Intervention and prevention trials:
Attention
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Can we control attention to reduce stress response?
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Where does etiology point us?
● Attention and avoidance
● Attention and entrapment
● Attention deployment and acceptance
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Avoidance: Thought suppression
Just don’t think about it!
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Avoidance: Thought suppression
“Try to pose for yourself this task: not to think of a polar bear, and you will see that
the cursed thing will come to mind every minute.”
—Dostoevsky, Winter Notes on Summer Impressions (1863)
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Avoidance: Thought suppression
Paradoxical effects of thought suppression
“Ironic process of mental controL”
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Avoidance: Thought suppression
Wegner et al. (1987)
● Participants talked for 5 minutes about “everything that comes to mind.”
● Group 1 (suppress, then express):
● Second five minutes: continue to verbalize, try not to think about a white
bear, but if you do ring a bell
● Third five minutes: same task, but try to think of a white bear
● Group 2: (express, then suppress)
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Avoidance: Thought suppression
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Entrapment: Rumination
Constant recycling of negative thoughts about self and world
Rumination is associated with more suppression attempts
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What helps?
● Based on brief experiments:
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Focused self distraction (“when a white bear comes to mind, think of a red
Volkswagen”)
Writing about the thought: expression reduces intrusiveness
Acceptance reduces aversive nature of unwanted self thoughts
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Can we alter problematic attention patterns to reduce
stress?
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Attention bias modification (ABM)
● ABM: Using computer-based training to modify biased attention to negative
stimuli
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Goal: to train attention avoidance of threat cues
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Attention bias modification (ABM)
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Attention bias modification (ABM)
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Trials to test impact of ABM on health outcomes
Reminder:
Type of trial
Question to be answered
Basic efficacy
Does this intervention work?
Comparative efficacy
Which of these interventions works best?
Differential efficacy
Who benefits most from this intervention?
Test of mechanism
Why does this intervention work?
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ABM trials
Amir et al. (2009)
● Randomized clinical trial
● Testing whether ABM interventions help people with social anxiety disorder
Type of trial
Question to be answered
Basic efficacy
Does this intervention work?
Comparative efficacy
Which of these interventions works best?
Differential efficacy
Who benefits most from this intervention?
Test of mechanism
Why does this intervention work?
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ABM trials
Amir et al. (2009)
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ABM trials
Amir et al. (2009)
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ABM trials
Amir et al. (2009)
Attention modification program (AMP)
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8 20-minute sessions over 4 weeks
Similar to dot probe with faces
(disgust, neutral)
But probe always went to neutral face
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ABM trials
Amir et al. (2009)
Attention Control Condition (ACC)
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All assessment procedures identical, except that probe went to disgust face 50% of the
time
Double-blind: that no one (investigator, research assistants, participants) knew which
condition was treatment vs. placebo
● Similar % of participants guessed they were in the treatment group (AMP; 21%) vs
control (28%; ACC)
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ABM trials
Amir et al. (2009)
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ABM trials
Amir et al. (2009)
Long-term effects?
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AMP followed for four months, but ACC not
AMP gains maintained, but we don’t know if ACC would have gotten better as well
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Attention deployment and acceptance
Aldao et al. (2012)
●
Reviewed 124 studies of emotion
regulation strategies and mental
health disorders (depression, anxiety,
substance use)
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Acceptance
● Accepting what comes, valuing the moment
● Adjust self (beliefs, hopes, goals, interpretations) to circumstance
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Interventions targeting acceptance
● Focused meditation (e.g., transcendental meditation; TM)
● Mindfulness-based stress reduction (MBSR)
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Interventions targeting acceptance
Transcendental Meditation (TM)
● Focus on specific target (sound, image, sensation) and continually return to that
target as mind wanders
● Programs involve training in meditation, establishing daily practice
● Evidence for reduction in biological indexes of stress response
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Interventions targeting acceptance
But… the problem of allegiance
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Most of the research on TM is by its proponents; few attempts to replicate in
independent labs
Allegiance effects: Subtle biases toward some outcome, due to strong personal
beliefs or economic incentives of investigators
Methods for reducing allegiance effects:
● Full disclosure
● Independent review
● Replication by other labs
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Interventions targeting acceptance
Mindfulness Based Stress Reduction (MBSR)
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Developed by Jon Kabat-Zinn
Borrows from Buddhist meditation tradition
First stage: uses concentration forms of meditation to develop base for awareness
(often the breath)
Second stage: rather than suppressing awareness of anything but focus, emphasizes
awareness of sensations, thoughts, feelings
Emphasizes intention to refrain from evaluation and observe non-judgmentally
Goal: develop an attitude of “friendly curiosity, interest, and acceptance toward all
observed phenomena”
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Interventions targeting acceptance
Mindfulness Based Stress Reduction (MBSR)
● Evidence from controlled trials
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Williams et al (2001): trained university staff in MBSR
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MBSR group reported reductions in daily hassles, distress, and medical symptoms as
compared to controls
Davidson et al (2003) trained biotech company employees in MBSR
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Using EEG, found greater activation in left anterior brain, and less asymmetry between left
and right activation (associated with positive emotions & reduced depression)
Found stronger antibody response to administration of flu vaccine
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Interventions targeting acceptance
Why does meditation work?
Type of trial
Question to be answered
Basic efficacy
Does this intervention work?
Comparative efficacy
Which of these interventions works best?
Differential efficacy
Who benefits most from this intervention?
Test of mechanism
Why does this intervention work?
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Interventions targeting acceptance
Goldin et al. (2016)
Assigned patients with Social Anxiety Disorder to 1 of 3 conditions:
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MBSR group
CBT group
Waitlist control
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Interventions targeting acceptance
Goldin et al. (2016)
Assigned patients with Social Anxiety Disorder to 1 of 3 conditions:
●
●
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MBSR group
CBT group
Waitlist control
Type of trial
Question to be answered
Basic efficacy
Does this intervention work?
Comparative efficacy
Which of these interventions works best?
Differential efficacy
Who benefits most from this intervention?
Test of mechanism
Why does this intervention work?
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Interventions targeting acceptance
Goldin et al. (2016)
MBSR group
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Specific mindfulness skills
● Observing
● Describing
● Acting With Awareness
● Nonreactivity to Inner Experience
● Non-judgment of Inner Experience
Attentional focusing
Attentional shifting
Rumination
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Interventions targeting acceptance
Goldin et al. (2016)
CBT group
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Frequency of cognitive reappraisal
Sense of self-efficacy about cognitive reappraisal
Cognitive distortions
Frequency of subtle avoidance or safety behavior
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Interventions targeting acceptance
Goldin et al. (2016)
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Basic efficacy:
○ People in both CBT and MBSR groups reported significantly reduced anxiety
compared to those in waitlist
○ Effects were maintained at follow-up
Comparative efficacy:
○ No differences between CBT and MBSR
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Interventions targeting acceptance
Goldin et al. (2016)
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Compared to WL, MBSR significantly improved
all intervention targets except attention shifting
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Mediation
Mediation: Do changes in intervention targets lead to changes in outcomes?
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“To mediate” means “to be in the middle”
In psychology: “to mediate” means “to carry the effect from one variable to another”
● Studying mediation is a way of testing mechanisms of action
Causal influences of one variable act on a second variable, and that second
variable (“in the middle”) has causal influence on a third variable
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Mediation
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Mediation
Goldin et al. (2016)
MBSR showed mediation through six of eight targets
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Mediation
Goldin et al. (2016)
CBT significantly changed all targets
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Mediation
Goldin et al. (2016)
CBT showed mediation through all targets
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Differences between conditions?
Goldin et al. (2016)
● MBSR and CBT were equally effective at changing intervention targets except:
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CBT slightly stronger on decreasing subtle avoidance behavior
Mediating effects of reappraisal efficacy and subtle avoidance stronger for CBT
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Conclusion
Goldin et al. (2016)
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CBT vs. MBSR: Similar efficacy (immediate and at 12-month follow-up), similar impact
on targets, subtle differences in mediation
Different people prefer different approaches? (although no differential dropout)
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Is it all the same stuff…?
Depression levels significantly reduced
in the tango (effect size d = 0.50, p =
.010), and meditation groups (effect
size d = 0.54, p = .025), relative to
waitlist control.
Stress levels significantly reduced only
in the tango group (effect size d =
0.45, p = .022).
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Summary
ABM
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Trials consistently show small benefits for anxiety and depression, but not often maintained at
follow-up
MSBR
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Strong evidence for basic efficacy
Comparative efficacy (value added) still unclear
Work on mediators (why it works) and moderators (for whom it works best) still in early stages
Attention interventions in general
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Attempts to suppress thoughts can make thoughts and stress worse
Acceptance strategies seem work well
Attention training methods can be useful for stress reduction
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