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Article history:
Received 19 February 2013
Received in revised form
11 March 2014
Accepted 7 April 2014
Anxiety disorders are associated with numerous costs and poor quality of life (QOL), and yet are highly
treatable. The present study evaluated the relations between putative change processes, anxiety
symptom severity, and QOL by employing path analysis to compare two theoretically-derived models
of anxious psychopathology in an examination of pre-intervention data from two self-help effectiveness
studies. Consistent with expectation, symptom severity predicted QOL in a model derived from cognitive
therapy principles, though the model did not provide a good t to the data. A model derived from
Acceptance and Commitment Therapy principles suggested that the impact of experiential avoidance
(EA) on QOL was independent of symptom severity and provided a better t to the data. In fact, the path
from anxious symptomatology to QOL became non-signicant when EA was allowed to relate to QOL
directly. Cognitive fusion strongly predicted anxiety sensitivity which, in turn, signicantly predicted
symptoms. Theoretical and practical implications of the ndings are discussed in the context of
improving available treatments for anxiety-related disorders.
& 2014 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
Keywords:
Acceptance and commitment therapy
Cognitive therapy
Experiential avoidance
Cognitive fusion
Anxiety
Fear
1. Introduction
Anxiety disorders are common, chronic, debilitating, and associated with a range of functional impairments and poor quality of
life (QOL; i.e., the subjective well-being of an individual across
multiple domains of life; Frisch, Cornell, Villaneuva, & Relatzaff,
1992; Mendlowicz & Stein, 2000). Yet, anxiety disorders respond
well to traditional Cognitive Behavioral Therapies (tCBT), including
cognitive therapy (CT), that employ a range of evidence-based
intervention strategies (see Olatunji, Cisler, & Deacon, 2010 for a
recent meta-analytic review). Generally, cognitive-based interventions aim to ameliorate anxious suffering by directly altering
problematic psychological and emotional content (i.e., symptomatology) as a means to reduce functional impairments and increase
QOL (Hofmannn & Asmundson, 2008). This line of work has
yielded an impressive array of time-limited and efcacious interventions for a broad range of problems (e.g., anxiety disorders, see
Clark et al., 2003; mood disorders, see DeRubeis et al., 2005; and
psychosis, see Drury, Birchwood, Cochrane, & Macmillan, 1996).
Though behavior-change techniques are utilized in tCBT, the
central aim of CT is to identify, challenge, and correct negative or
distorted cognitions, maladaptive beliefs, and assumptions (Beck,
n
Correspondence to: University at Albany, State University of New York,
Department of Psychology, Social Sciences 399, 1400 Washington Ave., Albany,
NY 12222, USA. Tel.: 1 518 442 4820; fax: 1 518 442 4867.
E-mail address: cberghoff@albany.edu (C.R. Berghoff).
http://dx.doi.org/10.1016/j.jcbs.2014.04.001
2212-1447/& 2014 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i
Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i
2. Method
2.1. Participants
All study candidates who entered the online portal consented
to participate, and 616 were deemed eligible for the treatment
study following eligibility screening. One hundred thirteen (18.3%)
eligible participants did not respond to our invitation to complete
the pre-intervention assessment. Analyses indicated that these
individuals reported having heard of ACT less frequently (18.3
versus 33.0%; 2(1) 9.033, p o.01) and reported lower rates of
seeing a mental health professional (35.7 versus 46.3%; 2(1)
4.161, p o.05), than did completers. The nal sample consisted of
503 participants from the United States and abroad (females 394,
Mage 38.05 years, age range: 1872). The geographic distribution
of participants was diverse, and included residents of the United
States (n339), United Kingdom (n54), Canada (n43), Australia
and New Zealand (n 41), Ireland (n 7), and various other
European, Asian, and North American countries (n 18). The selfidentied ethnic/racial distribution of the sample was predominately White (n 435), followed by Other (n 20), Asian (n 16),
Hispanic (n 16), Multiracial (n 9), African-American (n 4), and
Native American (n 3). More than 60% of participants reported
being in a committed relationship (n 316). Participants were
generally highly educated (166 individuals had obtained a college
degree; 145 completed at least some graduate education), yet
reported a high rate of unemployment (14.12%). Moreover, 46.7%
of participants reported currently seeing a mental health professional for psychological difculties, 49.7% reported current medication use, 82% had been given a psychiatric diagnosis at some
point in their lives, and 56% reported receiving an anxiety disorder
diagnosis.
2.2. Materials
Anxiety sensitivity index (ASI). The ASI (Peterson & Reiss, 1992;
Reiss et al., 1986) is a widely used (e.g., Arch, Eifert et al., 2012)
self-report measure that assesses fear of aversive anxiety symptoms (e.g., shortness of breath), a key component of anxiety
disorders (Craske et al. 2009). Agreement with 16 items (e.g.,
It scares me when I am nervous) is rated on a 5-point Likert-type
scale (0 very little to 4 very much). Higher total scores
(range064) represent greater levels of catastrophic fear and
negative evaluations of anxiety symptoms (i.e., fear of fear).
The ASI has demonstrated good internal consistency in both
clinical (.88; Zinbarg, Barlow, & Brown, 1997) and non-clinical
samples (.86; Schmidt & Joiner, 2002), in addition to good
2-week (r .75; Reiss et al., 1986) and 3-year (r .71; Maller &
Reiss, 1992) testretest reliability. Internal consistency was excellent in the present study (.91).
2.2.1. Acceptance and action questionnaire 16 (AAQ)
The AAQ (Hayes et al., 2004) is a self-report scale designed to
measure EA. The present study utilized the 16-item version that
includes items assessing behavioral (a) avoidance of private
experiences (e.g. I try hard to avoid feeling depressed or
anxious), (b) control of private experiences (e.g., I rarely worry
about getting my anxieties, worries, and feelings under control,
reverse scored), and (c) action in the presence of unwanted private
experiences (e.g., When I feel depressed or anxious, I am unable
to take care of my responsibilities). Items are rated on a 7-point
Likert-type scale (1 never true to 7 always true), with higher
total scores (range16112) indicating greater levels of EA.
The AAQ has acceptable to good internal consistency (.78.86;
Arch, Eifert et al., 2012), and had good internal consistency in the
present study (.80).
2.2.2. Believability of anxious feelings and thoughts questionnaire
(BAFT)
Consistent with prior research (Masuda et al., 2009), the BAFT
(Forsyth & Eifert, 2008a; Herzberg et al., 2012) is designed to
assess the believability of thoughts and feelings, and specically
the extent to which one's relation with unpleasant private events
is fused or defused. Respondents rate 16 self-report items (e.g.,
My happiness and success depends on how good I feel) on a
7-point Likert-type scale (1 not at all believable to 7 completely
believable). Higher total scores (range16112) represent more
fusion with private content. The BAFT has demonstrated excellent
internal consistency in healthy undergraduate (.90) and highly
anxious community samples (.91). In addition, the BAFT has
good testretest reliability (r .77), strong construct validity, and is
sensitive to an ACT self-help treatment (Herzberg et al., 2012).
Internal consistency in the present study was excellent ( .90).
2.2.3. Beck anxiety inventory (BAI)
The BAI (Beck, Epstein, Brown, & Steer, 1988) is a self-report
assessment of anxiety symptom severity. Respondents rate 21
common anxiety symptoms (e.g., unable to relax and face
ushed) on a 4-point Likert-type scale (0 not at all to 3 severely
I could barely stand it) indicating the degree to which the
symptoms bothered them over the past week. Scores range from
0 to 63, with scores below 7 suggestive of minimal anxiety and 26
or greater suggestive of severe anxiety. The BAI has excellent
internal consistency (a .92), good testretest reliability (r .75),
good convergent and discriminant validity, and distinguishes
between individuals diagnosed with an anxiety disorder and those
who are not (Beck et al., 1988). Internal consistency was excellent
in the present study ( .93).
2.2.4. Quality of life inventory (QOLI)
The QOLI (Frisch, 1994; Frisch et al., 1992) is a 32-item selfreport measure of general life satisfaction. Sixteen life domains
(e.g., work, friends, and family) are rated for both importance
(0 not at all important to 2 extremely important) and satisfaction
( 3 very dissatised to 3 very satised) using Likert-type scales.
Total QOL (range 6 to 6) is calculated as the average of the
domain composite scores (Importance Satisfaction) following
removal of domains rated as not at all important, with higher
scores representing greater QOL. The QOLI has acceptable to good
internal consistency ( .77.89), strong testretest reliability
(r .80.91), and good discriminant and convergent validity
Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i
Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i
SD
ASI
BAI
AAQ
BAFT
ASI
BAI
AAQ
BAFT
QOLI
36.00
31.30
78.30
82.56
.16
14.10
14.12
12.95
18.17
1.85
.718
.564
.695
.361
.542
.651
.343
.725
.582
.428
CT Model
Fusion
.72
.60
ANX Sensitivity
.13
.48
.72
ANX Symptoms
-.34
.51
Quality of Life
Avoidance
.88
ACT Model
.51
Fusion
.60
ANX Sensitivity
.48
.72
Table 2
Decomposition of effects from the path analyses of Study 1.
Effect
Parameter
estimate
ACT model
On anxiety sensitivity
Of experiential
avoidance
Of cognitive fusion
On anxiety symptom
severity
Of anxiety sensitivity
On quality of life
Of experiential
avoidance
Of cognitive fusion
Of anxiety symptom
severity
tCBT model
On anxiety sensitivity
Of experiential
avoidance
Of cognitive fusion
On anxiety symptom
severity
Of anxiety sensitivity
On quality of life
Of anxiety symptom
severity
Standardized
estimate
R2
.49
.14
.13
2.73n
.47
.60
12.97n
.52
.72
.72
22.98n
.08
.57
10.67n
.00
.01
.01
.04
.19
1.02
.14
.13
2.73n
.47
.60
12.97n
.34
.49
.52
.72
.72
22.98n
.05
.34
8.13n
.12
ANX Symptoms
Note: Estimates are of path coefcients.
.72
.13
-.57
Avoidance
p o .01.
Quality of Life
.66
2(df)
GFI
CFI
NNFI
CT Model
157.66(5)
0.89
0.88
0.77
ACT
50.02(3)
0.96
0.97
0.90
2(2) = 107.64, p < .001
Fig. 1. Path models and t statistics for Study 1. All variables are observed. Path
coefcients are standardized (). Non-signicant paths are not displayed, though
the models are derived from the full analysis, not a reduced form. Statistically
signicant differences between the models are emphasized in bold print.
ANX Anxiety. Avoidance Experiential Avoidance, as assessed by the Acceptance
and Action Questionnaire, 16-item version. Fusion Cognitive Fusion, as assessed
by the Believability of Anxious Feelings and Thoughts Scale. ANX Sensitivity
assessed by the Anxiety Sensitivity Index. ANX Symptoms assessed by the Beck
Anxiety Inventory. Quality of Life assessed by the Quality of Life Inventory. All
displayed paths are signicant at p o.01.
Table 3
Descriptive statistics and correlation matrix for variables tested in Study 2.
Scale
SD
ASI
BAI
AAQ
BAFT
ASI
BAI
AAQ
BAFT
QOLI
37.97
33.05
80.18
86.48
.24
13.05
13.15
10.95
13.83
1.86
.700
.515
.662
.308
.424
.594
.339
.570
.574
.363
Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i
CT Model
Fusion
.57
.51
.70
ANX Sensitivity
.55
.20
ANX Symptoms
Quality of Life
.89
ACT Model
.53
Fusion
.57
.55
.51
ANX Sensitivity
.70
ANX Symptoms
.20
-.55
Avoidance
Quality of Life
.66
(df)
Effect
-.34
.53
Avoidance
Table 4
Decomposition of effects from the path analyses of Study 2.
GFI
CFI
CT Model
63.44(5)
0.89
0.87
ACT
13.97(3)
0.97
0.98
2(2) = 49.47, p < .001
NNFI
0.75
0.93
Fig. 2. Path models and t statistics for Study 2. All variables are observed. Path
coefcients are standardized (). Non-signicant paths are not displayed, though
the models are derived from the full analysis, not a reduced form. Statistically
signicant differences between the models are emphasized in bold print.
ANX Anxiety. AvoidanceExperiential Avoidance, as assessed by the Acceptance
and Action Questionnaire, 16-item version. Fusion Cognitive Fusion, as assessed
by the Believability of Anxious Feelings and Thoughts Scale. ANX Sensitivity
assessed by the Anxiety Sensitivity Index. ANX Symptoms assessed by the Beck
Anxiety Inventory. Quality of Life assessed by the Quality of Life Inventory. All
displayed paths are signicant at p o.01.
Parameter
estimate
ACT model
On anxiety sensitivity
Of experiential
.24
avoidance
Of cognitive fusion
.51
On anxiety symptom
severity
Of anxiety sensitivity
.70
On quality of life
Of experiential
.09
avoidance
Of cognitive fusion
.00
Of anxiety symptom .02
severity
tCBT model
On anxiety sensitivity
Of experiential
.24
avoidance
Of cognitive fusion
.51
On anxiety symptom
severity
Of anxiety sensitivity
.70
On quality of life
Of anxiety symptom .05
severity
Standardized
estimate
R2
.47
.20
3.26n
.55
8.71n
.49
.70
13.90n
.55
7.55n
.04
.12
.14
1.85
.34
.47
.20
3.26n
.55
8.71n
.49
.70
13.90n
.34
5.12n
.11
p o .01.
Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i
Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i
Acknowledgment
This work was supported, in part, by New Harbinger Publications Inc., who generously provided us with the intervention
workbooks at reduced cost. New Harbinger Publications Inc. had
no role in the research design or collection, analysis, or interpretation of data.
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Please cite this article as: Berghoff, C. R., et al. Comparing paths to quality of life: Contributions of ACT and cognitive therapy
intervention.... Journal of Contextual Behavioral Science (2014), http://dx.doi.org/10.1016/j.jcbs.2014.04.001i