Effectiveness of ACT for Social Anxiety: Randomized Clinical Trial

Social anxiety disorder is a mental health condition characterized by intense fear and avoidance of social situations, often driven by concerns about being judged, embarrassed, or rejected by others.

Acceptance and Commitment Therapy (ACT) is a form of cognitive-behavioral therapy that aims to increase psychological flexibility by encouraging individuals to accept difficult thoughts and feelings while engaging in valued actions.

ACT may be recommended as a treatment for social anxiety disorder because it targets key maintaining factors, such as experiential avoidance and self-critical thoughts, while promoting behavior change in alignment with personal values.

By cultivating mindfulness, self-compassion, and committed action, ACT can help individuals with social anxiety disorder cope with their fears, reduce avoidance, and improve their quality of life.

Khoramnia, S., Bavafa, A., Jaberghaderi, N., Parvizifard, A., Foroughi, A., Ahmadi, M., & Amiri, S. (2020). The effectiveness of acceptance and commitment therapy for social anxiety disorder: a randomized clinical trial. Trends in psychiatry and psychotherapy, 42, 30-38. https://doi.org/10.1590/2237-6089-2019-0003 

Key Points

• Acceptance and Commitment Therapy (ACT) was effective in reducing external shame, social anxiety, difficulty in emotion regulation, and increasing psychological flexibility and self-compassion in students with social anxiety disorder.
• The largest effect size of ACT was for increasing psychological flexibility, while the lowest efficacy was for the components “difficulty in impulse control” and “limited access to emotional strategies.”
• Emotion and related problems can be identified as one of the main targets of ACT for treating social anxiety disorder.
• The study, while informative, has limitations such as a small sample size and lack of a more dynamic control group.

Rationale

Social anxiety disorder is a common and debilitating condition affecting approximately 13% of the population (Kessler et al., 2012). It can lead to social isolation, impaired functioning, and economic burden (Teo et al., 2013; Hofmann & Otto, 2008; Dams et al., 2017).

While cognitive-behavioral therapy has shown efficacy, some patients do not respond or symptoms remain (Dalrymple & Herbert, 2007).

Recent studies have explored the effectiveness of ACT for anxiety disorders (Twohig et al., 2006; Eifert et al., 2009; Roemer et al., 2008).

However, more research is needed to determine ACT’s efficacy for social anxiety disorder, especially in different cultures and for emotion regulation variables (Azadeh et al., 2016; Dalrymple & Herbert, 2007).

Method

This semi-experimental clinical trial randomly divided twenty-four students with social anxiety disorder into an experimental group (n=12) receiving 12 ACT sessions and a control group (n=12) on the waiting list.

Participants were assessed at pre-test, post-test, and two-month follow-up using the following measures:

Measures

• Self-Compassion Scale (SCS): This 26-item scale measures the degree to which individuals show self-kindness, common humanity, and mindfulness towards themselves in difficult times.
• Difficulties in Emotion Regulation Scale (DERS): The 36-item scale assesses problems in emotional awareness, acceptance, and ability to engage in goal-directed behaviors and access emotion regulation strategies when experiencing negative emotions.
• External Shame Scale (ESS): This 18-item measure evaluates the individual’s perception that others judge them negatively or see them as inferior, inadequate, or worthless.
• Social Phobia Inventory (SPIN): The 17-item scale assesses the severity of fear, avoidance, and physiological discomfort in social situations.
• Acceptance and Action Questionnaire (AAQ-II): This scale measures psychological flexibility, which involves accepting difficult thoughts and feelings while engaging in valued actions, in the context of social anxiety.

Procedure

Students with social anxiety symptoms underwent a diagnostic interview. Those meeting inclusion criteria were randomly assigned to the experimental or control group.

The experimental group received twelve 90-minute ACT sessions tailored to their needs, while the control group was put on a waiting list and received treatment after final evaluations.

Sample

Twenty-two students (15 women, 7 men) with a mean age of 22.12±1.08 completed the study.

Statistical Analysis

Multivariate analysis of covariance was used to compare the experimental and control groups on the target variables. Data normality was verified using the Kolmogorov-Smirnov test.

Equality of covariance matrices and error variances were checked using Box’s M and Leven’s tests, respectively.

Results

ACT significantly reduced external shame, social anxiety, difficulty in emotion regulation, and increased psychological flexibility and self-compassion in the experimental group compared to the control group at post-test and follow-up (p < 0.05).

The largest effect size was for increasing psychological flexibility (43-67%). The smallest effect sizes were for “difficulty in impulse control” and “limited access to emotional strategies” components.

Insight

This study demonstrates ACT’s effectiveness in improving psychological symptoms in students with social anxiety disorder.

By targeting acceptance, committed action, and psychological flexibility, ACT helped reduce shame, anxiety, and emotion dysregulation while increasing self-compassion.

The robust effects on psychological flexibility align with ACT’s theoretical model. Notably, ACT impacted emotion regulation, suggesting it changes emotional experience in addition to one’s relationship with emotions.

Future research could explore ACT’s mechanisms of change and long-term effects in larger, more diverse samples. Integrating self-compassion training into ACT may enhance outcomes.

Strengths

The study had several methodological strengths:

• The study randomly allocated participants to experimental and control conditions, minimizing bias and confounding variables.
• The research employed well-established, psychometrically sound instruments to assess the targeted constructs.
• The use of a standardized ACT protocol ensures consistency in treatment delivery and facilitates replication.
• Assessing outcomes after a two-month delay provides insight into the durability of ACT’s effects over time.
• By measuring a range of variables, including social anxiety, shame, self-compassion, emotion regulation, and psychological flexibility, the study offers a comprehensive evaluation of ACT’s impact.

Limitations

Some limitations should be noted:

• The study’s sample of 24 participants limits the generalizability of the findings to the broader population of individuals with social anxiety disorder.
• As the study only included university students, the results may not extend to other age groups or non-student populations.
• While a waiting list control group is useful for assessing treatment efficacy, it does not control for non-specific factors such as extra attention or expectancy effects that could contribute to improvement.
• The exclusive use of self-report questionnaires may be subject to response bias, social desirability, or inaccurate self-assessment, and does not provide an objective evaluation of treatment outcomes.
• The lack of an active treatment control group makes it difficult to determine if ACT is superior to other established interventions for social anxiety disorder.

Implications

ACT appears to be an effective treatment for social anxiety disorder, reducing symptoms and improving psychological flexibility and emotion regulation.

Clinicians may consider using ACT with socially anxious clients, emphasizing acceptance and action aligned with values.

The findings support ACT’s transdiagnostic applicability, as it impacted both disorder-specific and broader outcomes. Policymakers may promote access to ACT as an evidence-based option.

However, further research in real-world settings with larger and more diverse samples is warranted to confirm and extend the findings.

References

Primary reference

Khoramnia, S., Bavafa, A., Jaberghaderi, N., Parvizifard, A., Foroughi, A., Ahmadi, M., & Amiri, S. (2020). The effectiveness of acceptance and commitment therapy for social anxiety disorder: a randomized clinical trial. Trends in psychiatry and psychotherapy, 42, 30-38. https://doi.org/10.1590/2237-6089-2019-0003 

Other references

Azadeh, S. M., Kazemi-Zahrani, H., & Besharat, M. A. (2016). Effectiveness of acceptance and commitment therapy on interpersonal problemsand psychological flexibility in female high school students with social anxiety disorder. Global journal of health science, 8(3), 131.

Dams, J., König, H. H., Bleibler, F., Hoyer, J., Wiltink, J., Beutel, M. E., … & Konnopka, A. (2017). Excess costs of social anxiety disorder in Germany. Journal of Affective Disorders, 213, 23-29. https://doi.org/10.1016/j.jad.2017.01.041

Dalrymple, K. L., & Herbert, J. D. (2007). Acceptance and commitment therapy for generalized social anxiety disorder: A pilot study. Behavior modification, 31(5), 543-568. https://doi.org/10.1177/0145445507302037

Eifert, G. H., Forsyth, J. P., Arch, J., Espejo, E., Keller, M., & Langer, D. (2009). Acceptance and commitment therapy for anxiety disorders: Three case studies exemplifying a unified treatment protocol. Cognitive and behavioral practice, 16(4), 368-385. https://doi.org/10.1016/j.cbpra.2009.06.001

Hofmann, S. G., & Otto, M. W. (2008). Cognitive behavioral therapy for social anxiety disorder: Evidence-based and disorder-specific treatment techniques. Routledge. https://doi.org/10.4324/9780203927526

Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve‐month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International journal of methods in psychiatric research, 21(3), 169-184. https://doi.org/10.1002/mpr.1359

Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: evaluation in a randomized controlled trial. Journal of consulting and clinical psychology, 76(6), 1083. https://doi.org/10.1037/a0012720

Teo, A. R., Lerrigo, R., & Rogers, M. A. (2013). The role of social isolation in social anxiety disorder: A systematic review and meta-analysis. Journal of anxiety disorders, 27(4), 353-364. https://doi.org/10.1016/j.janxdis.2013.03.010

Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). Increasing willingness to experience obsessions: Acceptance and commitment therapy as a treatment for obsessive-compulsive disorder. Behavior therapy, 37(1), 3-13. https://doi.org/10.1016/j.beth.2005.02.001

Keep Learning

Here are some questions for a college class to discuss this paper:

1. How might ACT’s focus on values and committed action specifically help individuals with social anxiety reengage in meaningful social activities?
2. Given ACT’s transdiagnostic effects in this study, what other disorders commonly comorbid with social anxiety might benefit from ACT?
3. The study found differing effect sizes for various emotion regulation difficulties. What are some potential explanations for why ACT had greater impact on some aspects of emotion regulation than others?
4. How could future studies build on these findings to further elucidate the mechanisms through which ACT leads to symptom improvement in social anxiety disorder?
5. Considering the limitations of this study, what next steps would help strengthen the evidence base for ACT as a treatment for social anxiety disorder?