A randomized controlled trial of mindfulness and acceptance-based group therapy for excessive worry

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Anxiety and depression co-occur highly with each other, with 69% of anxious youth being diagnosed with depression and up to 75% of depressed youth meeting criteria for an anxiety disorder (Angold, Costello, & Erkanli, 1999). When different classes of disorders co-occur at such high rates, selecting an appropriate treatment approach can be challenging. Traditional CBT for anxiety or depression are mostly single-target approaches focusing specifically on either anxiety or depression. Evidence-based interventions for multiple problems required a therapist to prioritise treatment goals and treat one problem at a time (Barlow, Allen, & Choate, 2004). However, this approach risks client drop out before he or she receives essential treatment for co-occurring difficulties (Rohde, 2012). In addition, multiple interventions are often costly to the public health care system (Jacobson, Martell, & Dimidjian, 2001). Given that the high comorbidity rates complicate the conceptualisation and provision of treatment and are generally associated with higher dropout, lower recovery, and poorer maintenance of gains (Rohde, 2012), treatment strategies that are flexible enough to accommodate diverse problems are needed. Recent development in unified treatments suggests that a transdiag-nostic approach appears to be more efficient and effective than treating disorders in a serial manner (Barlow et al., 2004). Unlike most traditional disorder specific treatments, transdiagnostic approaches target common features underlying symptoms in comorbid disorders (Barlow et al., 2004). They are more time-efficient and cost effective, simplifying treatment for both the client and therapist, which could improve the quality of care and satisfy a great need in public health (Rohde, 2012). Recent research (Barlow, et al., 2004) has identified that one of the common features in anxiety and depression is worry, a repetitive negative valanced process that reflects an unsuccessful attempt to prevent the occurrence of negative events or to devise coping strategies in case such events occur. Worry is an essential feature of Generalised Anxiety Disorder (GAD) and is a presenting characteristic across all anxiety disorders and depressive disorders (Starcevic, et al., 2007). Worry is characterised by the repeated experience of thoughts about potential negative events, and reported proneness to worry varies continuously across the normal population (Ruscio, Borkovec, & Ruscio, 2001). According to the most widely recognized model of GAD (Borkovec, Alcaine, & Behar, 2004), worry functions as a cognitive avoidance response, suppressing images and somatic activation and preventing the individual from emotional processing of fear that is important for successful habituation and extinction (Foa, Huppert, & Cahill, 2006). Such avoidance brings initial relief but results in anxiety maintenance. The repetitive negative thoughts involving anticipating future threat in worriers may disrupt the implementation of effective strategies to solve problems, resulting in maintained or exacerbated levels of distress. Resent data has also highlighted the importance of behavioural avoidance in worry such as reassurance seeking, procrastinating, or over-preparing, aimed at reducing distress in the short term but contributing to the long term maintenance of symptoms (Beesdo-Baum et al., 2012). Therefore, an approach targeting such avoidance strategies in worriers is warranted. Drawing from findings by Borkovec and colleagues (2004), Roemer and Orsillo (2005, 2007) argued that cognitive avoidance in worry may be experiential. That is, excessive worriers may be actively and/or automatically avoiding unpleasant internal experiences (thoughts, feelings, or bodily sensations) by focusing on future events and such avoidance is paradoxically associated with increased distress. Accordingly, training in the skill of mindfulness (i.e., paying attention, on purpose, in the present moment in a non-evaluative and expanded way to both internal and external sensations) may help to break this habitual anxious cycle of worry. An acceptance-based behaviour therapy (ABBT) was developed to specifically target the experiential avoidance in people with generalized anxiety disorder (Roemer & Orsillo, 2005; Roemer & Orsillo, 2007). The principles of the ABBT include (1) expanding present-moment awareness, (2) encouraging acceptance (a willingness to have one’s internal responses in order to participate in meaningful experiences) rather than judgment and avoidance of internal experiences, and (3) promoting action in areas of importance to the individual. A recent meta-analysis has revealed that ABBT is effective at reducing worry and that gains are largely maintained at follow-up (Hanrahan, Field, Jones, & Davey, 2013). Further, Hayes, Orsillo, & Roemer (2010) found that both acceptance of internal experiences and engagement in meaningful activities were related to treatment responder’s status at post-treatment and predicted treatment outcome. Specifically, change in acceptance was related to quality of life at post-treatment. Based on these findings, the current study will emphasise the acceptance component and investigate whether such acceptance approach is effective at improving excessive worry in a sample of community populations. Specifically, we investigate the effect of a mindfulness and acceptance-based group therapy (MABGT) for excessive worry by comparing it with a waitlist control.

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