Running head: ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS ACT Protocol to Reduce Symptoms Associated with Anxiety: A Review of the Literature Submitted by: Bryn Kinders Capilano University 1 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 2 Abstract With the significant impact of anxiety and stress comes an increasing need for therapies that reduce the associated symptoms. Acceptance and commitment therapy (ACT), a third-wave therapy rooted in applied behavior analysis (ABA) and relational frame theory, shows great promise as an effective approach to reduce anxiety and stress related symptoms and increase quality of life. The aim of this literature review paper was to answer the following questions: (a) is ACT an effective method for reducing symptoms associated with stress and anxiety? (b) does ACT hold high social validity? (c) can we justify the reliability of the data produced by selfreported outcomes? (d) what are the future directions and implications of using ACT to address anxiety and stress? (e) does ACT hold the status as an evidence-based practice? The 12 studies selected for this review represent varying presentations of anxiety and stress that span across the lifespan. The reviewed research concluded that 1-10 sessions of ACT based protocol can be effective in decreasing various symptoms associated with stress and anxiety, most with longlasting effects. Future directions of the science of behavior that address the significant impact of the covert symptoms associated with anxiety and stress could be a big milestone for the field and might led to a broader application of ABA that also targets covert behaviors. ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 3 ACT Protocol to Reduce Symptoms Associated with Anxiety: A Review of the Literature Anxiety and stress can present in many forms, the most basic being, generalized anxiety disorder (Barlow, 2002, as cited in Ruiz et al., 2019), which impacts 4-7% of individual's alone, and can led to great impairments to one's quality of life (Kessler, 2000, as cited in Ruiz et al., 2019). Anxiety and stress impact many aspects of an individual's life beyond their mental health including symptoms that can interfere with one's career, ability to function effectively in daily life, social life, and relationships (Ruiz et al., 2019). Anxiety and stress can also cause withdrawal from everyday activities that were once enjoyable (Torabian et al., 2019). Not only do stress and anxiety cause symptoms associated with mental health but, they can also cause problems with physical health as well (Allgulander, 2012, as cited in Ruiz et al., 2019, p. 261262). Few presentations of anxiety, including many cases of generalized anxiety disorder, will improve without professional treatment (Wittchen, 2002, as cited in Ruiz et al., 2019, p. 262), which underscores the need for treatment options. A behavior analytic therapy that shows promise in addressing anxiety through acceptance of one's thoughts, unlike other conventional therapies, that does not rely on a talk-based symptom elimination framework is Acceptance and Commitment Therapy (ACT) (Hayes, 2004; Kahl, Winter, & Schweiger, 2012, as cited in Juncos & Markman, 2016, p. 936), a third-wave therapy that has emerged from relational frame theory (Dehbahneh, 2019). Within the field of ABA, covert behaviors have historically been avoided due to the difficulty in assessing and addressing them due to the private nature of these events (Wolf, 1978). With the significant and broad impacts of anxiety and stress (Ruiz et al., 2019), ACT might just be the evolution this field needed to support individuals to a broader extent that goes beyond observable behaviors. ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 4 ACT contains six core principles that aim to increase psychological flexibility including acceptance: one's ability to accept internal and external events without judgement, cognitive diffusion: the ability to diffuse the impact of our internal events through transformation of stimulus function, present moment: the ability to remain responsive to one's immediate environment and the sensory stimulus within it, self as context: the awareness of your own self as an observer, values: defining what is important and valuable to one's life, and finally, committed action: engaging in behaviors that move you closer to your value goals while allowing your internal events to remain unimpactful (Dehbahneh, 2019). The aim of ACT is not to reduce symptoms by removing them entirely but rather, ACT aims to increase the individual's acceptance of the negative covert behaviors they might experience in an attempt to diffuse them and reduce their impact (Juncos & Markman, 2016). ACT promotes mindfulness which is an individual's ability to remain responsive to the present moment and the sensations their body is experiencing on a sensory level rather than focusing on the thoughts or covert behaviors that might pull them away from the present moment and instead lead to thoughts of the past or future (Cardaciotto et al., 2008, as cited in Juncos & Markman, 2016, p. 937). To examine the impact that ACT might have on reducing symptoms associated with anxiety and stress, this paper reviewed 12 studies that used 1-10 sessions of ACT protocol to reduce a variety of related symptoms across ages 8-56 (Dehbahneh, 2019; Dehlin et al., 2013; Juncos & Markman, 2016; Ruiz et al., 2018; Ruiz et al., 2019; Ruiz et al., 2016; Ruiz et al., 2020; Salazar et al., 2020; Thompson et al., 2021; Twohig et al., 2006; Woidneck et al., 2014; Yadavaia & Hayes, 2012). This literature review paper aimed to answer the following questions: (a) is ACT an effective method for reducing symptoms associated with stress and anxiety? (b) does ACT hold high social validity? (c) can we justify the reliability of the data produced by ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 5 self-reported outcomes? (d) what are the future directions and implications of using ACT to address anxiety and stress? (e) does ACT hold the status as an evidence-based practice? Description of Literature Search A literature search was conducted using the Capilano University library databases with terms such as “acceptance and commitment therapy”, “anxiety”, “obsessive-compulsive disorder”, and “stress” which later was expanded to include terms such as, “single subject research”, “multiple baseline design”, “alternating treatments”, and “withdrawal design” to try to eliminate articles that were not single subject research focused. The primary databases searched were PsycInfo and PsycArticles. Once the Capilano library had been thoroughly searched, google scholar was utilized to locate a few more articles on obsessive compulsive disorder. Most of the sources found came from primarily psychology and behavior focused journals with only a few coming from medical or mental health journals. The selection criteria used to determine which research studies would be selected was as follows: a focus on anxiety and/or stress with a variety of presentations displayed across studies, use of ACT, across all ages, and the studies must utilize single subject research designs. Out of the 15 studies found initially, only 12 were included in this review as three of them did not contain enough information to justify their results. The 12 papers that made the final selection met all the criteria for selection and contained enough information to justify their use (Dehbahneh, 2019; Dehlin et al., 2013; Juncos & Markman, 2016; Ruiz et al., 2018; Ruiz et al., 2019; Ruiz et al., 2016; Ruiz et al., 2020; Salazar et al., 2020; Thompson et al., 2021; Twohig et al., 2006; Woidneck et al., 2014; Yadavaia & Hayes, 2012). ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 6 Dependent Variable(s) The dependent variables differed depending on the presentations of anxiety and stress that the participants experienced and were typically gathered through self-reported measures and questionnaires. The most common dependent variables used across the research studies reviewed were levels of worry, psychological distress, cognitive fusion, valued living, emotional symptoms, psychological flexibility, and repetitive negative thinking, all of which were measured in three of the 12 studies. General worry level was targeted in three of the 12 studies (Dehbaneh, 2019; Ruiz et al., 2019; Ruiz et al., 2016). One of the studies also included worry relative to couple dynamics (Ruiz et al., 2019). Psychological distress was also targeted in two of the 12 selected studies as a secondary measure (Ruiz et al., 2019; Ruiz et al., 2016) and was used in one study as a primary dependent variable (Ruiz et al., 2018). Cognitive fusion was used as a secondary measure in three of the 12 studies (Juncos & Markman, 2016; Ruiz et al., 2019; Ruiz et al., 2016). Valued living appeared as a secondary measure across three studies (Juncos & Markman, 2016; Ruiz et al., 2019; Ruiz et al., 2016). Emotional symptoms were measured in two studies as a primary measure (Ruiz et al., 2018; Salazar et al., 2020). Additionally, emotional symptoms were studied as a secondary measure in one study (Ruiz et al., 2016). Psychological flexibility was also studied as a primary measure across two studies (Salazar et al., 2020; Thompson et al., 2021). Psychological flexibility was additionally used as a secondary measure in one of the 12 studies (Juncos & Markman, 2016). Repetitive negative thinking appeared as a primary measure across three of the 12 studies (Ruiz et al., 2016; Salazar et al., 2020; Yadavaia & Hayes, 2012). One of those three studies looked at repetitive negative thinking in relation to one's identity (Yadavaia & Hayes, 2012). ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 7 The second most common variables consisted of experiential avoidance and compulsions. Experiential avoidance appeared in two studies, one as a primary variable (Dehlin et al., 2014), and one as a secondary variable (Ruiz et al., 2016). Compulsions also appeared in two studies as a primary variable in both (Dehlin et al., 2014; Twohig et al., 2006). One study looked at compulsions related to scrupulosity focused OCD (Dehlin et al., 2014). The other study looked at compulsions related to general OCD symptoms such as checking, cleaning, and hoarding (Twohig et al., 2006). Lastly, there were variables that appeared unique to single studies which were body dysmorphia, interpersonal problems, quality of life, music performance anxiety, mindfulness, general levels of depression, stress, and anxiety, rumination, generalized pliance, daily ritual duration, and PTSD symptoms. One study looked at levels of body dysmorphia, interpersonal problems, and quality of life in participants with body dysmorphic disorder (Dehbaneh, 2019). Another study looked at music performance anxiety and mindfulness as variables in a university student who was experiencing music performance anxiety (Juncos & Markman, 2016). Thirdly, a study looked at general levels of depression, stress, and anxiety in participants with comorbid depression and generalized anxiety disorder (Ruiz et al., 2020). Rumination was measured in a study that aimed to reduce worry related symptoms in adults (Ruiz et al., 2016). Generalized pliance was utilized as a primary measure in a study that looked at childhood depression (Salazar et al., 2020). Daily ritual duration was used as a measure in a study that looked at reducing OCD symptoms in adults (Thompson et al., 2021). Lastly, one of the studies looked at PTSD symptoms in adolescents who had all experienced traumatic events (Woidneck et al., 2014). ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 8 Independent Variable(s) All the studies selected utilized an ACT based protocol as their independent variable. Although all studies utilized ACT, five of the studies utilized a modified ACT protocol for specific presentations of anxiety as well, the 12 studies varied in the number of sessions from 110. The adapted protocols included two repetitive negative thinking focused ACT protocol, a music performance anxiety focused ACT protocol, an OCD focused ACT protocol, and an ACT protocol modified for PTSD. Most of the selected studies utilized a general ACT protocol to address symptoms associated with stress and anxiety (Dehbaneh, 2019; Dehlin et al., 2014; Ruiz et al., 2018; Ruiz et al., 2019; Ruiz et al., 2016; Thompson et al., 2021; Yadavaia & Hayes, 2012). Of these studies, three of them had a protocol where the number of sessions was below four (Ruiz et al., 2019; Ruiz et al., 2016; Thompson et al., 2021). The four remaining studies using a general ACT protocol had session numbers that were above six (Dehbaneh, 2019; Dehlin et al., 2014; Ruiz et al., 2018; Yadavaia & Hayes, 2012). The remaining five studies utilized adapted ACT protocols that focused on the specific presentations of anxiety. Two of the five studies adapted the ACT protocol to focus on repetitive negative thinking, both using a three session ACT protocol (Ruiz et al., 2020; Salazar et al., 2020). Another study used a 10 session ACT protocol that was modified to address music performance anxiety in a university student (Juncos & Markman, 2016). Another study applied eight sessions of an adapted ACT protocol that focused on symptoms associated with OCD (Twohig et al., 2006). The final study used 10 sessions of a modified ACT protocol was adapted to treat PTSD in adolescent individuals who had all experienced a past traumatic event (Woidneck et al., 2014). ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 9 Results ACT has shown its effectiveness across all 12 studies to varying degrees of success with most studies producing significant effects that maintained until follow-up. Majority of the studies showed significant and long-lasting change in the levels of anxiety and stress related symptoms being repetitive negative thinking, compulsions, worry, interpersonal problems, performance anxiety, fusion with thoughts, experiential avoidance, emotional symptoms, distress, psychological inflexibility, PTSD symptoms, and OCD rituals. Not only did the results prove effective across varying presentations of symptoms, but also showed significant improvements across various numbers of sessions. Only one participant showed an increase in the interference of their daily thoughts however, there was also a simultaneous decrease in the believability of these thoughts which shows that although the frequency of their thoughts increased, they no longer held the same intensity (Yadavaia & Hayes, 2012). Along with reduction in anxiety and stress related behaviors, most participants also experienced increased levels of quality of life (Dehbahneh, 2019; Yadavaia & Hayes, 2012) and experiential engagement (Dehlin et al., 2013; Ruiz et al., 2018; Ruiz et al., 2016; Ruiz et al., 2020). The cumulative and stable results across studies conclude strong evidence for the effectiveness of ACT as a treatment for anxiety and stress. Reliability Interobserver agreement is a measurement taken to evaluate the accuracy of the data collected and is typically based off the observations of at least two people and is important in proving the integrity of the data and results gained (Cooper et al., 2020). In order for IOA to be valid, observers must utilize the same recording methods, measure the same behaviors, and must be situated independently so that there is no influence on one another’s reports (Cooper et al., ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 10 2020). The standard for acceptable IOA measures is no less than 80% across at least 20% of sessions run (Cooper et al., 2020). IOA was not collected in majority of the studies chosen due to the nature of the observability of the events associated with stress and anxiety and the use of self-reports collected by the participants on their own covert behaviors where observation was not available. One of the studies that included data on observable variables such as compulsions and activity avoidance reported IOA across at least 20% of the sessions and obtained 97-100% agreement which meets requirements for IOA (Dehlin et al., 2013). Despite the lack of IOA reported, it can be assumed that the data collected is reliable due to the consistency within and across studies and the improvements expressed by the participants. The effectiveness shown in the data collected occurred across studies, ages, behaviors, diagnoses, and degrees of anxiety, with not much variability in effectiveness which shows strong evidence of the reliability of the data collected. Evidence Based Practice Status In the field of ABA, which is the science in which ACT is rooted, it is mandatory to align one's practice in a way that maintains the ethical standards outlined in The Ethics Code for Behavior Analysts which states that practices used must hold an evidence-based status in order to reduce the risk of harm to clients (Behavior Analyst Certification Board, 2020). In order for a practice to hold status as an evidence-based practice, it must meet certain standards including an operational definition of the practice and the location it will take place, reaching fidelity in implementation, a functional relationship shown between the independent and dependent variables, and experimental control must be shown across the predetermined conditions (results are consistent across five research studies published in a peer reviewed journals, single subject ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 11 research designs are used, a minimum of three different locations and three novel researchers are present, and across the five studies, a minimum of 20 participants were studied) (Horner et al., 2005). The studies chosen in this review assessed and proved the effectiveness of ACT across over five studies, 20 participants, three researchers and three locations. As well, majority of the studies selected showed alignment with the standard criteria for an evidence-based practice including high results of treatment fidelity (Juncos & Markman, 2016; Twohig et al., 2006; Woidneck et al., 2014), operational and complete definitions of both the procedures and the variables, specified locations, and a functional relationship between ACT and the chosen variables displayed. By these standards, acceptance and commitment therapy has been identified as an evidence-based practice due to its alignment with the determined criteria for a practice to be defied as such. Social Validity Social validity is important to consider as it indicates the degree of which the selected goals, behavior change tactics, and results align with people’s values and are viewed favorably (Wolf, 1978). Social validity addresses many factors relating to the validity of the measures including the degree of change, cost effectiveness of the procedures, the degree to which the results maintain across time, and the likability of the procedures (Richards, 2019). With the subjective and unobservable nature of the private events being examined in this review and with the questions that might arise about the reliability, social validity might play a large role in determining and confirming the effectiveness of the procedures and the significance of the results (Wolf, 1978). ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 12 Social validity was not specifically reported in many of the selected studies however, four studies did report on the social validity of the procedures and outcomes (Dehlin et al., 2014; Juncos & Markman, 2016; Twohig et al., 2006; Woidneck et al., 2014). Three of the studies utilized the Treatment Evaluation Inventory Short-From to assess social validity of the procedures and outcomes and in all cases, concluded that the success of the procedures was viewed favorably (Dehlin et al., 2014; Twohig et al., 2006; Woidneck et al., 2014). One study noted that the necessary exposure to triggers was not viewed as aversive by the participants and they viewed the exposure as socially valid and acceptable (Twohig et al., 2006). In another study, the participant reported an increased ability to accept her thoughts and navigate situations with confidence and this change was also noted by close people in her life that also noticed the difference and viewed it favorably (Juncos & Markman, 2016). As many of the studies did not include an analysis surrounding social validity, an analysis of the selected studies, the goals, procedures, and outcomes associated will be discussed below. The goals selected for each of the studies were relevant to the type of anxiety and stress the participants experienced and lead to positive change in quality of life (Dehbahneh, 2019; Yadavaia & Hayes, 2012). Anxiety and stress also impact many other aspects of an individual's life beyond their mental health including one's relationships, jobs, general quality of life, physical health, self-image, etc. (Dehbaneh, 2019; Ruiz et al., 2019). By selecting goals that aimed to reducing anxiety, broad effects across other domains of the participants lives such as, the quality of their relationships and overall quality of life, were also impacted simultaneously (Ruiz et al., 2019). ACT is an appealing and effective framework that has shown moderate to significant effectiveness in just one to three short sessions (Ruiz et al., 2019; Ruiz et al., 2016; Ruiz et al., ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 13 2020; Salazar et al., 2020). For individuals for whom life is often already full of responsibility or possible financial constraints, finding time and resources to address mental health challenges might be difficult. The efficiency of a 1-3 session approach to ACT, might be effective in mitigating these barriers. One of the studies also utilized a non-concurrent schedule which allowed for flexibility in the treatment schedule that did not impact the validity of the results which shows social validity in that it accounted for other commitments in the participants lives (Thompson et al., 2021). The procedures used also hold high social validly in that they were effectively adapted across many different presentations of anxiety (Dehbaneh, 2019; Dehlin et al., 2014; Juncos & Markman, 2016; Ruiz et al., 2019; Salazar et al., 2020; Thompson et al., 2021; Woidneck et al., 2014; Yadavaia & Hayes, 2012). Overall, the procedures used in the 12 selected studies led to positive outcomes across most participants. Symptoms associated with stress and anxiety such as, repetitive negative thinking, compulsions, and daily rituals can have a significant impact on one's life in extreme cases (Dehbahneh, 2019). Through the effectiveness shown through the outcomes of the studies, majority of the participants experienced a significant reduction in their symptoms associated with stress and anxiety, which would not only give them time back during their waking hours but, would also impact their quality of life positively (Dehbahneh, 2019; Yadavaia & Hayes, 2012). Lastly, several of the studies included a follow up where most of the studies concluded that effects that maintained over time (Dehlin et al., 2014; Juncos & Markman, 2016; Ruiz et al., 2016; Salazar et al., 2020; Twohig et al., 2006; Woidneck et al., 2014; Yadavaia & Hayes, 2012). Clinical Applications, Conclusions, and Future Directions This literature review aimed to summarize and identify whether ACT would be an effective and evidence-based practice, that also held social validity across the 12 selected studies. ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 14 Although limited, the research shows great success in reducing the symptoms experienced by individual's due to anxiety, stress, and depression and held high social validity across various studies, as well as lasting effects across time. The conclusions drawn from this literature review identify the use of ACT in treating anxiety and stress as an evidence-based practice. One limitation of the research when utilizing self-reports, is the inability to take IOA to determine the accuracy of the data. As covert behaviors are only observable to the individual experiencing them, it is harder to assess their accuracy. Secondly, as most of the current research focuses on neurotypical adults, future research might be needed to evaluate the effectiveness of ACT in reducing similar symptoms in adolescents or across varying populations such as individuals with comorbid diagnoses like autism spectrum disorder or attention deficit disorder. Despite the lack of research available, there is already strong diversity shown across various populations and presentations that will hopefully continue to expand in future research. ACT and other similar procedures that address covert behaviors, such as repetitive negative thinking, might provide a necessary expansion to the field of ABA that will allow for a broader scope of practice for practitioners. Until this point, ABA has focused on overt observable behaviors and the success of the current research has proven that ABA can be effective beyond merely overt behaviors. For BCBA’s working primarily with the autistic population, and often with individual's who experience high levels of mental health related concerns while simultaneously having greater barriers in accessing services to support them with these concerns (Gomez et al., 2021), ACT might provide an effective and socially valid method of providing support to this vulnerable population. One of these potential barriers to supports is challenges with vocal verbal communication for which ACT might have the potential to be an effective approach when adapted to the communication styles of specific clients, where regular talk- ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 15 therapies might not be effective due to these challenges (Gomez et al., 2021). Although great potential is shown with this population, most of the research has been focused on neurotypical adults and more research that specifically targets the autistic population might be necessary. In summary, ACT has proven to be an effective evidence-based to addressing anxiety and stress related symptoms and shows promise to produce impactful changes across a wide range of ages, presentations of anxiety, and diverse populations. ACT provides an important expansion to the field of ABA to address covert behaviors while also remaining in alignment with The Ethics Code for Behavior Analysts where it upholds the requirements of providing effective evidencebased and socially valid supports while putting the best interests of the client first (Behavior Analyst Certification Board, 2020). With its broad success as well as its alignment with participant values and ethical requirements, ACT just might be the evolution this field has been waiting for. ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 16 References Behavior Analyst Certification Board. (2020). Ethics Code for Behavior Analysts. Behavior Analyst Certification Board. https://www.bacb.com/wp-content/uploads/2022/01/EthicsCode-for-Behavior-Analysts-220316-2.pdf Cooper, J. O., Heron, T. E., & Heward, W. L. (2020). Applied behavior analysis (3rd edition). Pearson Education. Dehbaneh, M. A. (2019). Effectiveness of acceptance and commitment therapy in improving interpersonal problems, quality of life, and worry in patients with body dysmorphic disorder. Electronic Journal of General Medicine, 16(1), 1-7. https://doi.org/10.29333/ejgm/93468 Dehlin, J. P., Morrison, K. L., & Twohig, M. P. (2013). Acceptance and commitment therapy for scrupulosity in obsessive compulsive disorder. Behavior Modification, 37(3), 409-430. 10.1177/0145445512475134 Gomez, L. E., Navas, P., Verdugo, M. A., & Tasse, M. J. (2021). Empirically supported psychological treatments: The challenges of comorbid psychiatric and behavioral disorders in people with intellectual disability. World Journal of Psychiatry, 11(11), 1039-1052. 10.5498/wjp.v11.i11.1039 Horner, H. R., Carr, E. G., Halle, J., McGee, G., Odom, S., & Wolery, M. (2005). The use of single-subject research to identify evidence-based practice in special education. Council for Exceptional Children, 71(2), 165-179. 10.1177/001440290507100203 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 17 Juncos, D. G., & Markman, E. J. (2016). Acceptance and commitment therapy for the treatment of music performance anxiety: A single subject design with a university student. Psychology of Music, 44(5), 935-952. 10.1177/0305735615596236 Richards, S. B. (2019). Single subject research designs: Applications in education (3rd edition). Cengage. Ruiz, F. J., Florez, C. L., Garcia-Martin, M. B., Monroy-Cifuentes, A., Barreto-Montero, K., Garcia-Beltran, D. M., Riano-Hernandez, D., Sierra, M. A., Suarez-Falcon, J. C., Cardona-Betancourt, V., & Gil-Luciano, B. (2018). A multiple-baseline evaluation of a brief acceptance and commitment therapy protocol focused on repetitive negative thinking for moderate emotional disorders. Journal of Contextual Behavioral Science, 9, 1-14. https://doi.org/10.1016/j.jcbs.2018.04.004 Ruiz, F. J., Garcia-Beltran, D. M., Monroy-Cifuentes, A., & Suarez-Falcon, J. C. (2019). Singlecase experimental design evaluation of repetitive negative thinking-focused acceptance and commitment therapy in generalized anxiety disorder with couple-related worry. International Journal of Psychology and Psychological Therapy, 19(3), 261-276. Ruiz, F. J., Hernandez, D. R., Suarez-Falcon, J. C., & Luciano, C. (2016). Effect of a one-session ACT protocol in disrupting repetitive negative thinking: A randomized multiple-baseline design. International Journal of Psychology and Psychological Therapy, 16(3), 213-233. Ruiz, F. J., Luciano, C., Florez, C. L., Suarez-Falcon, J. C., & Cardona-Betancourt, V. (2020). A multiple-baseline evaluation of acceptance and commitment therapy focused on repetitive ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 18 negative thinking for comorbid generalized anxiety disorder and depression. Frontiers in Psychology, 11, 1-16. 10.3389/fpsyg.2020.00356 Salazar, D. M., Ruiz, F. J., Ramirez, E. S., & Cardona-Betancourt, V. (2020). Acceptance and commitment therapy focused on repetitive negative thinking for child depression: A randomized multiple-baseline evaluation. The Psychological Record, 70, 373-386. https://doi.org/10.1007/s40732-019-00362-5 Thompson, B. L., Twohig, M. P., & Luoma, J. B. (2021). Psychological flexibility as shared process of change in acceptance and commitment therapy and exposure and response prevention for obsessive-compulsive disorder: A single case design study. Behavior Therapy, 52, 286-297. Torabian, S., Sabet, V. H., & Meschi, F. (2019). The effectiveness of acceptance and commitment therapy on anxiety, depression, and stress in patients with spinal cord injuries. International Clinical Neuroscience Journal, 6(2), 46-52. 10.15171/icnj.2019.10 Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). Increased willingness to experience obsessions: Acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behavior Therapy, 37(1), 3-13. 10.1016/j.beth.2005.02.001 Woidneck, M. R., Morrison, K. L., & Twohig, M. P. (2014). Acceptance and commitment therapy for the treatment of posttraumatic stress among adolescents. Behavior Modification, 38(4), 451-476. 10.1177/0145445513510527 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 19 Wolf, M. M. (1978). Social validity: The case for subjective measurement of how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11 (2), 203214. Yadavaia, J. E., & Hayes, S. C. (2012). Acceptance and commitment therapy for self-stigma around sexual orientation: A multiple baseline evaluation. Cognitive and Behavioral Practice, 19, 545-559. 20 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS Table 1. TITLE Study 1 Dehbaneh, M. A. (2019) N 6 DV Severity of body dysmorphia, interpersonal problems, quality of life, and amount of worry. IV Acceptance and Commitment Therapy (weekly, 1-hour sessions) IOA Not reported. 2 Dehlin, J. P., Morrison, K. L., & Twohig, M. P. (2013) 5 OCD symptoms associated with scrupulosity. 8 sessions of ACT that were 1-1.5 hours in length occurring once per week. 20% of the SCID and YBOCS assessments were scored for IOA, the YBOCS assessments reached 97% Results Interpersonal problems: The mean score across participants changed from 65.83 at initial assessment to 39.28 at follow up. Physical (QOL): The mean score across participants changed from 41.83 at initial assessment to 75.86 at follow up. Psychological (QOL): The mean score across participants changed from 36.5 at initial assessment to 72.43 at follow up. Social (QOL): The mean score across participants changed from 32.33 at initial assessment to 75 at follow up. Environmental (QOL): The mean score across participants changed from 41.67 at initial assessment to 73.28 at follow up. Worry: The mean score across participants changed from 59.5 at initial assessment to 33 at follow up. Average across participants: On average, participants showed an average of 25 compulsions a day which reduced to 5.6 following treatment and was further reduced to 4.3 by follow-up. The average range for their pretreatment avoidance of activities was 6 which 21 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 3 Juncos, D. G., & Markman, E. J. (2016) 1 Music performance anxiety symptoms and music performance. agreement and the SCID assessments reached 100% agreement which meets the appropriate conventions for IOA. 1 hour ACTNo IOA based process reported. Three sessions weekly, sessions were across 10 evaluated for sessions that treatment was modified fidelity using for MPA. two raters where their level of agreement was 98%. However, the rater’s adherence levels were low so the raters were then asked to rate the authors levels of adherence to the protocols within sessions which the raters viewed as highly competent and reduced to 0.7 by post- treatment and decreased further to 0.5 by follow-up. PHLMS: Mindfulness Level: Levels changed from low levels of mindfulness at intake to high levels. Trend: a gradual increasing trend is seen. Variability: Graph shows little variability, stable data. OQ 45.2: Outcomes Level: Levels go from high levels to low levels. Trend: Gradual decreasing trend. Variability: stable PAI: Performance anxiety Level: levels go from high levels of performance anxiety to low levels at follow up. Trend: Gradual decreasing trend. Variability: Stable data. BAFT: fusion with anxious thoughts Level: levels go from high levels of fusion with anxious thoughts to low levels at follow up. Trend: Gradual 22 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS excellent in adherence. decreasing trend. Variability: Stable. *other measures were not graphed as big changes were not noted* 4 Ruiz, F. J., Luciano, C., Florez, C. L., SuarezFalcon, J. C., & CardonaBetancourt, V. (2020) 6 levels of 3 sessions of an depression, RNT-focused anxiety, and ACT protocol stress associated with comorbid depression and generalized anxiety disorder. Not reported Mean emotional symptom scores: Level change: High levels during baseline to low levels following treatment initiation Trend: Gradual decreasing trend. Variability: Stable rates. Mean depression scores: Level change: High level during baseline to low-moderate levels following treatment. Trend: Gradual decreasing trend. Variability: Stable rates. Mean stress scores: Level change: High levels of stress that decrease to moderate levels following treatment initiation. Trend: Gradual decreasing trend. Variability: Stable. Mean pathological worry scores: Level change: High levels of pathological worry that decrease to low- 23 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS moderate levels. Trend: Gradual decreasing trend. Variability: Stable. Mean experiential avoidance scores: Level change: Initial high levels in avoidance followed by a decrease to low levels post treatment initiation. Trend: Initial rapid decreasing trend that levels out. Variability: Stable. Mean cognitive fusion scores: Level change: Initial high levels at baseline followed by a decrease to low levels following treatment initiation. Trend: Initial rapid decreasing trend that levels out. Variability: Stable. 5 Ruiz, F. J., Florez, C. L., Garcia-Martin, M. B., Monroy-Cifuentes, A., Barreto-Montero, K., Garcia-Beltran, D. M., Riano-Hernandez, D., Sierra, M. A., SuarezFalcon, J. C., CardonaBetancourt, V., & GilLuciano, B. (2018) 10 emotional symptoms experienced by participants and the psychological distress associated with moderate emotional disorders An individual weekly ACT session across the 8 weeks of the study with a follow-up at week 12. Not reported Participant 1: Emotional symptoms: Went from high levels of symptoms to low levels with an immediate decreasing trend followed by a stable trend. Psychological distress: Went from high levels of symptoms to low levels with an immediate decreasing followed by a stable trend. Participant 2: 24 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS Emotional symptoms: Went from moderate-high levels to moderate levels with a very gradual decreasing trend. Psychological distress: Went from moderate levels to lowmoderate levels with a gradual decreasing trend. Participant 3: Emotional symptoms: Went from moderate levels to low levels with a gradual decreasing trend. Psychological distress: Went from moderate levels to low levels with a gradual decreasing trend. Participant 4: Emotional symptoms: High levels to low-moderate levels with a gradual decreasing trend following baseline. Psychological distress: Moderate levels to low-moderate levels with a gradual decreasing trend shown. Participant 5: Emotional symptoms: High levels that decrease to low levels with a stable trend, very gradual decrease. 25 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS Psychological distress: Moderate levels that decrease to low levels with a stable trend, very gradual decrease. Participant 6: Emotional symptoms: Moderate-high levels changing to lowmoderate levels following treatment with a decreasing trend.. Psychological distress: Moderate levels that decrease to low levels following treatment initiation with a stable gradual decreasing trend Participant 7: Emotional symptoms: High levels in baseline decreasing to moderate levels during intervention with a gradual decreasing trend. Psychological distress: Moderate levels at baseline decreasing to low levels in intervention with a level trend. Participant 8: Emotional symptoms: Moderate to high levels during baseline that decrease to low levels in intervention with a decreasing trend. Psychological distress: Moderate levels at baseline that decrease 26 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS to low-moderate levels in intervention with a very gradual decreasing trend. Participant 9: Emotional symptoms: Moderate-high levels during baseline that decrease to low levels during intervention with a very gradual decreasing trend. Psychological distress: Low-moderate levels during baseline that decrease to low levels in intervention with a level trend. Participant 10: Emotional symptoms: High levels during baseline that decrease to low levels in intervention with a gradual decreasing trend. Psychological distress: Moderate levels during baseline that decrease to low levels during intervention with a stable level trend. 6 Ruiz, F. J., GarciaBeltran, D. M., MonroyCifuentes, A., & SuarezFalcon, J. C. (2019) 3 GAD (couplerelated worry and general pathological worry) An ACT protocol across 3 sessions was employed. First session was 90 minutes and the following two Not reported Couple related worry: Participant 1: High levels during baseline that decrease to moderate-low levels in intervention. Trend: stable decreasing trend. 27 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS were 60 minutes. Participant 2: Level: High levels during baseline that decrease to moderate-low levels in intervention. Trend: Immediate decrease followed by a gradually decreasing trend. Participant 3: Level: High-moderate levels of worry during baseline that decreased to lowmoderate levels in intervention. Trend: Decreasing trend. General Pathological Worry: Participant 1: Level: High-moderate levels during baseline that decrease to moderate-low levels in intervention. Trend: very gradual decreasing trend. Participant 2: Level: High-moderate levels during baseline that decrease to moderate-low levels in intervention. Trend: Gradual decreasing trend. Participant 3: Level: Levels go from moderate during baseline to moderate-low during intervention. No huge jump in level for 28 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS this participant. Trend: Gradual decreasing trend. 7 Ruiz, F. J., Hernandez, D. R., Suarez-Falcon, J. C., & Luciano, C. (2016) 11 Daily worry, rumination, and negative thoughts. A single session of the ACT protocol. Not reported 8 Salazar, D. M., Ruiz, F. J., Ramirez, E. S., & Cardona-Betancourt, V. (2020) 9 Psychological inflexibility, generalized pliance, RNT, emotional symptoms. A staggered Not reported on three session (40 min) ACT protocol focusing on RNT. Across all participants: All participants experience negative thoughts in moderate-high rates during baseline. Following the single session of ACT, most participants showed consistent responding at lower levels of responding from baseline however, this change was not a huge as significant as I would have hoped. One participant did not experience much change and two participants experienced and increase in RNT. Trend at follow up was mostly stable across all participants which is to be expected without ongoing intervention. An immediate affect was shown for only one participant and data remained fairly stable across the board. Results across all participants were as follows: Psychological inflexibility: Level: went from moderate-high levels across participants during baseline down to low-moderate levels during intervention. Trend: Most participants experience a gradual decreasing trend however, a few experienced a significant dip followed by a level trend. Variability: Data across participants 29 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS showed stability other that initial large decreases in data across a few participants. Immediate affect: All except one participant showed an immediate affect where no data during baseline overlaps with data during intervention phases. This shows strong evidence for the effectiveness of the protocol. RNT: Level: went from moderate-high levels across participants during baseline down to low-moderate levels during intervention with most participants reaching low levels and only a few remaining in the moderate level. Trend: All participants experience either experienced a gradual decreasing trend or a significant dip in RNT followed by a level trend. Variability: Data across participants showed stability. Immediate affect: Again, all except one participant showed an immediate affect where no data during baseline overlaps with data during intervention phases. This shows strong evidence for the effectiveness of the protocol. Generalized Pliance: Level: went from moderate levels across all participants during baseline and 30 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS stayed there during intervention with only one participant showing a decrease to stably low levels of responding. Trend: Most participants experience a fairly stable trend with little change across intervention. Variability: Data across participants showed high stability with only one participant dipping down to low levels at the last data point. Immediate affect: Only one participant showed an immediate affect and even though no data points were overlapping, the change in level was not huge. This shows that ACT might not be effective for generalized pliance. 9 Thompson, B. L., Twohig, M. P., & Luoma, J. B. (2021) 4 This study aimed to decrease OCD symptoms such as daily ritual duration and increase psychological flexibility associated with an OCD diagnosis. ACT protocol Not reported on combined with exposure and response prevention (ERP). The study aimed to decipher whether ACT alone could produce changes in psychological flexibility as compared to ERP. Participants received 4 Daily ritual durations: All 4 participants showed decreases in minutes spent ritualizing however, some showed a steeper decrease than others. Participant 1 went from 103.83 minutes to 81.59 minutes during the ACT phase, Participant 2 went from 133.81 minutes to 57.93 minutes, Participant 3 went from 127.50 minutes to 109.69 minutes, and participant 4 went from 170.67 minutes to 159.64 minutes. # participants however, experienced a reduction in ritual time during the ERP phase which was before the ACT protocol which makes me question this comparison to 31 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS sessions of ACT protocol in total however, they were on an alternating schedule of ERP and ACT. 10 Twohig, M. P., Hayes, 4 S. C., & Masuda, A. (2006) A reduction in self-reported compulsions. 8 sessions of ACT protocol for OCD baseline due to a possible carryover affect. Psychological flexibility: All participants went from low levels of psychological flexibility in baseline to moderate levels during the ACT protocol. Participant 2 showed a slightly higher increase jumping up to moderatehigh levels during intervention. It looks like however, for two participants, level changes occurred in the ERP sessions prior to the ACT session being implemented which questions the validity of this comparison to baseline. For the other two participants, little to no change occurred in ERP and changes in level then occurred in the ACT phase. I wonder if it might have been smarter to study each protocol separately to avoid carry over effects? This makes me question the validity of the data a bit. Not reported Participant one: Checking compulsions: Level: went from relatively high levels of checking behaviors to moderate-low levels of behaviors. Near the end of intervention this participant remained steadily at low levels. Trend: Gradual decreasing trend. 32 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS Participant two: Hoarding compulsions: Level: Went from high-moderate levels of hoarding compulsions down to low consistent levels of responding near the end of intervention. Trend: Decreasing trend however, this participant experienced a significant drop at day 8 which stayed more or less very low with a very slight decrease over the remaining days. Participant three: Cleaning compulsions: Level: Went from high-moderate levels of cleaning compulsions during baseline to moderate to low levels during intervention. Trend: This participant showed a gradual decreasing trend across the study. Participant four: Checking Compulsions: Level: Went from moderate to high levels of checking compulsions during baseline down to very low levels of compulsions near the end of intervention. Trend: Initial gradual decreasing trend 33 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS followed by a level trend at near zero levels. 11 Woidneck, M. R., Morrison, K. L., & Twohig, M. P. (2014) 7 Frequency of PTSD symptoms and the severity of symptoms. A modified ACT protocol for PTSD Not reported Participant 1: Level: Levels went from moderate to high levels during baseline down to moderate to low during intervention. Remained low during follow up with a slight increase at the termination of the study. Trend: This participant experienced a very slight gradual decreasing trend during intervention. Participant 2: Level: Went from high levels during baseline to low levels at intervention and follow-up. Trend: Decreasing trend was shown. Participant 3: Level: Went from moderate levels at baseline to low levels during intervention and follow-up. Trend: This participant showed an initial decrease followed by stable low levels of responding. Participant 4: Level: Went from moderate to low levels during baseline up to moderate levels during intervention. Dropped 34 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS again to low-moderate during follow up. Trend: This participant experienced a gradual increasing trend in intervention which dropped back to low-moderate levels at follow-up. I wonder if this was potentially due to the focus that having to address the trauma put on their PTSD symptoms. Participant 5: Level: Went from low-moderate levels during baseline to low levels during intervention and remained low at follow up. Trend: Decreasing trend. Participant 6: Level: Went from high levels during baseline that eventually reached low stable levels at intervention and remained low at follow up. Trend: Decreasing trend. Participant 7: Level: Moderate levels during baseline that stayed at moderate levels during intervention with only a few data points falling below baseline levels. Remained low-moderate at follow up. Trend: A very slight decreasing trend during intervention. 35 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS 12 Yadavaia, J. E., & Hayes, S. C. (2012) 6 (one Primary lost to variables being attrition) measured were the number of negative thoughts around their identity that participants experienced ACT protocol was used. Not reported Participant 1: on interference of daily thoughts Level: Went from a high level of daily thoughts during baseline down to low levels of thoughts by the end of intervention. Trend: Decreasing trend. Participant 2: Level: moderate levels of data in baseline to low levels in intervention. Trend: decreasing trend. Participant 3: Level: went from high levels during baseline to low-moderate levels in intervention. Trend: initial decrease followed by a level trend. Participant 4: Level: Moderate to high levels during baseline to high-low levels during intervention. Did level out to low by the last 4 data points. Trend: decreasing trend. Participant 5: Level: Moderate levels during baseline that decreased to low following intervention. 36 ACT PROTOCOL TO REDUCE ANXIETY SYMPTOMS Trend: initial decrease followed by a stable trend. Participant 6: LOST due to attrition. *a notable reduction in average daily distress was also shown across participants which went from moderate-high levels of distress to low levels across all participants. *most participants also experienced a reduction in the number of thoughts experienced however, one experienced an increase (I wonder if this is due to the nature of self-monitoring and having to be aware of your thoughts and therefor giving them more “space to exist”). *With the above noted however, the believability of the thoughts experienced decreased across all participants showing that even though the thoughts did not decrease to zero, the participants view on the thoughts as accurate changed for the positive.