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Cited by 154Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesMindfulness and Compassion InterventionsPsychotherapy Techniques and Applications

A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder

Open access
Hayes-Skelton, Sarah A., Roemer, Lizabeth, Orsillo, Susan M.·2013·Journal of Consulting and Clinical Psychology
DOI 10.1037/a0032871PMC PMC3783580
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Abstract

Objective: To examine whether an empirically and theoretically derived treatment combining mindfulness- and acceptance-based strategies with behavioral approaches would improve outcomes in generalized anxiety disorder (GAD) over an empirically supported treatment. Method: This trial randomized 81 individuals (65.4% female, 80.2% identified as White, average age 32.92) diagnosed with GAD to receive 16 sessions of either an acceptance-based behavior therapy (ABBT) or applied relaxation (AR). Assessments at pretreatment, posttreatment, and 6-month follow-up included the following primary outcome measures: GAD clinician severity rating, Structured Interview Guide for the Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, Depression Anxiety Stress Scale, and the State-Trait Anxiety Inventory. Secondary outcomes included the Beck Depression Inventory - II, Quality of Life Inventory, and number of comorbid diagnoses. Results: Mixed effect regression models showed significant, large effects for time for all primary outcome measures (ds = 1.27 to 1.61) but nonsignificant, small effects for condition and Condition × Time (ds = 0.002 to 0.20), indicating that clients in the 2 treatments improved comparably over treatment. For secondary outcomes, time was significant (ds = 0.74 to 1.38), but condition and Condition × Time effects were not (ds = 0.004 to 0.31). No significant differences emerged over follow-up (ds = 0.03 to 0.39), indicating maintenance of gains. Between 63.3 and 80.0% of clients in ABBT and 60.6 and 78.8% of clients in AR experienced clinically significant change across 5 calculations of change at posttreatment and follow-up. Conclusion: ABBT is a viable alternative for treating GAD. © 2013 American Psychological Association.

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Crossref · 10.1037/a0032871

Cites

64 of 64 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

29 of 85 cited sources checked · 20 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    People with generalized anxiety disorder experience diminished quality of life.

    “Individuals with GAD are less likely to consistently engage in behaviors that are important to them (i.e., valued actions) and as a result experience a diminished quality of life (Michelson, Lee, Orsillo, & Roemer, 2011).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Michelson et al., 2011 source
  • Premisecitation

    Recent randomized controlled trials indicate that targeting interpersonal and emotion-focused aspects of generalized anxiety disorder produces effects comparable to existing CBTs.

    “Recent randomized controlled trials informed by these models indicate that targeting intolerance of uncertainty (Dugas et al., 2010), and the interpersonal and emotion focused aspects of GAD (Newman et al., 2011) yield effects comparable to existing CBTs for GAD.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Newman et al., 2011 source
  • Premisecitation

    This reaction to internal experiences motivates people with generalized anxiety disorder to use experiential avoidance strategies, including worry.

    “This reaction to internal experiences motivates individuals with GAD to engage in experiential avoidance (e.g., Lee et al., 2010) using a variety of strategies including worry, the central defining feature of GAD.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Lee et al., 2010 source
  • Premisecitation

    People with generalized anxiety disorder are less likely to consistently engage in behaviors that are important to them.

    “Individuals with GAD are less likely to consistently engage in behaviors that are important to them (i.e., valued actions) and as a result experience a diminished quality of life (Michelson, Lee, Orsillo, & Roemer, 2011).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Michelson et al., 2011 source

      The Discussion reports that participants with GAD were less likely than matched non-anxious participants to describe themselves as living consistently with their values. It also links valued action to quality of life, but calls the proposed causal explanation—that diminished valued activity produces impaired quality of life—preliminary and only partially supported. The citing sentence presents that explanation as established fact. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
  • Premisecitation

    The model suggests that people with generalized anxiety disorder have critical, judgmental reactivity toward their emotional responses.

    “and a critical, judgmental reactivity toward their emotional responses (e.g., Lee, Orsillo, Roemer, & Allen, 2010; Llera & Newman, 2010; Mennin, Heimberg, Turk, & Fresco, 2005) and thoughts (Wells & Carter, 1999).”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites Lee et al., 2010 source
    • cites Llera & Newman, 2010 source
    • cites Mennin et al., 2005 source
  • Classified as probably not a substantial claim. 43
  • May combine two claims. 49

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

    Premisecitation

    Generalized anxiety disorder is associated with high comorbidity.

    “Generalized anxiety disorder (GAD) is a chronic anxiety disorder associated with high comorbidity (Bruce, Machan, Dyck, & Keller, 2001), reduced quality of life (Hoffman, Dukes, & Wittchen, 2008) and significant health care utilization (Hoffman et al., 2008).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Bruce, Machan, Dyck, & Keller, 2001 source

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

    Premisecitation

    Generalized anxiety disorder is a chronic anxiety disorder.

    “Generalized anxiety disorder (GAD) is a chronic anxiety disorder associated with high comorbidity (Bruce, Machan, Dyck, & Keller, 2001), reduced quality of life (Hoffman, Dukes, & Wittchen, 2008) and significant health care utilization (Hoffman et al., 2008).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Bruce, Machan, Dyck, & Keller, 2001 source

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

    Premisecitation

    The 14 individuals with generalized anxiety disorder who received ACT demonstrated medium to large effects on outcome measures.

    “A recent study comparing ACT to CBT (with behavioral exposures in both conditions) showed comparable effects of the two treatments, with the 14 individuals with GAD who received ACT demonstrating medium to large effects on outcome measures (Arch et al., 2012).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Arch et al., 2012 source

      The Discussion (Primary Outcomes; page unavailable) reports moderate to large improvements in the ACT group, but those findings concern the mixed-anxiety sample, not specifically participants with GAD. The Results (Primary Outcomes; page unavailable) says Table 4 contains disorder-specific effect sizes; the passages available from our copy do not give the GAD values or establish that 14 participants with GAD received ACT. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

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

    Premisecitation

    A recent meta-analysis demonstrated the promise of mindfulness-based interventions in reducing anxiety generally.

    “A recent meta-analysis demonstrated the promise of mindfulness-based interventions in reducing anxiety generally (Hofmann, Sawyer, Witt, & Oh, 2010), and two preliminary trials of MBCT suggest an effect of treatment on self-reported GAD symptoms (Craigie, Rees, Marsh, & Nathan, 2008; Evans et al., 2008), although outcomes fell short relative to other GAD treatment trials.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Hofmann et al., 2010 source

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

    Study design and conductcitation

    The SIGH-A provides a reliable, valid structured format for administering the Hamilton Anxiety Rating Scale.

    “Structured Interview Guide for the Hamilton Anxiety Rating Scale (SIGH-A; Shear et al., 2001) provides a reliable, valid structured format for administering the Hamilton Anxiety Rating Scale (HARS; Hamilton, 1959), a widely used 14-item interviewer administered measure of anxiety.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites Shear et al., 2001 source
    • cites Hamilton, 1959 source

  • May combine two claims.

    Interpretationown data

    The pre-to-post Cohen's d values of 1.36 to 1.61 were somewhat lower than the d of 1.86 for a symptom severity composite (Newman et al., 2011) and fell between the effect sizes for Metacognitive Therapy (PSWQ d=3.41) and Applied Relaxation (PSWQ d=0.95; Wells et al., 2010).

    “compared to other GAD RCTs our pre to post treatment Cohen’s d effect sizes of 1.36 to 1.61 are slightly smaller than the Cohen’s d of 1.86 for a symptom severity composite variable (Newman et al., 2011) and in between the effect sizes for Metacognitive Therapy (PSWQ d=3.41) and Applied Relaxation (PSWQ d=0.95; Wells et al., 2010)5.”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Newman et al. (2011) source
    • cites Wells et al. (2010) source

  • May combine two claims.

    Interpretationown data

    ABBT's end-state functioning resembled Ladouceur et al. (2000) and exceeded every condition in Newman et al. (2011) and Borkovec et al. (2002) by more than 5 percentage points at post-treatment and 6-month follow-up.

    “the current study found that end state functioning for ABBT was similar to Ladouceur et al. (2000) and more than 5 percentage points higher than any condition in Newman et al. (2011) and Borkovec et al. (2002) at post-treatment and 6-month follow-up.”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites Ladouceur et al. (2000) source
    • cites Newman et al. (2011) source

      The Results (Statistical Analyses; page unavailable) define end-state functioning, and the Results (Effect of Treatment on GAD Symptom Severity; page unavailable) report it for both Newman trial conditions at two-year follow-up. The passages retrieved do not give end-state percentages at post-treatment or six months, so they cannot establish that ABBT exceeded every Newman condition by more than five percentage points at those times. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
    • cites Borkovec et al. (2002) source

  • May combine two claims.

    Findingown data

    For primary outcome measures, Condition and Condition X Time effects were non-significant and small, with effect sizes from 0.002 to 0.24.

    “Mixed Effect Regression Models showed significant large effects for Time for all primary outcome measures (d’s 1.36 to 1.61) but non-significant, small effects for Condition and Condition X Time (d’s 0.002 to 0.24), indicating clients in both treatments improved comparably over treatment.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For secondary outcomes, Condition and Condition X Time effects were not significant, with effect sizes from 0.11 to 0.31.

    “For secondary outcomes, Time was significant (d’s 0.74 to 1.38) but Condition and Condition X Time effects were not (d’s 0.11 to 0.31).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    No significant differences emerged over follow-up, with effect sizes from 0.02 to 0.16.

    “No significant differences emerged over follow-up (d’s 0.02 to 0.16) indicating maintenance of gains.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For SIGH-A, time showed a significant large effect, while condition and its interaction with time had non-significant small effects.

    “Similarly, for SIGH-A, there was a significant, large effect for Time but non-significant, small effects for Condition and for the Condition X Time effect.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For CSR, time showed a significant large effect, while condition and its interaction with time had non-significant small effects.

    “The MRM model for CSR showed a significant (large) effect for Time but non-significant, small effects for Condition and for the Condition X Time effect indicating that clients’ clinician rated severity of GAD diagnosis significantly decreased across treatment and follow-up and that this change was not different across the two treatments.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    From post-treatment to 6-month follow-up, time, condition, and their interaction were non-significant, and all effect sizes were small.

    “As shown in Table 4, there were no significant Time, Condition, or Time X Condition effects and all effect sizes were small, indicating comparable maintenance of gains across follow-up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The conditions did not differ significantly in clinical significance at either assessment, with small effect sizes (d = 0.01 to 0.28).

    “There were no significant differences between conditions at either time point, with small effect sizes (d’s from 0.01 to 0.28).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    ABBT did not produce significantly greater reductions in depression and comorbid conditions or greater increases in quality of life than AR.

    “Contrary to hypotheses, ABBT did not lead to significantly greater decreases in depression and comorbid conditions and increases in quality of life than AR.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    At post-treatment, clients rated both treatments as a good fit for their needs (means 7.41 and 7.39), with no significant difference.

    “At the end of treatment, clients rated both treatments to be a good match for their needs (means of 7.41 and 7.39 for ABBT and AR, respectively) on a 9-point Likert scale with no significant differences between treatments [F(1, 62) = 0.003, p = .96, d = 0.01].”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Clients in both arms rated their treatment as highly credible (mean 28.92 of 36), with no difference between arms.

    “As shown in Table 2, on average clients in both ABBT and AR rated their respective treatments as highly credible (28.92 out of 36) and ratings of credibility did not differ across treatments [F(1, 74) = 0.06, p = .80, d = 0.06].”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    AR showed a similar impact on depression, comorbid conditions, and quality of life.

    “Unexpectedly, AR demonstrated a comparable impact.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    ABBT significantly affected depression, comorbid conditions, and quality of life, with large effect sizes.

    “As expected, ABBT did have a significant impact on these outcomes, with large effect sizes.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    For each secondary outcome, time had a significant large effect, whereas condition and its interaction with time had non-significant small effects.

    “MRM models run for the secondary outcomes yielded consistent results, with significant (large) effects of Time for each outcome, but non-significant, small effects for both Condition and Condition X Time.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    At post-treatment, clinically significant change occurred in 63.3-80.0% of ABBT clients and 60.6-78.8% of AR clients.

    “At post-treatment 63.3–80.0% of clients in ABBT and 60.6–78.8% in AR exhibited clinically significant change.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    At follow-up, clinically significant change occurred in 66.7-80.0% of ABBT clients and 60.6-78.8% of AR clients.

    “Similar rates were found for ABBT, 66.7–80.0%, and AR, 60.6–78.8%, at follow-up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    On the self-report primary measures (PSWQ, DASS-Stress, STAI), clients improved significantly over time, and the treatments did not differ.

    “A similar pattern of results emerged on the self-reported primary outcome measures, indicating that clients significantly improved over time on self-reports of excessive worry (PSWQ), tension and GAD symptoms (DASS-Stress), and anxiety symptoms (STAI), while no differences emerged in these changes between treatments (with small effect sizes).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisereasoning

    These new skills and the explicit promotion of an accepting, willing stance reduce rigid experiential avoidance.

    “These new skills reduce rigid experiential avoidance, as does the explicit promotion of an accepting and willing stance towards internal experiences.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    Meta-analyses show that cognitive behavioral therapies are efficacious for generalized anxiety disorder.

    “Meta-analyses reveal that cognitive behavioral therapies are efficacious for GAD (Borkovec & Ruscio, 2001; Covin, Ouimet, Seeds, & Dozois, 2008).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Borkovec & Ruscio, 2001

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

    • cites Covin, Ouimet, Seeds, & Dozois, 2008 source

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

    Premisecitation

    A small pilot study found that targeting meta-cognition in generalized anxiety disorder produced better outcomes than applied relaxation.

    “A small pilot study found that targeting meta-cognition in GAD (Wells et al., 2010) produced better outcomes than applied relaxation, however, the very low rates of response to applied relaxation, coupled with the small sample size, indicate a need for further research to confirm this finding.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Wells et al., 2010 source

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

    Premisecitation

    Generalized anxiety disorder is associated with reduced quality of life.

    “Generalized anxiety disorder (GAD) is a chronic anxiety disorder associated with high comorbidity (Bruce, Machan, Dyck, & Keller, 2001), reduced quality of life (Hoffman, Dukes, & Wittchen, 2008) and significant health care utilization (Hoffman et al., 2008).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hoffman, Dukes, & Wittchen, 2008 source

  • Classified as probably not a substantial claim.

    Premisereasoning

    ABBT targets behavioral avoidance and constriction by encouraging clients to identify and mindfully engage in personally meaningful actions.

    “Behavioral avoidance and constriction are targeted by encouraging clients to identify and mindfully engage in personally meaningful actions.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    Generalized anxiety disorder is associated with significant health care utilization.

    “Generalized anxiety disorder (GAD) is a chronic anxiety disorder associated with high comorbidity (Bruce, Machan, Dyck, & Keller, 2001), reduced quality of life (Hoffman, Dukes, & Wittchen, 2008) and significant health care utilization (Hoffman et al., 2008).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Hoffman et al., 2008 source

  • May combine two claims.

    Premisecitation

    Worry reduces somatic arousal and helps distract a person from more emotional topics.

    “Although worry decreases somatic arousal and helps to distract an individual from more emotional topics (see Borkovec, Alcaine, & Behar, 2004, for a review), rigid habitual efforts at experiential avoidance can paradoxically increase distress (e.g., Hayes et al., 1996), leading to a cycle of reactivity and avoidance that in turn affects behavior.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Borkovec, Alcaine, & Behar, 2004

      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).

    Premisenone given

    Few studies have examined how treatment affects quality of life.

    “However, GAD remains one of the least successfully treated of the anxiety disorders (Waters & Craske, 2005), with most studies finding that fewer than 65% of clients meet criteria for high end-state functioning at post-treatment (e.g., Ladouceur et al., 2000; Newman et al., 2011) and few studies examining the impact of treatment on quality of life.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisereasoning

    ABBT aims to help clients develop expanded awareness and a compassionate, decentered stance toward internal experiences.

    “Specifically, this ABBT aims to help clients to cultivate an expanded (as opposed to narrowed, threat-focused) awareness along with a compassionate (as opposed to judgmental) and decentered (as opposed to seeing thoughts and feelings as all-encompassing indicators of truth) stance towards internal experiences.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    This model led to the development of acceptance-based behavior therapy for generalized anxiety disorder.

    “This model led to the development of an acceptance based behavior therapy for GAD (ABBT; Roemer & Orsillo, 2009; Roemer & Orsillo, In press), a flexible treatment adapted from traditional CBT for GAD (e.g., Borkovec et al., 2004), as well as other acceptance-based behavioral therapies including Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999), Mindfulness-based Cognitive Th”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Roemer & Orsillo, 2009

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

    • cites Roemer & Orsillo, In press

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

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The trial randomly assigned 81 people with GAD to 16 sessions of either ABBT or applied relaxation.

    “This trial randomized 81 individuals (65.4% female, 80.2% identified as White, average age 32.92) diagnosed with GAD to receive 16 sessions of either an Acceptance Based Behavior Therapy (ABBT) or Applied Relaxation (AR).”
    Quote in the paperSubstantial claim

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

    Study design and conductown data

    Eighty-one participants met inclusion and exclusion criteria, consented, and were randomized.

    “Thus, 81 participants met inclusion/exclusion criteria, consented to the study, and were randomized.”
    Quote in the paperSubstantial claim

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

    Study design and conductnone given

    Eligibility was primarily assessed by an independent assessor who conducted the diagnostic assessment.

    “Eligibility was primarily assessed by an independent assessor (IA) who conducted the diagnostic assessment.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    Post-doctoral fellows or doctoral students administered the SIGH-A after training, and 15% were rated twice for interrater reliability, with an ICC of .89.

    “Post-doctoral fellows or doctoral students, after training, administered the measure, and 15% were rated twice for interater reliability, revealing an ICC of .89.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    No AR session contained a prohibited technique.

    “No AR sessions had a forbidden strategy.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Thirty percent of interviews were scored by a second rater, and the interclass correlation between raters on the clinician severity rating for generalized anxiety disorder was .73.

    “Additionally, 30% of interviews were scored by a second rater, with an interclass correlation (ICC) between raters on CSR for GAD of .73.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    In this sample, PSWQ internal consistencies were .82 at pre-treatment, .90 at post-treatment, and .92 at follow-up.

    “In this sample, the internal consistencies were .82 at pre, .90 at post, and .92 at follow-up.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    The DASS-21 has separate, reliable, and valid self-report scales for depression, anxiety, and stress.

    “Depression Anxiety Stress Scale – 21-item version (DASS-21; Lovibond & Lovibond, 1995) has separate, reliable and valid self-report scales for depression, anxiety (i.e., anxious arousal), and stress (i.e., general anxiety and tension) (Antony, Bieling et al., 1998).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Lovibond & Lovibond, 1995

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

    • cites Antony, Bieling et al., 1998 source

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

    Study design and conductcitation

    The State-Trait Anxiety Inventory Trait Form Y is a reliable, valid 20-item self-report measure of trait anxiety.

    “State-Trait Anxiety Inventory – Trait Form Y (STAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983) is a reliable, valid 20-item self-report measure that assesses trait levels of anxiety.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983

      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.

    Study design and conductnone given

    All study procedures were approved by university institutional review boards and by a Data Safety and Monitoring Board.

    “All study procedures were approved by the [removed for blinding] University Internal Review Boards as well as by a Data Safety and Monitoring Board.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    A second rater assessed 28 AR sessions (27.4%), yielding excellent reliability (κ=.91).

    “Twenty-eight (27.4%) of these sessions were rated by a second rater with excellent reliability (κ=.91).”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    All participants provided informed consent for the study.

    “All participants provided informed consent for the study.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    STAI internal consistencies were .88 at pre-treatment, .95 at post-treatment, and .94 at follow-up.

    “Internal consistencies were .88 at pre, .95 at post, and .94 at follow-up.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    In the ABBT arm, the permitted techniques were generally scored as covered thoroughly and delivered with skill.

    “In the ABBT condition, the allowed components were typically rated as being addressed in detail [means from 1.67 (SD=0.66) to 1.96 (SD=0.20)] and executed skillfully [means from 1.85 (SD=0.36) to 1.98 (SD=0.14)].”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    Slips linking identification numbers and conditions were concealed from all study staff, and the therapist drew the appropriate slip after participant consent.

    “Slips of paper linking ID numbers and conditions were then concealed from all study staff; the therapist drew the appropriate slip after participant consent.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given

    Diagnoses were confirmed in a consensus meeting with a doctoral-level psychologist and by therapists.

    “Diagnoses were confirmed in a consensus meeting with a doctoral-level psychologist (removed for blinding) and by therapists.”
    Quote in the paperNot a substantial claim

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

    Study design and conductcitation

    The Penn State Worry Questionnaire is a widely used, reliable, valid 16-item self-report measure of trait worry.

    “Penn State Worry Questionnaire (PSWQ: Meyer, Miller, Metzger, & Borkovec, 1990) is a widely used, reliable, valid 16-item self-report measure of trait levels of worry.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Meyer, Miller, Metzger, & Borkovec, 1990 source

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

    Study design and conductown data

    A second rater assessed 25 ABBT sessions (26.0%), yielding adequate reliability (κ=.73).

    “Twenty-five (26.0%) of these sessions were rated by a second rater with adequate reliability (κ=.73).”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    QOLI internal consistencies were .80 at pre-treatment and .86 at post-treatment and follow-up.

    “Internal consistencies were .80 at pre, .86 at post and follow-up in this sample.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    BDI-II internal consistencies were .91 at pre-treatment, .95 at post-treatment, and .95 at follow-up.

    “In this sample, the internal consistencies were .91 at pre, .95 at post, and .95 at follow-up.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Applied relaxation is recommended in NICE clinical guideline 113.

    “AR is an empirically supported treatment for GAD (Chambless & Ollendick, 2001) and is recommended in the NICE clinical guideline 113 (National Collaborating Centre for Mental Health and the National Collaborating Centre for Primary Care, 2011).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites National Collaborating Centre for Mental Health and the National Collaborating Centre for Primary Care, 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).

    Study design and conductown data

    Therapists saw roughly equal numbers of clients in each condition.

    “Post-doctoral fellows (n = 3) or advanced doctoral students (n = 8), supervised by the study authors, saw roughly equal number of clients in each condition with an average of 3.64 (SD=3.79, range 1 to 11) ABBT and 3.73 (SD=3.23, range 1 to 11) AR clients.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    WAI-S internal consistencies were .92 for clients and .91 for therapists.

    “The internal consistencies were .92 for clients and .91 for therapists.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    A research assistant assigned treatment by randomly allocating conditions to participant identification numbers with a random integer generator, forcing even distribution in each block of eight participants.

    “A research assistant determined the treatment assignment by randomly allocating conditions to participant identification numbers using a random integer generator while forcing even distribution in each block of eight participants at the commencement of the study.”
    Quote in the paperSubstantial claim

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

    Study design and conductcitation

    For generalized anxiety disorder, the ADIS-IV has demonstrated adequate reliability, with kappa of .67.

    “For GAD, the ADIS-IV has demonstrated adequate reliability (κ = .67; Brown, DiNardo, Lehmann, & Cambell, 2001).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Brown, DiNardo, Lehmann, & Cambell, 2001

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

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

    Study design and conductown data

    Independent assessors were post-doctoral fellows or graduate students who were unaware of treatment condition and trained in administering and scoring the ADIS.

    “Independent assessors were post-doctoral fellows or graduate students, unaware of treatment condition, trained in the administration and scoring of the ADIS3.”
    Quote in the paperSubstantial claim

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

    Study design and conductown data

    Forty participants were randomized to ABBT and 41 to applied relaxation.

    “Forty participants were randomized to ABBT and 41 to AR.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    In the AR arm, the permitted techniques were generally scored as covered thoroughly and delivered with skill.

    “Similarly, in the AR condition, the allowed components were typically rated as being addressed in detail [means from 1.89 (SD=0.37) to 1.96 (SD=0.20)] and executed skillfully [means from 1.91 (SD=0.29) to 1.97 (SD=0.17)].”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data

    Of the 81 participants, 63 were considered treatment completers.

    “Of the 81 participants, 63 were considered treatment completers2.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    The treatments did not differ significantly in medication use for anxiety or depression or in receipt of additional psychotherapy.

    “There were no significant patterns of difference across treatments for whether or not clients were on anxiety or depression medications [post-treatment - χ2(1) = 0.91, p = .34; 6-month follow-up - χ2(1) = 0.04, p = .85] or received additional psychotherapy since the previous assessment [post-treatment - χ2(1) = 0.002, p = .97; 6-month follow-up - χ2(1) = 1.78, p = .18].”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    MBCT did not include behavioral strategies, which may partly explain its more modest effects.

    “Unlike ACT and ABBT, MBCT did not incorporate behavioral strategies, which may partly explain the more modest effects.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    There were no significant differences between conditions on demographic variables, psychotropic medication, previous therapy, or presence of comorbid diagnoses.

    “As shown in Table 1, there were no significant differences between conditions on demographic variables, psychotropic medication, previous therapy, or the presence of comorbid diagnoses.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Previous ABBT studies were limited by the absence of an active control condition and by modest sample sizes.

    “While findings for ABBT are promising, previous studies were limited by absence of an active control condition and modest sample sizes.”
    Quote in the paperSubstantial claim

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

    Study design and conductcitation

    The WAI-S is a reliable, valid 12-item measure of client and therapist perceptions of agreement on therapy goals and tasks and of the therapeutic bond, given after session 4.

    “Working Alliance Inventory – short (WAI-S; Tracey & Kokotovic, 1998) is a reliable, valid 12-item measure of client and therapist perceptions of the agreement in the goals and tasks of therapy as well as the therapeutic bond that was given after session 4 in this study.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Tracey & Kokotovic, 1998

      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).

    Study design and conductown data

    In this sample, SIGH-A internal consistencies were .76 at pre-treatment and .82 at both post-treatment and follow-up.

    “In this sample, internal consistencies were .76 at pre and .82 at both post and follow-up.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    A strong focus on reducing anxious responding habits may help clients engage more fully in life even without explicit behavioral activation.

    “Extensive focus on reducing habits of anxious responding may in turn help clients naturally engage more in their lives even without an explicit focus on behavioral action.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Both treatments produced statistically and clinically significant improvement from pre-treatment through short-term follow-up.

    “Both an Acceptance Based Behavior Therapy and Applied Relaxation led to statistically and clinically significant change across treatment and short-term follow-up.”
    Quote in the paperSubstantial claim

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

    Interpretationreasoning

    AR and ABBT may have mechanisms of change in common.

    “It is also quite possible that AR and ABBT share common mechanisms of change.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    ABBT is flexible and adapts to clients' circumstances, a strength noted by clients.

    “while this ABBT is flexible and adapts to client’s circumstances, which was mentioned as a strength of ABBT by our clients (Fuchs et al., 2012, April).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Fuchs et al. (2012, April)

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

  • May combine two claims.

    Premisecitation

    Wells and colleagues (2010) reported only 20% recovered and 10% improved at post-treatment.

    “while Wells and colleagues (2010) reported only 20% recovered and 10% improved at post-treatment.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Wells et al. (2010) source

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    How ABBT would perform in routine clinical practice remains unclear.

    “Because of these limitations it is unclear how ABBT would perform in routine clinical practice.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    All therapists were relatively inexperienced (graduate students and post-doctoral fellows), possibly lowering intervention efficacy.

    “An additional limitation is that all of our therapists were relatively inexperienced (graduate students and post-doctoral fellows), which may have reduced the efficacy of interventions.”
    Quote in the paperNot a substantial claim
75 of 75

  • The authors state this as an assumption.

    The processes that ABBT targets are presumed to underlie many forms of psychopathology.

    “Additionally, because the processes targeted in ABBT are presumed to underlie many forms of psychopathology, we hypothesized that ABBT would be associated with greater decreases in depression and comorbidity than AR.”

  • The paper relies on this without support.

    Applied relaxation is simple enough to learn that therapists are likely to deliver it with good adherence and competence.

    “AR is also straightforward and relatively easy to learn, which increases the probability that therapists can deliver it with good adherence and competence.”

  • The authors state this as an assumption.

    The data are missing at random.

    “MRM models analyze data using maximum likelihood estimation to account for missing data, which assumes that data are “missing at random.””

  • The paper relies on this without support.

    Applied relaxation has long been regarded as one of the leading treatments for generalized anxiety disorder.

    “AR has long been considered one of the leading treatments of GAD”

  • The paper relies on this without support.

    Applied relaxation is simple.

    “AR is simple, which makes it seem like a good candidate for dissemination.”

  • The paper relies on this without support.

    Applied relaxation is more inflexible and requires more client time.

    “it is more inflexible and demanding in terms of client time required”
6 of 6

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?

  • ABBT and established CBT both produced significant change across treatment and follow-up.

    “More recently, investigators examined the effectiveness of ABBT in comparison to an established CBT treatment (Hayes-Skelton et al., 2013) showing that both treatments led to significant change across treatment and follow-up.”

    From Randomized pilot trial of cognitive-behavioral therapy and acceptance-based behavioral therapy in the treatment of Spanish-speaking Latino primary care patients with generalized anxiety disorder (2021) · cites this paper as Hayes-Skelton et al., 2013

    The Discussion (page not provided) reports statistically and clinically significant improvement with both ABBT and applied relaxation (AR) through short-term follow-up. The Methods identify AR—not CBT—as the trial’s comparison treatment, and the paper discusses CBT as a separate treatment in other studies. Thus the improvement finding is supported, but describing the comparison arm as established CBT is not. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • More comprehensive contemporary interventions such as ABBT and metacognitive therapy produce larger effect sizes than less comprehensive approaches during acute treatment and follow-up.

    “have demonstrated considerably larger effect sizes compared with less comprehensive approaches during the acute period of treatment as well as throughout follow-up (Hayes-Skelton, Roemer, & Orsillo, 2013; Wells et al., 2010).”

    From A Pilot Study of Emotion Regulation Therapy for Generalized Anxiety and Depression: Findings From a Diverse Sample of Young Adults. (2018) · cites this paper as Hayes-Skelton, Roemer, & Orsillo, 2013

    The Discussion reports large pre-to-post effects for ABBT and cites a larger effect for metacognitive therapy than for applied relaxation in another trial, while cautioning that cross-study comparisons are difficult. But the Results found ABBT and applied relaxation improved comparably, with no significant differences during treatment or follow-up. This paper therefore does not support the claim that ABBT produced considerably larger effects than a less comprehensive approach throughout both periods. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • The ABBT and AR in this RCT were adherent and competent, with no procedural breaks.

    “The ABBT and AR provided in this RCT were adherent and competent, and there were no procedural breaks (Hayes-Skelton et al., 2013).”

    From Reductions in experiential avoidance as a mediator of change in symptom outcome and quality of life in acceptance-based behavior therapy and applied relaxation for generalized anxiety disorder (2016) · cites this paper as Hayes-Skelton et al., 2013

    The Methods section, “Adherence and Competency,” reports that ABBT and AR components were typically delivered in detail and skillfully, supporting the adherence and competence claim. It also reports one ABBT session with a forbidden strategy, so the assertion that there were no procedural breaks is not supported. (LLM, conf=0.91)

    Experimental — accuracy not yet measured

  • The AR in this trial was delivered adherently and competently, with no procedural breaks.

    “the AR provided in this trial was adherent and competent, and there were no procedural breaks (Hayes-Skelton et al., 2013)”

    From Reductions in experiential avoidance as a mediator of change in symptom outcome and quality of life in acceptance-based behavior therapy and applied relaxation for generalized anxiety disorder (2016) · cites this paper as Hayes-Skelton et al., 2013

    The Methods section (“Adherence and Competency”) reports that rated AR sessions addressed permitted components skillfully, received high competency ratings, and had no forbidden strategies. But adherence was assessed in 102 sampled AR sessions, so the paper does not establish that there were no procedural breaks anywhere in the trial. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Mindfulness based interventions may have beneficial effects for pregnant women.

    “Mindfulness based interventions may have beneficial effects for pregnant women [ Hayes-Skelton SA et al., 2013 ].”

    From MINDFULNESS-BASED COGNITIVE THERAPY ON ANXIETY OF PREGNANT WOMEN DURING THE COVID-19 OUTBREAK IN TEHRAN, IRAN (2025) · cites this paper as Hayes-Skelton SA et al., 2013

    The Methods > Interventions passage describes a therapy that includes mindfulness exercises, and the Results > Primary and Secondary Outcomes passage reports improvement among participants with generalized anxiety disorder. The Methods > Participants passage identifies the study population by GAD diagnosis, not pregnancy; the paper does not establish benefits for pregnant women. Page numbers were not available in our copy. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • ConsistentF(1, 79) = 0.37reported p = .54 · recomputed p = .545

    “F(1,79) = 0.37, p = .54”

  • ConsistentF(1, 79) = 0.69reported p = .41 · recomputed p = .409

    “F(1,79) = 0.69, p = .41”

  • ConsistentF(1, 77) = 2.86reported p = .1 · recomputed p = .095

    “F(1,77) = 2.86, p = .10”

  • ConsistentF(1, 77) = 0.002reported p = .96 · recomputed p = .964

    “F(1,77) = 0.002, p = .96”

  • ConsistentF(1, 77) = 0.1reported p = .75 · recomputed p = .753

    “F(1,77) = 0.10, p = .75”

  • ConsistentF(1, 77) = 0.31reported p = .58 · recomputed p = .579

    “F(1,77) = 0.31, p = .58”

  • ConsistentF(1, 77) = 2.58reported p = .11 · recomputed p = .112

    “F(1,77) = 2.58, p = .11”

  • ConsistentF(1, 79) = 0.92reported p = .34 · recomputed p = .340

    “F(1,79) = 0.92, p = .34”

  • ConsistentF(1, 79) = 0.08reported p = .78 · recomputed p = .778

    “F(1,79)=0.08, p = .78”

  • Consistentχ²(1) = 0.91reported p = .34 · recomputed p = .340

    “χ2(1) = 0.91, p = .34”

  • Consistentχ²(1) = 0.04reported p = .85 · recomputed p = .841

    “χ2(1) = 0.04, p = .85”

  • Consistentχ²(1) = 0.002reported p = .97 · recomputed p = .964

    “χ2(1) = 0.002, p = .97”

  • Consistentχ²(1) = 1.78reported p = .18 · recomputed p = .182

    “χ2(1) = 1.78, p = .18”

  • ConsistentF(1, 74) = 0.06reported p = .8 · recomputed p = .807

    “F(1, 74) = 0.06, p = .80”

  • ConsistentF(1, 64) = 0.8reported p = .38 · recomputed p = .374

    “F(1, 64) = 0.80, p = .38”

  • ConsistentF(1, 65) = 0.94reported p = .34 · recomputed p = .336

    “F(1, 65) = 0.94, p = .34”

  • ConsistentF(1, 62) = 0.003reported p = .96 · recomputed p = .956

    “F(1, 62) = 0.003, p = .96”

17 of 17

Self-check

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

Self-check results appear here once an independent check has confirmed them.

Cites

Flagged first, then by citations

1 of the 65 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Hayes-Skelton, S. A., Roemer, L., & Orsillo, S. M.
Affiliations
  • University of Massachusetts Boston (US)
  • Suffolk University (US)
ORCID
Venue
Journal of Consulting and Clinical Psychology
Publisher
American Psychological Association (APA)
Published
2013
Volume
81
Issue
5
Pages
761-773
ISSN
  • 0022-006X (ISSN-L)
  • 1939-2117
DOI
10.1037/a0032871
PMC
PMC3783580
OpenAlex
W1991979798
Cited by
153
References
65
Citations by year
2026: 6 · 2025: 5 · 2024: 8 · 2023: 6 · 2022: 10 · 2021: 10 · 2020: 20 · 2019: 15 · 2018: 15 · 2017: 17 · 2016: 11 · 2015: 13 · 2014: 12 · 2013: 4
FWCI
18.02
Type
journal article
Language
en
Open access
Locations
  • Journal of Consulting and Clinical Psychology (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (MH074589, MH085060)
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
generalized anxiety disorder, applied relaxation, mindfulness, acceptance and commitment therapy, empirically supported treatments, anxiety treatment, treatment comparison, worry, depression, quality of life, comorbidities
MeSH terms
Adult, Anxiety Disorders, Female, Follow-Up Studies, Humans, Male, Middle Aged, Psychiatric Status Rating Scales, Relaxation Therapy, Treatment Outcome, Young Adult, Acceptance and Commitment Therapy

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

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.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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