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Cited by 29Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesMindfulness and Compassion InterventionsPsychotherapy Techniques and Applications

A Fresh Look at Potential Mechanisms of Change in Applied Relaxation for Generalized Anxiety Disorder: A Case Series

Open access
Hayes-Skelton, Sarah A., Usmani, Aisha, Lee, Jonathan K., Roemer, Lizabeth, Orsillo, Susan M.·2012·Cognitive and Behavioral Practice
DOI 10.1016/j.cbpra.2011.12.005PMC PMC3718512
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Abstract

Applied relaxation (AR), which involves noticing early signs of anxiety and responding with a relaxation response, is an empirically supported treatment for generalized anxiety disorder (GAD). However, research on hypothesized mechanisms of AR (e.g., reduced muscle tension) has been mixed, making it likely that additional mechanisms are contributing to the efficacy of AR. Stemming from more recent conceptualizations of GAD, it is hypothesized that mindfulness, decentering, and acceptance may be potential mechanisms of change in AR. Outcome, mechanism data, and case descriptions from three individuals diagnosed with GAD who received 16 weeks of AR as part of a larger randomized controlled trial are presented to demonstrate the ways that AR may lead to clinical improvement through mindfulness, decentering, and acceptance. © 2012.

Integrity signals

Registry

Crossref · 10.1016/j.cbpra.2011.12.005

Cites

55 of 55 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

5 of 40 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Findingown data

    Some clients appear to use progressive muscle relaxation and early cue detection to change their relationships with internal experiences in a mindful, decentered, or self-compassionate way.

    “however, as illustrated below, some clients do appear to use PMR and early cue detection to change their relationships with their internal experiences in a mindful, decentered, or self-compassionate way.”
    Quote in the paperSubstantial claim
  • Findingown data

    Doug's DASS-stress scores only began a steady decline around session twelve.

    “It was not until around session 12 that Doug began to experience a steady decline in his DASS-stress scores.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Kendra's AAQ scores changed only slightly between sessions four and twelve.

    “Although Kendra demonstrated changes in acceptance towards her emotions in her description of different events, her AAQ scores only showed a modest change from session 4 to 12.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Some of Kendra's comorbid conditions, especially panic and social anxiety, fell to subclinical levels.

    “Interestingly, several of her comorbid diagnoses, particularly panic and social anxiety, also decreased to subclinical levels.”
    Quote in the paperNot a substantial claim
  • Findingown data

    At the end of treatment, Doug's decentering and mindfulness scores were about 1.5 and 2 standard deviations above the mean.

    “By the end of therapy, Doug’s decentering and mindfulness scores were approximately 1.5 and 2 standard deviations above the mean.”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 37
  • May combine two claims. 39
  • The quote only partly states this claim. 3

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The alternative to experiential avoidance is acceptance, the recognition that experiences come and go and that judging or resisting them is not useful.

    “The alternative to experiential avoidance is acceptance (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), or the recognition that experiences will come and go and that judging or resisting them is not useful.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Hayes, Luoma, Bond, Masuda, & Lillis, 2006 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Experiential avoidance has been shown to differentiate individuals with and without a diagnosis of generalized anxiety disorder.

    “and has been shown to differentiate those with and without a diagnosis of generalized anxiety disorder (Lee, Orsillo, Roemer, & Allen, 2010).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Lee, Orsillo, Roemer, & Allen, 2010 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The Five Factor Mindfulness Questionnaire subscales have demonstrated good internal consistency and both incremental and discriminant validity.

    “The five subscales have demonstrated good internal consistency (alphas from .75 to .91) and both incremental and discriminant validity (Baer et al., 2006).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Baer et al., 2006 source

      In Deriving Mindfulness Facets (p. 10), all five subscales have the stated alpha range (.75–.91), and analyses show that their content is largely distinct. But Part 5 (p. 15) finds incremental validity in predicting psychological symptoms for only three facets—not all five—so the sentence overgeneralizes that result. (LLM, conf=0.90)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim.

    Premisecitation

    On average, undergraduate students scored 37.51 with a standard deviation of 3.58 on the Experiences Questionnaire decentering subscale.

    “On average undergraduate students scored 37.51 (SD = 3.58) on the decentering subscale (Fresco, Moore, et al., 2007).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Fresco, Moore, et al., 2007 source

      Study 1 identifies Sample 2 as college students (method, p. 3), and its 11 decentering item means sum to 37.51 (results, p. 6). The table reports standard deviations for individual items, not for the total subscale score, so our copy does not support the claimed SD of 3.58. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The Experiences Questionnaire decentering subscale has demonstrated convergent and discriminant validity and good internal consistency in nonclinical and clinical samples.

    “The decentering subscale has demonstrated convergent and discriminate validity and good internal consistency in both nonclinical and clinical samples with alpha coefficients of .83 and .84, respectively (Fresco, Moore, et al., 2007; Fresco, Segal et al., 2007).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Fresco, Moore, et al., 2007 source

      The General Discussion (p. 10) reports adequate-to-good internal consistency in undergraduate and clinical samples, but says convergent and discriminant validity was established in an undergraduate sample. Study 3 (pp. 9–10) examined clinical validity in patients with remitted depression, not the same range of convergent and discriminant relationships. The Results report α = .83 for a student sample (p. 3); the retrieved passages do not establish the cited clinical coefficient of .84. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites Fresco, Segal et al., 2007

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Findingown data

    Kendra's AAQ scores stayed near the norm through session four, yet her reported acceptance did not match how she presented in session.

    “Although Kendra’s AAQ scores were close to the normative level through session 4, this self-reported level of acceptance was not consistent with her in session presentation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At post-treatment, Julia scored above the mean on FFMQ and EQ-decentering and below the mean on AAQ.

    “Likewise, her FFMQ and EQ-decentering scores were both above the mean and her AAQ was below the mean (indicating more acceptance).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Julia's DASS-stress score before treatment was about 2.5 standard deviations above the mean.

    “Her DASS-stress score was approximately 2.5 standard deviations above the mean.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    By the end of treatment, Kendra had much less frequent work anxiety, no longer dreaded work, and found engaging with students easier.

    “By the end of therapy, Kendra stated that while she still occasionally experienced anxiety at work, it was considerably less frequent.”
    • Also stated in: § Kendra: A demonstration of increased mindfulness shifting experiential avoidance · plain
      “She no longer dreaded going to work each morning and found it easier to engage with her students in the classroom.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At baseline, Julia's mindfulness and acceptance scores were near the norm, and her decentering score was about half a standard deviation below the mean.

    “Her initial scores for mindfulness and acceptance were close to the norm, whereas her initial decentering score was approximately half a standard deviation below the mean.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In the middle phase of therapy, Doug first had significant gains in mindfulness and then in decentering.

    “During the middle section of therapy, Doug experienced significant increases first in his mindfulness and then his decentering scores.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    At baseline, Kendra's mindfulness and decentering scores were below the mean.

    “Scores on mindfulness and decentering were below the mean”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At post-treatment and twelve-month follow-up, Kendra's anxiety and worry were much lower, and the independent assessor rated her GAD as subclinical.

    “As can be seen in Table 2, her anxiety and worry were significantly reduced at the post-treatment and 12 month follow-up assessments and the independent assessor rated her GAD as subclinical.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Before treatment, Kendra's DASS-stress score was about two standard deviations above the mean.

    “with her pre-treatment DASS-Stress score approximately two standard deviations above the mean.”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    Julia became more accepting of her emotional experiences over therapy, including accepting loss as part of human experience.

    “Similarly, Julia explicitly talked with her therapist about how much more accepting of her emotional experiences she became over the course of therapy.”
    • Also stated in: § Discussion · plain
      “Specifically, she described how in the midst of grieving for the loss of her father she could accept that losing someone was part of the human experience.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Before treatment, Doug's DASS-stress score was about 2.5 standard deviations above the mean.

    “For example, at the pre-treatment assessment, his DASS-stress score was approximately 2.5 standard deviations above the mean.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Over the same period, Kendra's DASS-stress scores fell, and by session twelve she was within one standard deviation of the norm.

    “During the same period, her DASS-stress scores began to decrease, so that by session 12, her score was within one standard deviation of the norm.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    From session four to twelve, Julia's decentering and mindfulness continued to rise, reaching about one and two standard deviations above the mean at session twelve.

    “Between sessions four and 12, Julia reported continued increases in decentering and mindfulness, as her scores were approximately one and two standard deviations above the mean at session 12.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At the start of treatment in this study, Julia and Doug had mindfulness scores near the normative level, while Julia and Kendra had experiential avoidance scores near the norm.

    “in this study Julia and Doug began therapy with mindfulness scores close to the normative level and Julia and Kendra began therapy with experiential avoidance scores near the norm.”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    From about session eight, Kendra showed greater emotional clarity and started describing her internal experiences from a decentered stance.

    “Beginning around session 8, Kendra began to express more clarity regarding her emotions.”
    • Also stated in: § Kendra: A demonstration of increased mindfulness shifting experiential avoidance · plain
      “During this phase of therapy, Kendra also began to describe her internal experiences from a decentered perspective.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    By session four, Doug showed an initial decrease in DASS-stress and a nearly two-standard-deviation change in self-reported acceptance.

    “By session 4, Doug reported an initial drop in his DASS-stress score and a large, almost two standard deviation, change in self-reported acceptance.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At baseline, Doug's acceptance and decentering scores were about 1.5 and 2 standard deviations from the mean in the direction of less acceptance and decentering, while his mindfulness score matched the population mean.

    “His initial scores on acceptance and decentering were approximately 1.5 and 2 standard deviations away from the mean indicating less acceptance and decentering, whereas his mindfulness score was similar to the population mean”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In these three cases, AR seemed to raise mindfulness and decentering while lowering experiential avoidance.

    “Although AR appears to have increased mindfulness and decentering and decreased experiential avoidance in these three individual cases”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The three cases represent the kinds of changes routinely observed in AR clients.

  • May combine two claims.

    Findingown data

    By the end of treatment, Julia's DASS-stress score was normal and it kept falling at follow-up.

    “Her DASS-stress score was in the normal range by the end of therapy and it continued to decline at follow-up.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Each of the three clients reported greater acceptance and reduced experiential avoidance regarding anxiety and other internal experiences.

    “All three of these clients explicitly described how AR led them to be more accepting, and less experientially avoidant of their anxiety and other internal experiences.”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    At post-treatment and twelve-month follow-up, Julia's anxiety had fallen across measures, and an independent assessor rated her GAD as subclinical.

    “As can be seen in Table 2, her anxiety across measures had decreased by post-treatment and at 12 month follow-up.”
    • Also stated in: § Julia: A demonstration of increasing acceptance · plain
      “Her independent assessor found her GAD to be at a subclinical level.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In the first four sessions, Julia improved significantly on DASS-stress and showed early gains in mindfulness and decentering.

    “During the first four sessions of therapy, Julia experienced significant improvement in her DASS-stress score as well as initial increases in mindfulness and decentering.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At post-treatment, Doug received no diagnoses from the independent assessor, and his self-reported anxiety and worry were below subclinical cutoffs.

    “He did not receive any diagnoses during his post-treatment independent assessment and his self-reported anxiety and worry fell below subclinical thresholds.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Kendra attempted to avoid and discount anxiety before treatment, but her willingness to engage in exercises increased over therapy.

    “Kendra who noted that before treatment began she attempted to do everything possible to avoid and discount feelings of anxiety before therapy began.”
    • Also stated in: § Discussion · plain
      “However, over therapy her willingness to engage in the exercises increased and by the end of therapy she was more willing to encounter uncomfortable situations.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Despite her grief, Julia kept reporting gains in mindfulness and acceptance and drops in DASS-stress for the remainder of therapy.

    “However, even in the midst of this painful loss, Julia continued to report increases in mindfulness and acceptance and decreases in her DASS-stress scores throughout the rest of therapy.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Mindfulness involves a compassionate, less judgmental type of awareness.

    “In addition to present-moment awareness, mindfulness also involves a compassionate, less judgmental type of awareness (Kabat-Zinn, 2005).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Kabat-Zinn, 2005

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    One study found cognitive-behavioral therapy superior to relaxation therapy, but that study used only progressive muscle relaxation and did not integrate Applied Relaxation.

    “One study showed a clear benefit of CBT over relaxation therapy (Butler, Fennell, Robson, & Gelder, 1991); however, this study used only progressive muscle relaxation (PMR) and did not integrate applied relaxation (Öst, 1987).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Butler, Fennell, Robson, & Gelder, 1991 source
    • cites Öst, 1987

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Premisecitation

    Applied Relaxation aims to teach clients to notice the earliest signs of anxiety and to respond with relaxation before the anxiety cycle strengthens.

    “AR is aimed at teaching clients to notice the earliest signs of anxiety and to react with a different response, namely relaxation, before the cycle of anxiety has a chance to strengthen.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Borkovec & Costello, 1993 source
    • The authors state this as an assumption: Interrupting the anxiety cycle is easier early in the spiral, when anxiety levels are lower.

  • May combine two claims.

    Interpretationreasoning

    Recording early cues and observing and reporting responses during an imaginal exercise require the client to decenter and consider responses objectively.

    “Furthermore, the acts of recording early cues on a monitoring sheet and observing and reporting on responses during an imaginal exercise both require the client to decenter and more objectively consider her or his responses.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Applied Relaxation is an empirically supported treatment for generalized anxiety disorder.

    “Cognitive-behavioral therapy, and in particular Applied Relaxation (AR), is considered an empirically supported treatment for GAD (Chambless & Ollendick, 2001).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Chambless & Ollendick, 2001 source

  • Classified as probably not a substantial claim. May combine two claims.

    Premisereasoning

    Strategies that cultivate mindfulness and promote decentering are proposed to change a problematic relationship with internal experiences and reduce anxiety and related distress.

    “Therefore, strategies that cultivate mindfulness, or a curious, non-judgmental awareness of the present moment (Kabat-Zinn, 2005) and promote decentering, that is, the process of seeing thoughts and feelings as objective events in the mind rather than personally identifying with them (Safran & Segal, 1990), are proposed to change this problematic relationship and reduce anxiety and related dist”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Kabat-Zinn, 2005

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Safran & Segal, 1990

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S1 (asserted).

    Premisenone given

    It has been hypothesized that Applied Relaxation reduces anxiety by decreasing muscle tension.

    “It has been hypothesized that AR leads to changes in anxiety by decreasing muscle tension.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Although reduced tension likely plays some role in Applied Relaxation's efficacy, other mechanisms likely play important roles as well.

    “Therefore, while the reduction in tension likely plays some role in the efficacy of AR, there are likely other mechanisms of action that are playing important roles as well.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Experiential avoidance has been considered a fundamental process in anxiety disorders.

    “Experiential avoidance, or the tendency to want to avoid or change one’s internal experience, has also been considered a fundamental process in anxiety disorders (Hayes, Strosahl, & Wilson, 1999)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hayes, Strosahl, & Wilson, 1999

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Self-monitoring requires a different type of awareness, characterized by a more objective and curious stance toward anxious responses.

    “The act of self-monitoring requires a different type of awareness, one that is characterized by a more objective and curious stance towards anxious responses.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Applied Relaxation is based on the premise that anxiety involves an interacting system of cognitive, physiological, affective, and behavioral responses.

    “As described in Borkovec and Costello (1993), AR is based on the premise that anxiety involves an interacting system of cognitive, physiological, affective, and behavioral responses.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Borkovec & Costello, 1993 source

  • May combine two claims.

    Premisecitation

    Avoidance of uncomfortable experiences is often ineffective and may paradoxically increase distress.

    “Although a natural response to uncomfortable experiences like anxiety is to avoid the anxiety-provoking stimuli, this response is often ineffective and may actually paradoxically increase distress (Salters-Pedneault, Tull, & Roemer, 2004).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Salters-Pedneault, Tull, & Roemer, 2004 source

  • Probably not a substantial claim: may not pass S1 (asserted). May combine two claims.

    Premisecitation

    If psychological distress arises from a generalized stress activation response involving multiple central and peripheral physiological systems, then reducing activation in one system, such as the muscular system, should also reduce activation in other systems.

    “If psychological distress stems from a generalized stress activation response that is comprised of multiple central and peripheral physiological systems (e.g., Öst, 1987), then learning to reduce activation of one system, here the muscular system, should also reduce activation in other systems (e.g., Gellhorn & Kiely, 1972).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Öst, 1987

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Gellhorn & Kiely, 1972 source

  • May combine two claims.

    Premisecitation

    Research on reduced muscle tension as a mechanism of Applied Relaxation has been mixed, suggesting that additional mechanisms contribute to its efficacy.

    “However, the research on the role of reduced muscle activation has been mixed at best (see Conrad & Roth, 2007 for a review).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Conrad & Roth, 2007 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Applied Relaxation has incremental benefits over progressive muscle relaxation in treating panic disorder.

    “AR has incremental benefits over PMR in the treatment of panic disorder (Öst, 1988).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Öst, 1988

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisereasoning

    The inability to remove or change an unwanted experience serves as a reminder of the struggle with control, eliciting more negative reactions and urges to avoid, which perpetuates the anxiety cycle.

    “Each time an unwanted sensation arises, the inability to remove or change the unwanted experience serves as a reminder of the struggle with control. This inability to change the experience then elicits more negative reactions and urges to avoid and escape, perpetuating the cycle of anxiety.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Anxiety is partially maintained by a rigid, fused, judgmental relationship with internal experiences.

    “It has been proposed that anxiety is partially maintained by a rigid, fused, judgmental relationship with internal experiences (Roemer & Orsillo, 2009).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Roemer & Orsillo, 2009 source

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    In the Applied Relaxation model, anxiety responses develop over time, with each channel amplifying the others and increasing the intensity of the anxious response.

    “These responses are proposed to develop over time, with each channel amplifying the others, increasing the intensity of the anxious response.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Borkovec & Costello, 1993 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Selected sessions were randomly chosen and evaluated for therapist competence and adherence by independent raters.

    “Further, selected sessions were randomly chosen to be evaluated for therapist competence and adherence by independent raters.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Other unmeasured mechanisms of change could also account for the results.

    “Additionally, there are other potential mechanisms of change (e.g., new learning through exposure, reduction in physical tension) not assessed here that could also be responsible.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In a community-based sample, the average Five Factor Mindfulness Questionnaire score was 116.90 with a standard deviation of 14.16.

    “In a community based sample, the average score on the FFMQ was 116.90 (SD = 14.16; Baer et al., 2008).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Baer et al., 2008 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The Quality of Life Inventory has demonstrated good internal consistency, excellent test-retest reliability, and adequate validity.

    “The QOLI has demonstrated good internal consistency (α’s from .83 to .89), excellent test-retest reliability (r = .91), and adequate validity as assessed by correlations with other measures of well-being and satisfaction (Frisch et al., 1992).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Frisch et al., 1992 source

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Compliance with the instruction to avoid acceptance and mindfulness elements was assessed.

    “and adherence to this is measured”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    All therapists received weekly supervision to ensure competence and adherence to the Applied Relaxation treatment manual.

    “All therapists received weekly supervision to ensure competence and adherence to the Applied Relaxation treatment manual (Hayes-Skelton, Roemer, & Orsillo, 2011).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hayes-Skelton, Roemer, & Orsillo, 2011

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The Depression Anxiety Stress Scales-21-item version has demonstrated excellent internal consistency, and the longer 42-item version has demonstrated adequate test-retest reliability.

    “The DASS-21 has demonstrated excellent internal consistency (α from .88 to .94; Antony, Bieling, Cox, Enns, & Swinson, 1998) and the longer 42-item version has demonstrated adequate test-retest reliability (Brown, Chorpita, Korotitsch, & Barlow, 1997).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Antony, Bieling, Cox, Enns, & Swinson, 1998 source
    • cites Brown, Chorpita, Korotitsch, & Barlow, 1997 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Penn State Worry Questionnaire scores discriminate generalized anxiety disorder from other anxiety disorders.

    “Additionally, scores on the PSWQ has been found to discriminate GAD from other anxiety disorders (Brown, Antony, & Barlow, 1992).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Brown, Antony, & Barlow, 1992 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Acceptance and Action Questionnaire has demonstrated adequate internal consistency and test-retest reliability over four months in an undergraduate sample.

    “This measure has demonstrated adequate internal consistency (α = .70) and test-retest reliability (r = .64) over four months in an undergraduate sample (Hayes et al., 2004).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hayes et al., 2004 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Assessors were blind to participants' treatment condition for post-treatment assessments.

    “Assessors were blind to participants’ treatment condition for the post-treatment assessments.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Repeated progressive muscle relaxation practice may teach clients that they can have worries without needing to respond to them, and that if they let worries be and focus elsewhere, the worries or their response to them eventually change on their own.

    “Many clients report that they worry during PMR and so the repeated experience of practicing may be teaching clients that they can have worries without needing to respond to them; demonstrating that if they just let the worries be and focus their attention elsewhere (on relaxation), then the worries or their response to the worries eventually do change on their own.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Raters and supervisors checked sessions for therapist statements about acceptance, mindfulness, or experiential avoidance.

    “Likewise, adherence raters and supervisors monitored sessions for any mention of acceptance, mindfulness, or experiential avoidance on the part of the therapists.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Depression Anxiety Stress Scales Stress scale discriminated between clients with generalized anxiety disorder and those with other anxiety disorders.

    “Additionally, the Stress scale discriminated between clients with GAD and those with other anxiety disorders (Brown, et al., 1997).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Brown, et al., 1997 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Acceptance and Action Questionnaire scores moderately correlate with measures of cognitive avoidance, with a correlation of .50.

    “Scores on the AAQ moderately correlate with measures of the related construct of cognitive avoidance (r = .50).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The early cue detection exercises might have boosted mindful awareness and helped raise Kendra's FFMQ scores from pre-treatment to session four.

    “Although this strategy is used in AR to identify when relaxation can be applied, it also may increase mindful awareness of internal experiences and may have contributed to the increase in FFMQ scores Kendra experienced from pre-treatment to session 4.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    All participants were assessed using the Anxiety Disorders Interview Schedule for DSM-IV-Lifetime version.

    “All participants were assessed using the Anxiety Disorders Interview Schedule for DSM-IV-Lifetime version (ADIS-IV-L; DiNardo, Brown, & Barlow, 1994).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites DiNardo, Brown, & Barlow, 1994

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Study design and conductown data

    For these three cases, therapists were rated as adherent and competent.

    “For these three cases, therapists were rated as adherent and competent.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The treatment manual and handouts for clients used a goal-oriented version of AR.

    “the therapy manual and client handouts were written with a more goal-oriented approach of AR”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The Penn State Worry Questionnaire has demonstrated good to very good internal consistency and good test-retest reliability.

    “The PSWQ has demonstrated good to very good internal consistency (α from .86 to .93) and good test-retest reliability (Molina & Borkovec, 1994).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Molina & Borkovec, 1994

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

67 of 67

  • The authors state this as an assumption.

    Interrupting the anxiety cycle is easier early in the spiral, when anxiety levels are lower.

    “Early cue detection is based on the premise that it is easier to interrupt the cycle of anxiety early in the spiral when anxiety levels are lower.”

  • The paper relies on this without support.

    The three cases represent the kinds of changes routinely observed in AR clients.

    “These three cases were specifically selected because they most clearly demonstrated the kinds of changes that we have been routinely seeing in our AR clients.”

  • The paper relies on this without support.

    Experiential avoidance is not usually considered a target of AR.

    “While experiential avoidance is not typically discussed as one of the targets of AR”

  • The paper relies on this without support.

    People with GAD show lower mindfulness and greater experiential avoidance than people without GAD.

    “individuals diagnosed with GAD have lower mindfulness and higher experiential avoidance scores than individuals without a diagnosis of GAD”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Julia's AAQ score is said to increase while moving below the mean

    Minor

    A score moving from approximately the norm to more than half a standard deviation below the mean has decreased, not increased. The paper also states that lower AAQ scores indicate greater acceptance, so the direction of the stated score change is wrong.

  • The treatment schedule exceeds the stated 16 weeks

    Minor

    Sixteen sessions cannot fit into 16 weeks under the stated schedule: holding the last two sessions every other week places session 16 in approximately week 18. This conflicts with the abstract's description of 16 weeks of treatment.

2 of 2

Cites

Flagged first, then by citations

8 of the 63 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Hayes-Skelton, S. A., Usmani, A., Lee, J. K., Roemer, L., & Orsillo, S. M.
Affiliations
  • Harvard University (US)
  • Suffolk University (US)
  • University of Massachusetts Boston (US)
ORCID
Venue
Cognitive and Behavioral Practice
Publisher
Elsevier BV
Published
2012-08
Volume
19
Issue
3
Pages
451-462
ISSN
1077-7229 (ISSN-L)
DOI
10.1016/j.cbpra.2011.12.005
PMC
PMC3718512
OpenAlex
W2021393095
Cited by
29
References
63
Citations by year
2023: 1 · 2022: 1 · 2020: 3 · 2019: 2 · 2017: 5 · 2016: 3 · 2015: 3 · 2014: 5 · 2013: 6
FWCI
6.00
Type
journal article
Language
en
Open access
Licence
Locations
  • Cognitive and Behavioral Practice (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (MH085060, MH074589)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords
applied relaxation, generalized anxiety disorder, mechanisms of change, mindfulness, decentering, acceptance, relaxation response, muscle tension

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Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

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