1) First apply a complementary or an alternative therapy to the case of Henry (s

Question

1) First apply a complementary or an alternative therapy to the case of Henry (see the case study narrative "The Case of Henry" below). To do so, read Norton, Abbott, Norberg, and Hunt's 2015 article found Below.

2) Specify how the theory would conceptualize Henry's "problem," identify what key concepts could be applied, and discuss a specific intervention you would use with Henry.

Case Study: The Case of Henry

Presenting Information: Henry is a 46-year-old Japanese man. He was born in Japan and moved to the United States by himself when he was in his early 20s to go to college and work. He presents to counseling with multiple complaints of depressive symptoms, anxiety about being in social situations, relationship problems, and financial challenges. He reports feeling irritable and down most of the time but continues to go to work even though he does not have the energy. He also states that he experiences nervousness when he is around people at work and socially, so much so that he has begun to isolate himself. He feels afraid to talk to people because he thinks, "They will look at me like I am stupid and just walk away. So, I just don't talk to people. I am better off that way anyway because nobody understands my situation." He states that it is difficult for him to come to counseling because his Japanese beliefs do not support counseling. Strong encouragement from one of his American friends convinced him to come.

Social History: Henry states that he was engaged to be married but his fiancée left him for another man about six months ago. They were together for about three years. Henry says, "I came home from work one day and she had all of her stuff packed. She told me she did not love me anymore, and then she left. I just did not know what to say or do, and ever since then I have been stuck." His fiancée was Japanese, too, but was more Americanized than Henry feels he is. Even though he has lived in the United States for many years, he states that he tries to remain close to his cultural roots. Henry has never been married and does not have any children. He has a few friends but says that he does not spend much time with them anymore. He feels like they see him as weak because he cannot move on from the breakup. He was also involved in karate as a four-time black belt but has dropped out of the dojo.

Mental Health and Addictions History: Henry states that he has never been to counseling and has never abused any substances.

Family History: Henry's family still live in Japan, and he feels that they have a close relationship. His parents are elderly and are very traditional in their Japanese ways, so he does not talk to him about his problems or about seeking counseling. He is an only child. Henry reports that while in high school he was bullied a lot by other students and frequently physically harmed. He tried to talk to his father, but his father said that he had to be a man and stand up for himself. Henry continued to be bullied but never spoke of it again. He said he had forgotten about the incidents for many years but has now begun to think about it more. He reports that he has even had nightmares about his coworkers and friends bullying him.

Occupational and Educational History: Henry has a bachelor's degree in business and computer technology and is the information technology specialist at a local company. He is currently having financial problems due to his fiancée moving out and taking a substantial amount of money from their joint savings account.

ARTICLE: Journal of Clinical Psychology, April 2015 meta-analysis) and the association between mindfulness and psychological well-being (see Keng, Somoski, & Robins, 2011 for review), MABTs have been investigated as plausible stand-alone treatments or potentially additive treatment components to a pure cognitive-behavioral approach for SAD. Mindfulness has been defined as “the non-judgmental observation of the ongoing stream of internal and external stimuli as they arise” (Baer, 2003, p. 125). Bishop et al. (2004) proposed two components of mindfulness: (a) self-regulation of attention, involving the ability to sustain attention to present experience and switch attention between aspects of experience; and (b) adoption of a curious, open, and accepting attitude toward all internal and external stimuli. Hence, mindfulness training has been adopted by contemporary psychology with the aim of increasing awareness and skilful responding to mental processes that contribute to emotional distress and maladaptive behavior (Keng et al., 2011). Specifically, it is postulated that a mindful stance of nonjudgmental, present-focused awareness may be an effective antidote to problematic self-focused attention (SFA), which is considered a key maintaining feature in all cognitive models of SAD. Herbert and Cardaciotto (2005) have proposed an acceptance-based model of SAD, positing that the effect of SFA on anxiety symptoms, negative cognitions, and behavioral disruption is moderated by the degree of nonjudgmental experiential acceptance. Low levels of acceptance activate use of experiential control strategies, creating a vicious cycle of amplified awareness and increased efforts to control experience and escalating anxiety-related arousal (Herbert & Cardaciotto, 2005). In contrast, high levels of nonjudgmental acceptance enable thoughts and feelings to be observed, without attempting to control, avoid, or escape from such experiences. This is thought to disrupt the vicious cycle of anxiety by facilitating a decentred perspective on experiences (Hayes-Skelton & Graham, 2013) and by reducing behavioral avoidance. MABTs that have been investigated for the treatment of SAD include mindfulness-based stress reduction (MBSR, Kabat-Zinn, 1990), mindfulness-based cognitive therapy (MBCT, Segal, Williams, & Teasdale, 2002), acceptance and commitment therapy (ACT; Hayes, Stosahl, & Wilson, 1999), and mindfulness and acceptance-based group therapy (MAGT; Kocovski, Fleming, & Rector, 2009). Herbert, Gershkovich, and Forman (2014) have classified these MABTs into two broad categories: (a) meditation-based programs, including metacognitive approaches (MBSR, MBCT) and (b) modern behavior-analytic approaches (ACT, MAGT). Despite differing philosophical underpinnings and core therapeutic techniques, these approaches share an emphasis on encouraging behavioral change in the presence of distressing cognitions and emotions, rather than directly attempting to alter negative cognitions or affect (Herbert et al., 2014). Meditation-based programs (MBSR, MBCT) are rooted in Eastern Buddhist traditions and teach mindfulness via three main forms of meditation practice (body scan, sitting meditation, and Hatha Yoga practice; Kabat-Zinn, 1990). MBSR was originally developed to reduce physical and mental suffering experienced by chronic pain patients (Kabat-Zinn, 1990) and has also demonstrated benefits for depression, generalized anxiety disorder (GAD), and panic disorder (Grossman, Niemann, Schmidt, & Walach, 2004; Hoge et al., 2013; Miller, Fletcher, & Kabat-Zinn, 1995). MBCT borrows meditation practices derived from MBSR and also includes cognitive techniques and exercises derived from CBT. These techniques were initially designed to combat depressive relapse by enhancing metacognitive awareness, a decentred perspective, explanatory flexibility, and reducing extreme responding (Fresco, Flynn, Mennin, & Haigh, 2011). MBCT has been found to decrease depressive symptoms and relapse (e.g., Kenny & Williams, 2007; Teasdale et al., 2002), as well as reducing anxiety symptomatology in anxiety disorder patients (e.g., Hoge et al., 2013). Modern behavior analytic approaches are rooted in relational frame theory (RFT), and focus on developing a stance of experiential acceptance, that is, increasing willingness to experience psychological events (cognitions, emotions) without attempting to alter their form or frequency (Hayes & Wilson, 2003; Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Hence, acceptance strategies aim to reduce maladaptive tendencies to avoid, suppress, or over-engage distressing thoughts and emotions, and consequently increase values-consistent behavior (Hayes et al., 2006). Mindfulness Interventions for SAD 285 Modern behavior analytic approaches (ACT, MAGT) do not involve formal meditation training. Rather, therapeutic exercises are designed to encourage the nonjudgmental observation of internal experiences as phenomena separate from the person (Hayes et al., 2006). These exercises aim to help patients relinquish counterproductive efforts to control experience and enable a focus on identifying values and committing to life goals (Hayes & Wilson, 2003). Recent studies have demonstrated that ACT may be effective in treating depression and anxiety disorders (see Pull, 2008 and Swain, Hancock, Hainsworth, & Bowman, 2013, for reviews). MAGT was developed specifically for SAD, predominantly based on ACT, but containing exposure exercises and mindfulness exercises adapted from MBCT and MBSR (Kocovski et al., 2009). Brief analogue mindfulness and acceptance interventions for SAD have yielded mixed findings. When socially anxious participants were in a nonanxious state, a brief mindfulness induction was found to reduce state anxiety and increase positive thinking (Vassilpoulos, 2008), as well as decreasing autonomy-related negative self-judgements (Vassilopoulos & Watkins, 2009). However, when participants were anxiously activated, only one of three studies found signification reductions in distress were evident after a mindfulness intervention, and these benefits were not over and above engaging in distraction (Cassin & Rector, 2011). Moreover, when anxiety was activated by a current social task (an impromptu speech), Wong and Moulds (2012) found mindful self-focus to be detrimental in strengthening maladaptive self-beliefs. Hence, these studies indicate that for socially anxious individuals, brief periods of mindful attention yield limited benefits at best, and may be potentially detrimental. However, the brevity of the interventions and predominantly nonclinical samples in these studies limit the generalizability of these findings to a clinical population completing a course of MABT. Given the theoretical and empirical interest in this area, this review evaluates the benefits of MABTs for SAD, and outcomes are compared with CBT where possible. Specifically, this review analysed eligible studies based on seven key areas: design, participants, clinical status, assessment, treatment, outcome measures, and major outcomes (symptoms and processes). Risk of bias within and across these studies was assessed based on domains outlined by the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011). Hence, the quality of the research and reliability of current findings regarding the efficacy of MABTs for SAD will be evaluated for all relevant published literature. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and guidelines were used to guide the summarizing of evidence and ensure appropriate and transparent reporting of results (Liberati et al., 2009). Method Summary of Search Strategy A comprehensive literature search was conducted among articles indexed in the PsycInfo, Medline, PubMed, and Cochrane Central Register of Controlled Trials. The key words employed included: social anxiety, SAD, social phobia, mindful, experiential, concrete, nonjudgmental, nonreactive, meta-awareness, metacognition, decentering, observer self, acceptance, intervention, induction, modification, change, treatment, therapy, trial, anxiety, mood, emotion, and avoidance. Reference lists of relevant articles were also closely examined for additional studies. Articles were limited to English language, and no limitations were made regarding publication date. The last date searched was July 7, 2014. Selection and Exclusion Studies were retained that included an MABT for socially anxious adults (aged 18–65 years). Studies were excluded that did not include meaningful quantitative statistical analyses (including case studies), included an irrelevant intervention (e.g., social skills training), contained an analogue intervention, were not specific to SAD (e.g., test anxiety), or were not peer reviewed (e.g., dissertation theses). All applicable treatment studies were considered regardless of sample size.

MBSR. Three studies implemented a standard MBSR program. All studies demonstrated significant within-group improvements on all symptom and process variables after the intervention, and one study reported significant improvements maintained at follow-up (predominantly medium effect sizes). However, the AE intervention was found to be as effective as MBSR (Jazaieri et al., 2012). One study reported that CBGT was significantly more efficacious than MBSR for improving social anxiety symptomatology, illness severity, and current disability, but it produced equivalent outcomes for reducing depression and improving quality of life (Koszycki et al., 2007). MBCT. Two studies implemented MBCT, and one of these studies combined MBCT with Task Concentration Training (Bogels, Sijbers, & Voncken, 2006), which has established efficacy for reducing social anxiety (Mulkens, Bogels, de Jong, & Louwers, 2001). Both studies reported significant improvements in social anxiety at posttreatment and at follow-up (small to Mindfulness Interventions for SAD 295 large effect sizes). Only one study reported a significant reduction in general psychopathology posttreatment, but both studies reported significant improvements at follow-up. Significant improvements were also reported in functional impairment and distress at both posttreatment and follow-up (Piet, Hougaard, Hecksher, & Rosenberg, 2010), as well as on most measures of SFA, and the discrepancy between patients’ ratings of their ‘actual’ and ‘ideal’ selves (Bogels et al., 2006). Compared to CBGT, Piet et al. reported no significant between-group differences but noted that CBGT was marginally more efficacious in reducing social anxiety symptoms. ACT. Both studies of ACT reported significant reductions in social anxiety symptomatology and experiential avoidance at posttreatment (medium to large effect sizes) and follow-up (small to large effect sizes). Dalrymple and Herbert (2007) also reported significantly reduced functional impairment and improved quality of life at both posttreatment and follow-up, whereas Ossman, Wilson, Storaasli, and McNeill (2006) found improved quality of life at follow-up only. Neither study included a control condition. MAGT. Both studies of MAGT reported significant improvements in social anxiety, depression, mindfulness, experiential avoidance, and rumination at both posttreatment and followup. Kocovski and colleagues (2013) also reported increases in cognitive reappraisal. Compared to the waitlist, Kocovski et al. (2013) reported that both MAGT and CBGT demonstrated greater improvements in social anxiety, depression, quality of life, mindfulness, and experiential avoidance. However, MAGT and CBGT did not differ significantly on any outcomes. Risk of Bias (see Table 3) Overall risk of bias across the nine studies was high, as the proportion of information at unclear or high risk of bias is sufficient to affect interpretation of results (see Table 3). Specifically, risk of bias across all studies suggested high risk of selection bias, performance bias and detection bias, low reporting bias, varied attrition bias, and varied risk of bias from other sources relevant to this area. Of note, less than half the studies included a control condition, and only three of these studies reported adequate random allocation. Small sample sizes in three studies reflect insufficient power, and eight studies reported significant attrition (ranging from 15% to 45%). Five studies used the “last observation carried forward,” and only two studies imputed missing values using the expectation–maximization (EM) method, which is considered to yield more reliable and unbiased estimates than other imputation techniques (Salim, Mackinnon, Christensen, & Griffiths, 2008). Discussion Summary of Outcomes Increasing evidence for the psychological benefits of cultivating mindfulness and acceptance combined with a growing interest in improving therapeutic interventions for social anxiety has stimulated investigation of MABTs for SAD. Hence, this review aimed to evaluate the efficacy of MABTs for SAD. Review of nine identified studies across four MABTs provided inconclusive support for the use of MABTs as a first-line treatment for social anxiety. Although studies indicate that MABTs provide significant benefits for reducing symptomatology among SAD patients, these benefits may not be over and above the benefits achieved with CBT. Moreover, the substantial methodological limitations of the literature lead outcome evidence to be considered weak. Consequently, outcomes must be interpreted with caution due to a paucity of studies, lack of replication, and significant methodological limitations that considerably weaken outcome reliability. Notably, most studies lacked active control conditions, and when a comparison group was included, most of studies found the alternative intervention (CBGT or AE) to be comparable or more effective. Moreover, most studies included small sample sizes, many depleted by high attrition rates, which were often inadequately addressed in statistical analyses.

Explanation / Answer

As per the case study,modern behavior-analytic approaches (ACT, MAGT) may be helpful for the case of Henry because he adopted his anxiety fron his boyhood and from that gradually the depression occured.These approaches share an emphasis on encouraging behavioral change in the presence of distressing cognitions and emotions, rather than directly attempting to alter negative cognitions or affect (Herbert et al., 2014).Here the anxiety leads to depression.These approaches reported significant improvements in social anxiety, depression.

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