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Acceptance as a mediator in internet-delivered acceptance and commitment therapy and cognitive behavior therapy for tinnitus

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Abstract

Despite demonstrated efficacy of behavioral and cognitive techniques in treating the impact of tinnitus (constant ringing in the ears), little is known about the mechanisms by which these techniques achieve their effect. The present study examined acceptance of tinnitus as a potential mediator of treatment changes on global tinnitus severity in internet-delivered acceptance and commitment therapy (iACT) and internet-delivered cognitive behavior therapy (iCBT). Data from 67 participants who were distressed by tinnitus and who were randomly assigned to 1 of the 2 treatments were analyzed using a multilevel moderated mediation model. We predicted that acceptance as measured with the two subscales of the tinnitus acceptance questionnaire (i.e., activity engagement and tinnitus suppression) would mediate the outcome in iACT, but not in iCBT. Results provided partial support to the notion that mediation was moderated by treatment: tinnitus suppression mediated changes in tinnitus severity in iACT, but not in iCBT. However, inconsistent with the view that the treatments worked through different processes of change, activity engagement mediated treatment changes across both iACT and iCBT. Acceptance is identified as a key source of therapeutic change in behavioral-based treatments for tinnitus.

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Notes

  1. Linear time was estimated for several reasons. First, in many situations, especially when the time period is short or when the number of measurement points is few, a linear model can provide a good approximation of complex growth processes (Raudenbush and Bryk 2002). Second, to our knowledge, little is currently known about how the estimated combined multivariate model of mediation performs when non-linear associations are estimated in terms of, for example, accuracy of estimates and SE. Third, and most important, despite the fact that there was room for improvement, linear models provided a reasonable fit to the observed data (fit indices for linear models can be provided upon request from the first author).

  2. We also considered models in which we allowed the effect of the time-varying predictor, TAQ, on the outcome, THI, to vary across individuals (i.e., random effect of the b j coefficient). Kenny et al. (2003) have suggested to included the covariance of a and b paths in lower level multilevel models in the computation of the standard error of the ab-product. However, as the variance associated with the TAQ was not significantly different from zero in any of the estimated models, and thus, the covariance of a and b paths was fixed at zero.

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Acknowledgments

This study was funded by a grant from the Swedish Council for Working Life and Social Research to Gerhard Andersson. The preparation of this manuscript was sponsored in part by a grant from the Swedish Research Council (HEAD Linneaus grant). We wish to thank all research collaborates in the original trial: Tore Gustafsson, Charlotte Lundén, Oskar Henrikson, Kidjan Fattahi, Per Carlbring, Elina Mäki-Torkko, and Viktor Kaldo.

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Authors and Affiliations

  1. Department of Behavioural Sciences and Learning, Linnaeus Centre HEAD, Swedish Institute for Disability Research, Linkö** University, 581 83, Linkö**, Sweden

    Hugo Hesser, Vendela Zetterqvist Westin & Gerhard Andersson

  2. Department of Clinical Neuroscience, Psychiatric Section, Karolinska Institutet, Stockholm, Sweden

    Gerhard Andersson

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  1. Hugo Hesser
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  2. Vendela Zetterqvist Westin
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  3. Gerhard Andersson
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Correspondence to Hugo Hesser.

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Hesser, H., Westin, V.Z. & Andersson, G. Acceptance as a mediator in internet-delivered acceptance and commitment therapy and cognitive behavior therapy for tinnitus. J Behav Med 37, 756–767 (2014). https://doi.org/10.1007/s10865-013-9525-6

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