group on the variables evaluated, in comparison with the control group. The chi-square test was used to compare the number of participants and the independent t test was used to compare the mean age of the experimental and control groups.

Measurements

Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV)

This is a semi-structured, clinical and diagnostic interview for anxiety disorders developed in 1994 by Brown et al.3333. Brown TA, Barlow DH, Liebowitz MR. The empirical basis of generalized anxiety disorder. Am J Psychiatry. 1994;151:1272-80. In addition to anxiety disorders, it also measures mood disorders, somatization, psychosis, and drug abuse. The Clinical Severity Rating (CSR) is scored on a scale from zero (no sign) to eight (severely disturbed). Accordingly, a severity grading of four or more indicates that the patient’s symptoms are at or beyond the diagnostic threshold of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR). A degree of severity of three or below is attributed to diagnoses that are at partial or full improvement levels. In post-treatment studies using the ADIS-IV, clinical grade scores are usually used as an indicator for assessing post-treatment improvement.3333. Brown TA, Barlow DH, Liebowitz MR. The empirical basis of generalized anxiety disorder. Am J Psychiatry. 1994;151:1272-80. The validity of the Persian version of this program has been confirmed and its retest reliability coefficient was reported as 0.83.3434. Mohammadi A, Birashk B, Gharaie B. Comparison of the effect of group transdiagnostic therapy and group cognitive therapy on anxiety and depressive symptoms. Iran J Public Health. 2013;42:48-55. In this study, this measurement will be used to screen for social anxiety disorder, to confirm clinical diagnosis, and to assess clinical severity.

Self-Compassion Scale (SCS)

This questionnaire consists of 26 items with a five-point Likert response scale measuring three bipolar components in the form of six sub-scales. These components are Self-kindness vs. Self-judgment, Common humanity vs. Isolation, and Mindfulness vs. Over-identification.3535. Azizi A, Mohammadkhani P, Lotfi S, Bahramkhani M. The validity and reliability of the Iranian version of the Self-Compassion Scale. Pract Clin Psychol. 2013;1:149-55. The Cronbach’s alpha coefficient of 0.92 represents an internal consistency superior to the original version of this scale. Convergent validity, discriminant validity, and appropriate retest reliability for this scale have been reported.3535. Azizi A, Mohammadkhani P, Lotfi S, Bahramkhani M. The validity and reliability of the Iranian version of the Self-Compassion Scale. Pract Clin Psychol. 2013;1:149-55. In an Iranian student sample, the six-factor structure of the validation questionnaire was confirmed and a Cronbach’s alpha coefficient of 0.86 for the whole scale was reported. Cronbach’s alpha coefficients for sub-scales were in the range of 0.79-0.85.3535. Azizi A, Mohammadkhani P, Lotfi S, Bahramkhani M. The validity and reliability of the Iranian version of the Self-Compassion Scale. Pract Clin Psychol. 2013;1:149-55.

Difficulty in Emotion Regulation Scale (DERS)

This scale is a comprehensive measurement for assessing difficulty in emotion regulation that is based on the concept of mindfulness and acceptance and was designed in 2004.3636. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. J Psychopathol Behav Assess. 2004;26:41-54. A self-report measure with 36 items that measure usual levels of difficulty in emotion regulation as well as its specific dimensions.3737. Mazaheri M. Psychometric properties of the persian version of the Difficulties in Emotion Regulation Scale (DERS-6 & DERS-5-revised) in an Iranian clinical sample. Iran J Psychiatry. 2015;10:115. The scale’s dimensions are Non-acceptance, Goals lack, Impulse, Awareness, Strategies, and Clarity.3737. Mazaheri M. Psychometric properties of the persian version of the Difficulties in Emotion Regulation Scale (DERS-6 & DERS-5-revised) in an Iranian clinical sample. Iran J Psychiatry. 2015;10:115. Responses are scored on a five-point Likert scale. The reliability coefficient for the total scale is 0.93 and the test-retest is 0.88, while its construct validity is desirable.3737. Mazaheri M. Psychometric properties of the persian version of the Difficulties in Emotion Regulation Scale (DERS-6 & DERS-5-revised) in an Iranian clinical sample. Iran J Psychiatry. 2015;10:115. This scale has been translated into Persian by Khanzadeh et al. in Iran.3838. Khanzadeh M, Saeediyan M, Hosseinchari M, Edrissi F. Factor structure and psychometric properties of Difficulties in Emotional Regulation Scale. Int J Psychol Behav Sci. 2012;6:87-96. The subscale validity of this questionnaire was reported as Cronbach’s alphas between 0.66 and 0.88 and test-retest reliability between 0.97 and 0.91.3737. Mazaheri M. Psychometric properties of the persian version of the Difficulties in Emotion Regulation Scale (DERS-6 & DERS-5-revised) in an Iranian clinical sample. Iran J Psychiatry. 2015;10:115.,3838. Khanzadeh M, Saeediyan M, Hosseinchari M, Edrissi F. Factor structure and psychometric properties of Difficulties in Emotional Regulation Scale. Int J Psychol Behav Sci. 2012;6:87-96.

External Shame Scale (ESS)

This scale is an 18-item self-report measure, designed by Gross et al. to measure external shame.3939. Foroughi A, Khanjani S, Kazemini M, Tayeri F. Factor structure and psychometric properties of Iranian version of External Shame Scale. Shenakht J Psychol Psychiatry. 2015;2:49-58. Each option is scored from “never” to “almost always” using Likert scales. A higher score indicates greater external shame.3939. Foroughi A, Khanjani S, Kazemini M, Tayeri F. Factor structure and psychometric properties of Iranian version of External Shame Scale. Shenakht J Psychol Psychiatry. 2015;2:49-58. The reliability of this measure was reported as desirable, based on its Cronbach’s alpha (0.94) and 5-week retest reliability (0.94). This measure has a moderate correlation with a negative evaluation of fear and higher correlations with other methods of measuring shame in clinical student populations.3939. Foroughi A, Khanjani S, Kazemini M, Tayeri F. Factor structure and psychometric properties of Iranian version of External Shame Scale. Shenakht J Psychol Psychiatry. 2015;2:49-58. Also, this scale has appropriate validity and Cronbach’s alphas for the whole scale and its related components have been reported as in the range of 0.71 to 0.93.3939. Foroughi A, Khanjani S, Kazemini M, Tayeri F. Factor structure and psychometric properties of Iranian version of External Shame Scale. Shenakht J Psychol Psychiatry. 2015;2:49-58.

Acceptance and Action in Social Anxiety Questionnaire, 2nd edition (AAQ-II)

This questionnaire was developed to measure the symptoms of social anxiety or the extent to which individuals are aware of their thoughts and feelings about their social anxiety without attempting to change them.4040. Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Therapy. 2011;42:676-88. A Cronbach’s Alpha of 0.94 has been reported by the scale’s developers.4141. Abasi E, Fti L, Molodi R, Zarabi H. Psychometric properties of Persian version of Acceptance and Action Questionnaire-II. J Psychol Models Methods. 2013;3:65-80. The questionnaire also has good validity.4141. Abasi E, Fti L, Molodi R, Zarabi H. Psychometric properties of Persian version of Acceptance and Action Questionnaire-II. J Psychol Models Methods. 2013;3:65-80. The reliability of this questionnaire in Iran was 0.84 for test-retest and 0.84 for Cronbach’s alpha and its validity was also desirable.4141. Abasi E, Fti L, Molodi R, Zarabi H. Psychometric properties of Persian version of Acceptance and Action Questionnaire-II. J Psychol Models Methods. 2013;3:65-80. The results of factor analysis by principal component analysis revealed three components: acceptance, experience without judgment, and action.4040. Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Therapy. 2011;42:676-88.

Social Phobia Inventory (SPIN)

This questionnaire is a self-report scale with 17 items that are designed to assess anxiety or social anxiety.4242. Connor KM, Davidson JR, Churchill LE, Sherwood A, Weisler RH, Foa E. Psychometric properties of the Social Phobia Inventory (SPIN): new self-rating scale. Br J Psychiatry. 2000;176:379-86. This scale consists of three subscales of fear (6 items), avoidance (7 items), and physiological discomfort (4 items), and each item has a 5-degree Likert response scale, ranging from 1 to 5.4242. Connor KM, Davidson JR, Churchill LE, Sherwood A, Weisler RH, Foa E. Psychometric properties of the Social Phobia Inventory (SPIN): new self-rating scale. Br J Psychiatry. 2000;176:379-86. A cut-off score of 19 is used to screen for social anxiety. The test-retest reliability of this scale has been reported as 0.78 to 0.89 in groups with diagnosed social anxiety and its internal consistency has been reported as 94% in a group of healthy individuals.4242. Connor KM, Davidson JR, Churchill LE, Sherwood A, Weisler RH, Foa E. Psychometric properties of the Social Phobia Inventory (SPIN): new self-rating scale. Br J Psychiatry. 2000;176:379-86. The convergent validity of this questionnaire was reported as 0.57-0.85.4242. Connor KM, Davidson JR, Churchill LE, Sherwood A, Weisler RH, Foa E. Psychometric properties of the Social Phobia Inventory (SPIN): new self-rating scale. Br J Psychiatry. 2000;176:379-86.

Intervention

An ACT protocol for anxiety disorders developed by Eifert and Forsyth2424. Eifert GH, Forsyth JP, Arch J, Espejo E, Keller M, Langer D. Acceptance and commitment therapy for anxiety disorders: Three case studies exemplifying a unified treatment protocol. Cogn Behav Pract. 2009;16:368-85. was used with the intervention group. This protocol consists of 12 sessions, each with specific goals. Activities were tailored to the individual needs of clients, while standard sessions were maintained. In ACT, emphasis is put on establishment of a context for acceptance, followed by commitment to values and action as the main psychological processes. The purpose of the first session was psycho-education and familiarity with treatment. In the second and third sessions, the emphasis was placed on establishing a framework for acceptance for treatment through evaluation and cost estimation of past control efforts and creating a space for new solutions, acceptance, or willingness to change. The fourth and fifth sessions focused on acceptance and value-based life as an alternative to managing anxiety. The purpose of the sixth session was to create a pattern of behavior through value-based exposures. The seventh to eleventh sessions dealt with commitment to values and action. In the final session, the treatment sessions were reviewed and clients were prepared for recurrence and failure. Various assignments and exercises in sessions were tailored to the needs of the patients, such as mindfulness, life-enhancing, and practicing. The sessions were approximately 90 minutes long. After the fourth session, one of the clients dropped out of the treatment sessions and was excluded from the final evaluations.

Results

Based on demographic variables, the mean age of the participants was 22.12±1.08. Twenty-four subjects participated in this study, 17 of whom were women (70.8%) and 7 of whom were men (29.2%). There was no significant difference between the two groups in terms of age (p > 0.05). There was no significant difference between the two groups in terms of gender (Table 1). One member of each group was excluded from the study because of non-completion of the evaluation and drop-out from treatment sessions respectively.

Table 1
Demographic features of participants

Table 2 illustrates changes in the target variables in the control and experimental groups. The table shows means and standard deviations of variables in different conditions. The confidence interval diagram is shown in Figure 2.

Table 2
Comparison of means and standard deviations of target variables in the control and experimental groups

Figure 2
Confidence interval diagram for target variables. AAQ-II = Acceptance and Action Questionnaire; DERS = Difficulty in Emotion Regulation Scale; ESS = External Shame Scale; SCS = Self-Compassion Scale; SPIN = Social Phobia Inventory.

Before statistical inference, the Kolmogorov-Smirnov test was performed to verify normality of the data and the data assumption was confirmed. The results of Box’s M test showed that the matrix of covariance was equal in multivariate covariance analysis (p > 0.05). The Leven test was performed to test the equality of error variances (p > 0.05). Wilk’s Lambda test to measure the efficacy of the treatment on all target variables showed that the linear combination of “difficulty in emotion regulation” and its components was significantly different for control and experimental groups (Wilk’s Lambda = 0.003, p = 2.784, F = 0.476). Multivariate analysis of covariance was performed to determine the difference between the control and experimental groups according to each target variable.

According to Table 3, the results of multivariate covariance analysis indicate that there were significant changes in all therapeutic variables among students with social anxiety in experimental and control groups (p < 0.05). In other words, ACT had a significant effect, reducing external shame, social anxiety, and difficulty in emotion regulation and its components, while increasing psychological flexibility and self-compassion in the post-test and follow-up stages. The effect of this treatment in increasing the psychological flexibility of 43% and 67%, respectively, in post-test and follow-up, shows the highest degree of efficacy for ACT. Among the variables studied, the components of “difficulty in impulse control” and “limited access to emotional strategies” had the smallest effect sizes in the post-test and follow-up stages, respectively.

Table 3
Descriptive statistics and the effect of acceptance and commitment therapy, based on multivariate covariance analysis of target variables in the experimental group.

Discussion

The purpose of this study was to evaluate the effectiveness of ACT for improvement of psychological symptoms in students with social anxiety disorder. The psychological symptoms examined were external shame, psychological flexibility, social anxiety severity, self-compassion, and difficulty in emotion regulation and its components. The findings of this study showed that ACT improved these symptoms in students with social anxiety disorder in the experimental group, compared to the control group. The results of a randomized clinical trial conducted with 73 students by Yadavaia and colleagues showed that ACT had a significant effect, increasing self-compassion from pre-test to follow-up.4343. Yadavaia JE, Hayes SC, Vilardaga R. Using acceptance and commitment therapy to increase self-compassion: A randomized controlled trial. J Contextual Behav Sci. 2014;3:248-57. Vowles et al. found that self-compassion itself could be a powerful mediator of the effectiveness of ACT, undergoing change under the influence of treatment.4444. Vowles KE, Sowden G, Ashworth J. A comprehensive examination of the model underlying acceptance and commitment therapy for chronic pain. Behav Therapy. 2014;45:390-401. Also, the results of this study showed that the effectiveness of ACT in terms of the significant increase in students’ self-compassion from pre-test to follow-up (compared with a control group) is consistent with previous studies. Although ACT do not emphasize self-compassion as a target variable, it has been argued that increased focus on self-compassion in this treatment may result in a greater effect size for the effectiveness of ACT.4545. Luoma JB, Platt MG. Shame, self-criticism, self-stigma, and compassion in acceptance and commitment therapy. Curr Opin Psychol. 2015;2:97-101.

Luoma et al.4545. Luoma JB, Platt MG. Shame, self-criticism, self-stigma, and compassion in acceptance and commitment therapy. Curr Opin Psychol. 2015;2:97-101. showed that ACT is effective for reducing shame in people with a history of substance abuse. In another study,4646. Etzel JC. A diagnostic exemplar of experiential avoidance: examining shame and self-harm in battered women with PTSD. Dissertation Abstracts International: Section B: The Sciences and Engineering. 2006;66:4480. it was shown that experiential avoidance can be regarded as a mediator of shame and self-harmful behaviors. On the other hand, shame can be a sign and experiential avoidance is a characteristic experienced by people with social anxiety disorder,99. Kashdan TB, Farmer AS, Adams LM, Ferssizidis P, McKnight PE, Nezlek JB. Distinguishing healthy adults from people with social anxiety disorder: evidence for the value of experiential avoidance and positive emotions in everyday social interactions. J Abnorm Psychol. 2013;122:645.,1919. Hedman E, Ström P, Stünkel A, Mörtberg E. Shame and guilt in social anxiety disorder: effects of cognitive behavior therapy and association with social anxiety and depressive symptoms. PloS One. 2013;8:e61713.

20. Matos M, Pinto Gouveia J, Gilbert P. The effect of shame and shame memories on paranoid ideation and social anxiety. Clin Psychol Psychother. 2013;20:334-49.
-2121. Gilbert P. The relationship of shame, social anxiety and depression: the role of the evaluation of social rank. Clin Psychol Psychother: 2000;7:174-89. and experiential avoidance is one of the criteria of psychological inflexibility in ACT. Therefore, it can be expected that ACT is effective for reducing feelings of shame and experiential avoidance, and subsequently for reducing the self-harmful behaviors of people with social anxiety disorder, which has been detailed in several studies.1919. Hedman E, Ström P, Stünkel A, Mörtberg E. Shame and guilt in social anxiety disorder: effects of cognitive behavior therapy and association with social anxiety and depressive symptoms. PloS One. 2013;8:e61713.

20. Matos M, Pinto Gouveia J, Gilbert P. The effect of shame and shame memories on paranoid ideation and social anxiety. Clin Psychol Psychother. 2013;20:334-49.
-2121. Gilbert P. The relationship of shame, social anxiety and depression: the role of the evaluation of social rank. Clin Psychol Psychother: 2000;7:174-89. In line with this conclusion, in the present study this treatment was effective at reducing the feelings of shame experienced by students with social anxiety disorder.

One of the main goals of this study was to reduce the main symptoms of social anxiety disorder in response to a psychological treatment. Because these symptoms are debilitating and can have an adverse effect on individual, social, and occupational health, it is important to attempt to reduce the symptoms experienced. This study showed that ACT was effective for reducing the social anxiety symptoms of the experimental group in comparison with the control group, as measured by the Social Phobia Inventory (SPIN). In this study, it was also shown that this treatment could be effective for increasing students’ psychological flexibility, which had the largest effect size of all target variables. In several other studies, in common with the results of the present study, ACT has been shown to be effective for reducing the symptoms of social anxiety disorder.22. Azadeh SM, Kazemi-Zahrani H, Besharat MA. Effectiveness of acceptance and commitment therapy on interpersonal problemsand psychological flexibility in female high school students with social anxiety disorder. Glob J Health Sci. 2016;8:131.,4747. Burklund LJ, Torre JB, Lieberman MD, Taylor SE, Craske MG. Neural responses to social threat and predictors of cognitive behavioral therapy and acceptance and commitment therapy in social anxiety disorder. Psychiatry Res Neuroimaging. 2017;261:52-64.,4848. Craske MG, Niles AN, Burklund LJ, Wolitzky-Taylor KB, Vilardaga JCP, Arch JJ, et al. Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: outcomes and moderators. J Consult Clin Psychol. 2014;82:1034. Yadavaia et al. also showed that ACT is effective for improving psychological flexibility,4343. Yadavaia JE, Hayes SC, Vilardaga R. Using acceptance and commitment therapy to increase self-compassion: A randomized controlled trial. J Contextual Behav Sci. 2014;3:248-57. which is in line with the results of this study and previous studies.22. Azadeh SM, Kazemi-Zahrani H, Besharat MA. Effectiveness of acceptance and commitment therapy on interpersonal problemsand psychological flexibility in female high school students with social anxiety disorder. Glob J Health Sci. 2016;8:131.,4949. Paliliunas D, Belisle J, Dixon MR. A randomized control trial to evaluate the use of acceptance and commitment therapy (ACT) to increase academic performance and psychological flexibility in graduate students. Behav Anal Pract. 2018:1-13. The explanatory factors of these results indicate that acceptance and committed action in ACT can be considered as the main psychological processes, and it seems that this treatment, considering the history of research, is effective for improvement of psychological flexibility and reduction of symptoms experienced by people with social anxiety disorder.

The main purpose of this study was to investigate the effectiveness of ACT at reducing the difficulty in emotion regulation of people with social anxiety disorder, which has been shown to be a major concern in their daily lives.5050. Forman EM, Herbert JD, Moitra E, Yeomans PD, Geller PA. A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behav Modif. 2007;31:772-99.,5151. Blackledge JT, Hayes SC. Emotion regulation in acceptance and commitment therapy. J Clin Psychol. 2001;57:243-55. Of the components of difficulty in emotion regulation, ACT had the greatest impact on “lack of acceptance of emotional responses”. In view of the main psychological processes in this treatment, this result was not expected. So far, many studies have been conducted on the effectiveness of psychological treatments on emotions and related problems.5252. Kring AM, Sloan DM, editors. Emotion regulation and psychopathology: a transdiagnostic approach to etiology and treatment. New York: Guilford; 2009.

53. Mennin DS, Fresco DM. Emotion regulation therapy. In: Gross JJ, editor. Handbook of emotion regulation. New York: Guilford; 2014. p. 469-90.
-5454. Morgan D. Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. Abingdon: Taylor & Francis; 2003. It has been argued that ACT emphasizes the experience of problematic emotions rather than trying to change knowledge or reduce emotional levels.5151. Blackledge JT, Hayes SC. Emotion regulation in acceptance and commitment therapy. J Clin Psychol. 2001;57:243-55. It seems that ACT is also effective for emotional problems and changes in levels of emotion. The results presented in other studies are in line with this.5050. Forman EM, Herbert JD, Moitra E, Yeomans PD, Geller PA. A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behav Modif. 2007;31:772-99.,5151. Blackledge JT, Hayes SC. Emotion regulation in acceptance and commitment therapy. J Clin Psychol. 2001;57:243-55. In the present study, the results showed that the experimental group compared favorably to the control group in ability to effectively reduce the difficulty in emotion regulation and its components.

Several limitations of this study should be noted. First, the sample size limits the capability for generalization, which it is recommended should be addressed in future studies to increase reliability of results. Second, the sample studied consisted entirely of students, who are not comparable with the general population in terms of social, economic, or intellectual capabilities. Third, the use of a waiting list group as control group is a limitation. It is suggested that more dynamic control groups be used to help clients in future studies.

Conclusion

Given the limitations of this study, it can be concluded that, by increasing concentration on self-compassion, ACT can be effective in reducing feelings of shame and experiential avoidance in students with social anxiety disorder. This treatment can be an appropriate psychological intervention to reduce the symptoms of people with social anxiety disorder and help them to promote psychological flexibility. According to the results of this study and the literature on the efficacy of ACT, emotion and related problems can be identified as one of the main targets of this treatment.

Acknowledgments

We are grateful to all of the participants in the research and for assistance in carrying out and implementing this project.

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Publication Dates

  • Publication in this collection
    17 Apr 2020
  • Date of issue
    Jan-Mar 2020

History

  • Received
    11 Jan 2019
  • Accepted
    04 June 2019
Associação de Psiquiatria do Rio Grande do Sul Av. Ipiranga, 5311/202, 90610-001 Porto Alegre RS/ Brasil, Tel./Fax: (55 51) 3024 4846 - Porto Alegre - RS - Brazil
E-mail: trends@aprs.org.br