Cognitive Behaviour Therapy

ISSN: 1650-6073 (Print) 1651-2316 (Online) Journal homepage: http://www.tandfonline.com/loi/sbeh20

Acceptability of a brief computerized intervention

targeting anxiety sensitivity

Nicole A. Short, Kelly Fuller, Aaron M. Norr & Norman B. Schmidt

To cite this article: Nicole A. Short, Kelly Fuller, Aaron M. Norr & Norman B. Schmidt (2016):
Acceptability of a brief computerized intervention targeting anxiety sensitivity, Cognitive Behaviour
Therapy, DOI: 10.1080/16506073.2016.1232748

To link to this article: http://dx.doi.org/10.1080/16506073.2016.1232748

Published online: 07 Oct 2016.

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Cognitive Behaviour Therapy, 2016
http://dx.doi.org/10.1080/16506073.2016.1232748

Acceptability of a brief computerized intervention targeting

anxiety sensitivity
Nicole A. Short, Kelly Fuller, Aaron M. Norr and Norman B. Schmidt
Department of Psychology, Florida State University,Tallahassee, FL, USA

ABSTRACT ARTICLE HISTORY

Despite the well-documented efficacy of cognitive behavioral Received 21 June 2016
treatments for anxiety disorders, the acceptability of these treatments Accepted 1 September 2016
remains an under-researched area. A better understanding of KEYWORDS
acceptability could help to improve the initiation of, and engagement Acceptability; tolerability;
in, these effective interventions. Recent research has suggested anxiety sensitivity; treatment
computerized interventions of anxiety-related risk factors may be one
way to improve acceptability and overcome several common barriers to
treatment. Considering this, the current study tested the acceptability
of a computerized, anxiety sensitivity (AS)-focused treatment among
a sample of treatment-seeking community participants and military
veterans (N=58). Results indicated that the majority of participants
rated the intervention as acceptable, and that drop-out rate was low
(ie 5%). Moreover, higher acceptability scores were associated with
older age, veteran status, lower income levels, African-American race,
and being separated/divorced. Findings suggest that a computerized
AS-focused treatment may be an acceptable treatment method, and
may have advantages in acceptability for hard to reach populations.

Anxiety disorders represent the most prevalent form of psychiatric disorders in the United
States (US), with an estimated 40 million adults, or 18% of the population, affected (Kessler,
Chiu, Demler, & Walters, 2005). These disorders are more common among certain popula-
tions, particularly veterans (Black et al., 2004b). The specific conditions currently recognized
as anxiety disorders are panic disorder, agoraphobia, generalized anxiety disorder, specific
phobia, and social anxiety disorder (American Psychiatric Association, 2013). Although
symptoms of these disorders vary, they each are associated with significant personal dis-
tress and disability, such as functional impairment (eg missing work, getting along with
family and friends, taking care of things at home; Kroenke, Spitzer, Williams, Monahan, &
Lwe, 2007). Moreover, these disorders result in a substantial societal burden, including an
estimated $42 billion per year in directly related health care costs as well as indirect costs,
such as lost productivity at work (Greenberg et al., 1999).
The prevalence of and cost associated with anxiety disorders raises the need for effective
treatment strategies. Fortunately, effective psychological treatments have been developed,
with cognitive behavioral therapies (CBT) considered to be a well-established treatment

CONTACT Norman B. Schmidt schmidt@psy.fsu.edu Department of Psychology, Florida State University,

Tallahassee, FL 32306-4301, USA
2016 Swedish Association for Behaviour Therapy
2 N. A. Short et al.

for these disorders (Chambless & Ollendick, 2001; Kaczkurkin & Foa, 2015). Furthermore,
a rapidly growing area in the literature is the use of technology to deliver principles of
CBT-related interventions. However, although our knowledge of effective psychotherapies
is increasing, many individuals with anxiety disorders either do not receive these effective
treatments, or fail to fully participate once they have sought such treatment (Corrigan, 2004).
Indeed, less than 50% of individuals with anxiety disorders present for treatment (Andrews,
Issakidis, Sanderson, Corry, & Lapsley, 2004). Unfortunately, populations who are vulnerable
to these disorders tend to be more affected by this imbalance between need and seeking
services. For example, veterans with a diagnosable mental illness are even less likely to seek
treatment compared to those from the general populations (35%; Milliken, Auchterlonie,
& Hoge, 2007). Furthermore, rates of anxiety disorders in veterans can be high, particular
for panic disorder (ie 8%), generalized anxiety disorder (ie 12%), and for veterans who have
been deployed (ie up to twice the rate of non-deployed veterans; Black et al., 2004a; Gros,
Frueh, & Magruder, 2011; Milanak, Gros, Magruder, Brawman-Mintzer, & Frueh, 2013).
These low rates of treatment seeking in both community individuals and veterans can be at
least partially explained by common treatment barriers: accessibility to relevant resources,
stigma, affordability, convenience, and acceptability of treatment (Andrews et al., 2004).
Acceptability is one important and under-researched area in anxiety treatment that, if
better understood and enhanced, could result in decreased treatment barriers and improved
engagement in treatment. Kazdin (2000) defined treatment acceptability as one of the many
dimensions of an effective treatment. Specifically, treatment acceptability refers to the extent
to which consumers view the treatment as pleasant, fair, reasonable, and justified. There
is a relative paucity of literature examining interventions delivered via computer or inter-
net. However, extent literature on acceptability of anxiety treatments indicates that CBT
is perceived as a durable treatment with potential advantages in patient acceptability over
other forms of treatment (Otto & Deveney, 2004). However, it may also be important to
specifically examine drop-out rates, considering that studies have shown that even though
CBT is a preferred treatment for panic disorder, 11% of individuals with panic disorder
declined treatment altogether, while another 7% dropped out (Barlow, Gorman, Shear, &
Woods, 2000). Similarly, in a sample of individuals with social anxiety disorder, 30% of
participants dropped out during group CBT (Barlow et al., 2000). Furthermore, studies have
shown that treatment dose (ie attending more sessions, not dropping out of treatment), as
well as patient engagement (ie demonstrating commitment to CBT, which may be reliant on
acceptability) are important factors in long-term treatment outcomes (Glenn et al., 2013).
Taken together, individuals typically perceive CBT to be acceptable, though drop-out rates
are not necessarily in line with perceived acceptability. Overall, as Rachman, Radomsky,
and Shafran (2008) suggest, better understanding and enhancing the acceptability of psy-
chological treatments may help reduce the risk of refusal of and dropout from treatment,
and, in turn, improve the overall outcomes of treatment (Glenn et al., 2013).
As previously discussed, one way researchers have attempted to increase the acceptability
of treatments for clients is to design computerized or Internet-based treatments, as these
may address many general barriers of psychotherapy (eg access, stigma, affordability, con-
venience; Hoge et al., 2004). The available literature on acceptability for these treatments is
promising. Indeed, systematic reviews indicate that individuals with anxiety and depres-
sion treated with a computer-based treatment report high levels of acceptability (Gun,
Titov, & Andrews, 2011). Specifically, computerized CBT treatments for major depression,
 Cognitive Behaviour Therapy 3

social phobia, panic disorder, and generalized anxiety disorder have shown high levels of
satisfaction and adherence despite the reduced amount of face-to-face contact with a cli-
nician (Andrews, Cuijpers, Craske, McEvoy, & Titov, 2010). In fact, a study examining the
acceptability of a computerized CBT treatment for obsessivecompulsive disorder found
that less than 10% of the sample reported dissatisfaction with reduced time with a clinician,
while all participants endorsed the acceptability of the computer-based treatment as a whole
(Wootton, Titov, Dear, Spence, & Kemp, 2011). Considering this, computerized anxiety
treatments may be a promising way to overcome common barriers of psychotherapy, and
improve overall treatment acceptability, particularly for populations vulnerable to these
barriers, such as veterans.
In sum, the current literature points to a need for increased investigation of the accepta-
bility of novel, effective treatments for anxiety-related conditions, particularly among vet-
erans. Further research in this area will help us to better understand potential treatment
barriers, the acceptability of computer-based treatments, and, ultimately, a better ability
to disseminate effective treatments. As such, the current study tested the acceptability of a
recently developed computerized intervention for anxiety sensitivity (AS). This intervention
is brief and focuses on a well-established risk factor for anxiety disorders (ie AS), and has
been shown to effectively reduce AS, and, in turn, anxiety symptoms, over a one-month
period (Schmidt, Capron, Raines, & Allan, 2014). Specifically, this intervention focused on
AS cognitive concerns (ie fears of cognitive dyscontrol), which are elevated not only in those
with anxiety disorders, but also those with related conditions, such as PTSD and depression
(Cox, Enns, & Taylor, 2001; Schmidt et al., 2014; Taylor et al., 2007). For the current study,
we investigated treatment acceptability among community participants and veterans using
a self-report measure of acceptability developed for the current investigation, as well as
drop-out throughout treatment as an additional measure of treatment acceptability. We were
interested in investigating whether acceptability was similar in veterans versus non-veterans,
as they may experience higher levels of stigma that may prevent them from engaging in
treatment and evaluating treatments as acceptable (Mittal et al., 2013). Additionally, drop-
out from treatment can be influenced by demographic variables (eg marital status, age, race,
and income levels; Davis, Hooke, & Page, 2006; Santana & Fontenelle, 2011), but to our
knowledge research has not yet investigated whether treatment acceptability also varies by
demographic category. As such, we examined whether acceptability scores differed across
various demographic variables.

Method
Participants
Participants were individuals recruited from the community to participate in a randomized
clinical trial examining the efficacy of a computerized intervention targeting AS, a risk factor
associated with anxiety, PTSD, substance use, and suicide (N=240; Capron & Schmidt,
2016; Schmidt et al., 2014; Schmidt et al., 2007). To be eligible for the inclusion, participants
were required to be at least 18years of age, an English speaker, and demonstrate elevated
risk for suicidality (ie elevated levels of AS cognitive concerns, perceived burdensomeness,
or thwarted belongingness; Capron et al., 2012; Van Orden et al., 2010). In the current study,
all individuals demonstrated elevated levels of AS cognitive concerns, as they were eligible
4 N. A. Short et al.

to receive the AS intervention. Exclusion criteria included evidence of a current psychotic

and/or bipolar spectrum disorder not controlled by medication, or unstable psychiatric
medication usage.
For the current study, participants were selected if they were randomized to the active AS
intervention, resulting in a sample size of 63 participants. Participants were then included
in analyses only if they completed the acceptability measure (n=58), while those who did
not complete it, due to missing their appointment or technical malfunction, were dropped.
Ages of participants ranged from 18 to 67 (M=34.84, SD=16.37). The majority of partici-
pants were single/never married (63.5%), while others reported being divorced or separated
(19.0%), married or cohabitating (15.9%), or other (eg widowed; 1.6%). In terms of race,
participants identified as White/Caucasian (57.1%), Black/African-American (25.4%), and
other (eg more than one race, 16.5%). Approximately a third of participants were veterans
(27.0%). Of the veterans who reported details regarding their combat history (52.9%),
44.4% were deployed at some point in their service (conflicts indicated were Desert Storm
[22.2%], Gulf War [11.1%], and Operation Iraqi Freedom/Operation Enduring Freedom
[11.1%]), and most were in the Army (88.8%), followed by the Navy (11.1%). The majority
of participants met criteria for at least one psychiatric diagnosis (87.3%), with an average of
2.03 diagnoses. Specifically, 71.4% met criteria for at least one anxiety disorder, 44.4% for
a depressive disorder (eg major depressive disorder, persistent depressive disorder), 22.2%
for posttraumatic stress disorder, and 4.8% for a substance use disorder.

Procedure
Participants were recruited from the local community through various media outlets,
including newspaper advertisements, flyers, and social media postings discussing a new
study for anxiety, depression, suicide, and veterans. Interested participants called the lab-
oratory and completed a brief telephone screen to determine initial eligibility. Those who
were deemed potentially eligible were scheduled for a baseline appointment, during which
participants completed a diagnostic interview (Structured Clinical Interview for DSM-5;
SCID), and a battery of self-report measures. Participants were then randomized to one of
four conditions: an AS intervention, mood intervention, combined AS and mood interven-
tion, and a repeated contact control. Intervention sessions occurred once a week over three
weeks, and participants were then periodically followed up with over a six-month period.
All active interventions were computerized, and participants were not recruited based on
their interest in computerized interventions. Participants responded to a self-report measure
of acceptability following their first intervention session. Participants were paid after each
appointment in increments depending on the length ($25$75). All appointments took
place within the laboratory. All participants provided written informed consent and all
study procedures were approved by the universitys institutional review board.

Condition
All participants in the current study completed the active AS intervention. Participants
returned to the laboratory to complete the interventions once a week over three weeks.
During their first session, individuals participated in the Cognitive Anxiety Sensitivity
Treatment (CAST). CAST is a computerized intervention involving audio, video, and inter-
active features. The intervention provides psychoeducation regarding the nature of anxiety
 Cognitive Behaviour Therapy 5

and its physiological effects, and is designed to dispel maladaptive beliefs regarding the
threat associated with physiological arousal associated with anxiety. In addition, individuals
participate in a hyperventilation interoceptive exposure (IE) exercise and learn four other
examples of IE exercises that they are encouraged to try on their own. The intervention lasts
approximately 45min. The CAST intervention is only administered once, during the first
appointment. For more details regarding this intervention, please see Schmidt et al. (2014).
Next, participants completed a computerized cognitive bias modification intervention
designed to target AS-related interpretation biases. Specifically, participants were asked
to view pairings of an ambiguous word/phrase (eg chest pain) followed by either a neu-
tral phrase (I might have indigestion), or a negative one (Im having a heart attack).
Participants judged the relatedness of the word/phrase and the sentence, and were given
feedback regarding whether their response was correct or incorrect. Participants were
trained to judge the negative combinations to be unrelated and the neutral/positive com-
binations to be related. The interpretation bias modification component of the treatment
took approximately 1520min per session, and participants completed it a total of three
times across the three intervention sessions (once per session).

Measures
Structured clinical interview for DSM-5research version (SCID-5-RV)
All participants were interviewed using the SCID-5-RV to evaluate diagnostic status (First,
Williams, Karg, & Spitzer, 2015). SCIDs were administered by trained clinical psychology
graduate students who completed extensive training in SCID administration and scoring.
Training included reviewing SCID training tapes, observing live SCID administrations,
and conducting practice interviews with other trained individuals. Feedback was provided
throughout the training process until individuals demonstrated high levels of reliability.
Additionally, all SCIDs were reviewed by a licensed clinical psychologist to confirm accurate
diagnoses. SCIDs were used to provide data on specific diagnoses, meeting criteria for a
current anxiety or depressive diagnosis, and the number of current diagnoses (out of all
possible diagnoses in the SCID).

Demographics
Participants completed a demographics measure used in and designed for the current
study. Participants identified their sex (1=Male, 2=Female), race (1=Caucasian/White,
2=African-American/Black, 3=Asian, 4=Pacific Islander, 5=American Indian/Native
American, and 6=Other; in the current study, participants only consistent of White, Black,
and those who reported as Other). However, the current sample only included those who
endorsed White, Black, and other. Next, participants reported their age, veteran status
(0=Not a veteran, 1=Veteran), education level (1=Less than high school, 2=High school
or equivalent, 3=Non-college business/trade/technical certificate, 4=Some college/Two-
year degree [AA], 5=Four-year college degree [BA, BS], 5=Graduate school or higher
[MA, MS, JD, PhD, MBA]), annual family income (1=Less than $10,000, 2=$10,000
$25,000, 3=$25,000$40,000, 4=$40,000$75,000, 5=$75,000$100,000, 6=$100,000
$150,000, and 7 = >$150,000), and marital status (1=Married, 2=Single, 3=Cohabitating,
4=Separated, 5=Divorced, 6=Widowed, 7=Other; consistent with prior studies, we
combined married and cohabitating, and separated/divorced; eg Alim et al., 2006).
6 N. A. Short et al.

Acceptability
Treatment acceptability was measured using an 11-item self-report measure designed for
the current study. Participants responded to nine items (eg Did you find the presentation
easy to understand? Do you think the information in the presentation was helpful? Do you
feel the information in the presentation is applicable to your daily life?) on a four-point
Likert-type scale (0=no; 1=somewhat; 2=moderately; 3=yes). Additionally, participants
responded to two free-response items asking for suggestions for improving the treatment,
and any additional comments. Items 19 were summed to create a total acceptability score.
Acceptability scores were missing for 2% of participants. This measure demonstrated good
internal consistency (=.80).

AS index3 (ASI-3)
AS was measured using the ASI-3, an 18-item self-report measure assessing feared conse-
quences of symptoms associated with anxious arousal (Reiss, Peterson, Gursky, & McNally,
1986; Taylor et al., 2007). Participants responded to each item on a five-point Likert-type
scale. The total score was used in the current study as an overall measure of AS. Previous
research has demonstrated that the ASI-3 has good psychometric properties (Taylor et
al., 2007). Consistent with this, the ASI-3 evidenced excellent internal consistency in the
current study (=.94).

Beck depression inventory2nd edition (BDI-II)

Depressive symptoms were assessed using the BDI-II, a 21-item self-report measure (Beck,
Steer, & Carbin, 1988). Respondents read a group of statements and selected the one that
best described how they have felt over the past 2 weeks. The BDI-II is scored using a
four-point Likert-type scale ranging from 0 to 3, with higher scores reflecting more severe
depressive symptoms. The BDI-II has demonstrated strong internal consistency and good
testretest reliability (Beck et al., 1988). Internal consistency in the present sample was
excellent (=.95).

Beck anxiety inventory (BAI)

Participants completed the BAI, a 21-item self-report measure, to assess anxiety symptoms
(Beck & Steer, 1993). Participants responded to how often they had experienced various anx-
iety symptoms on a four-point Likert-type scale. The BAI has well-established psychometric
properties and demonstrated excellent internal consistent in the current study (=.92).

Beck scale for suicidal ideation (BSS)

The BSS is a 21-item questionnaire that was used to measure levels of suicidality and included
items related to suicidal ideation, plans and preparations, and past attempts (Beck, Kovacs,
& Weissman, 1979). Prior research has indicated that the BSS has good psychometric prop-
erties across multiple populations (Beck et al., 1979). In the current investigation, internal
consistency was excellent (=.93).

PTSD checklistCivilian version (PCL-C)

The PCL-C is a 17-item questionnaire in which respondents indicate presence and severity
of posttraumatic stress symptoms, derived from the DSM-IV symptoms for posttraumatic
stress (Weathers, Litz, Herman, Huska, & Keane, 1993). We used the total score as a measure
 Cognitive Behaviour Therapy 7

of overall PTSD symptoms in the current study. The PCL-C has well-established psycho-
metric properties (Weathers et al., 1993), and demonstrated excellent internal consistency
in the current study (=.95).

Results
Descriptive statistics
Means, standard deviations, and zero-order correlations are presented in Table 1. Regarding
means of clinical variables, AS scores were in the high range (Allan, Capron, Raines, &
Schmidt, 2014), anxiety and depressive symptoms were in the moderate range (Beck &
Steer, 1993; Beck et al., 1988), PTSD symptoms were in the clinical range (Blanchard, Jones-
Alexander, Buckley, & Forneris, 1996), while suicidality scores were not in the clinical range
(Beck et al., 1979). Frequencies of endorsing each possible response are reported in Table 2.

Primary analyses
Overall, the majority of participants rated the intervention as at least moderately easy to
follow (85.7%) and helpful (72.9%). Additionally, most participants reported the infor-
mation was at least somewhat applicable to their daily lives (69.9%), with the majority of
veterans reporting the intervention was applicable to stressors experienced during their
service (93.3%). Most participants reported they were at least somewhat engaged (77.7%)
and interested (79.3%) during the presentation. Finally, over half of participants indicated
they would be at least somewhat likely to recommend this treatment to a friend struggling
with similar problems (60.0%).
To test the association between acceptability scores and demographic/clinical variables
of interest, correlations were used for continuous demographic/clinical measures (Table 1)
and ANOVAs were used for categorical demographic/clinical variables (Table 3). Specifically,
regarding correlations, higher acceptability scores were significantly associated with older
age (r=.28, p<.05) and lower income levels (r=.36, p<.01). No other continuous var-
iables were significantly associated with acceptability scores.
In terms of categorical variables, acceptability scores were higher for veterans versus
non-veterans (F (1,57) = 6.44, p=.014). Acceptability also differed across marital status (F
(2, 56) = 4.93, p=.011), with separated/divorced individuals scoring significantly higher
than married/cohabitating individuals. Acceptability differed across race (F (3, 55) = 3.96,
p=.013), with Black/African-American participants scoring higher than White or other
individuals. No other categorical variables were significantly associated with acceptability
scores.

Additional analyses
Attrition rates
As an additional measure of treatment acceptability, we examined attrition during the
intervention period, over the 3weeks of treatment. Three participants dropped out of the
study during the intervention period (4.7%).
 8

Table 1.Zero-order correlations between acceptability total score and continuous demographic/symptom variables.
N. A. Short et al.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
1 Acceptability
2 Sex .16
3 Race .02 .35
4 Age .28* .34** .06
5 Veteran .32* .56*** .09 .64***
6 Education .20 .29* .07 .01 .17
7 Income .36** .19 .17 .40** .38** .18
8 Marital status .46*** .18 .08 .44*** .40** .15 .35**
9 Diagnoses count .15 .12 .00 .44*** .40** .15 .35** .20
10 Depressive disorder .24 .13 .08 .13 .18 .05 .25* .27* .42*
11 Anxiety disorder .03 .09 .01 .08 .17 .11 .09 .16 .53*** .07
12 Anxiety sensitivity .22 .05 .00 .08 .07 .22 .12 .15 .35** .36** .26*
13 BDI-II .12 .08 .16 .06 .06 .20 .11 .18 .33** .47*** .20 .48***
14 BAI .20 .04 .15 .07 .01 .36** .20 .12 .35** .47*** .20 .49*** .51***
15 BSS .10 .20 .05 .04 .16 .28* .11 .04 .02 .19 .06 .32* .51*** .19
16 PTSD symptoms .11 .03 .20 .01 .20 .20 .13 .19 .48*** .38** .29* .46*** .69** .53*** .33**
Mean/% 19.36 1.57 34.84 .27 2.03 .44 .71 32.32 21.81 19.29 2.17 45.74
(SD)/(n) (5.02) (.50) (16.37) (.45) (1.64) (.50) (.46) (17.57) (12.53) (12.41) (4.90) (17.39)
Note: n=58, For sex, 1=male, 2=female. For veteran status, 0=non-veteran, 1=veteran. BDI-II=Beck Depression Inventory2nd Edition, BAI=Beck Anxiety Inventory, PTSD=Posttraumatic
Stress Disorder, BSS=Beck Scale for Suicidal Ideation. Depressive and anxiety disorder indicates meeting criteria for a current depressive or anxiety disorder according to the Structured Clinical
Interview for DSM-5.
*=p<.05; **=p<.01; ***=p<.001.
 Cognitive Behaviour Therapy 9

Table 2.Frequencies of responses to acceptability items.

Responses % (n)
Did you find the presentation easy to understand?
No 0% (0)
Somewhat 5.2% (4)
Moderately 6.9% (3)
Yes 87.9% (51)
Did you find the presentation easy to follow?
No 1.7% (1)
Somewhat 5.2% (3)
Moderately 13.8% (8)
Yes 79.3% (46)
Do you think the information in the presentation was helpful?
No 3.5% (2)
Somewhat 17.2% (10)
Moderately 17.2% (10)
Yes 62.1% (36)
How likely are you to use the information and techniques you learned in the presentation?
Unlikely 6.9% (4)
A little likely 17.2% (10)
Somewhat likely 32.8% (19)
Very likely 43.1% (25)
How applicable do you feel the information in the presentation is to your daily life?
Not applicable 5.1% (3)
A little applicable 18.9% (11)
Somewhat applicable 32.8% (19)
Very applicable 43.1% (25)
If you are in the military, did you find the information in the presentation to be applicable to the stressors you encountered
during your time in the service?*
Not applicable 6.6% (1)
A little applicable 0% (0)
Somewhat applicable 33.4% (5)
Very applicable 60% (9)
How engaged were you during the presentation?
Not engaged 5.2% (3)
A little engaged 10.3% (6)
Somewhat engaged 36.2% (21)
Very engaged 48.3% (28)
How interested were you throughout the presentation?
Not interested 3.5% (2)
A little interested 10.3% (6)
Somewhat interested 37.9% (22)
Very interested 48.3% (28)
How likely are you to recommend this presentation to a friend?
Not likely 15.5% (9)
A little likely 18.9% (11)
Somewhat likely 29.4% (17)
Very likely 36.2% (21)
Note: n=58.
*Only responses from veterans were used when calculating frequencies.

Qualitative reports
Finally, we examined participants responses to the open-ended items on the survey. Of
those who completed the acceptability measure, 72% chose to respond to at least one of
these items. Based on initial readings of the items identifying common themes, responses
were coded by the first author. Many of these individuals spontaneously reported that the
10 N. A. Short et al.

Table 3. ANOVA omnibus tests and contrasts comparing acceptability total score across categorical
demographic and diagnostic variables.
Acceptability mean
Veteran status* F (1,57) = 6.44, p = .014
Not a Veteran 18.42
Veteran 22.07
Sex F (1, 57) = 1.48, p = .228
Male 20.28
Female 18.67
Marital status* F (2, 56) = 4.93, p = .011
Single/never married 18.67
Married/cohabitating 17.20*
Separated/divorced 23.09*
Race* F (3, 55) = 3.96, p = .013
White 18.12*
Black 22.64*
Other 18.20*
Depressive diagnosis F (1, 57) = 3.27, p = .076
None 18.23
1 20.57
Anxiety diagnosis F (1, 57) = .05, p = .833
None 19.60
1 19.28
Note: n=58.
*p<.05.

intervention was good or helpful (26.0%), with comments such as the presentation was
very helpful to me, good tips, surely broke some myths, and I liked the visual exercise
with the words, I think that helps, get used to associate positive facts to bodily sensations and
to reject negative ideas and myths that just increase the stress. Participants also responded
with ways to improve the treatment, such as making it more interactive (24.8%), and giving
more coping strategies (11.9%, eg techniques for how to deal with stressful thoughts,
breathing exercises).

Discussion
Overall, the current findings indicate that a brief, computerized intervention focusing on AS
was considered to be an acceptable treatment for the majority of participants. This is consist-
ent with prior research on cognitive behavioral interventions in general, with reviews of CBT
for anxiety disorders concluding that CBT is acceptable to most patients (Otto & Deveney,
2004). Additionally, findings are consistent with research indicating that Internet-based and
computerized treatments are considered acceptable treatments for anxiety and depression
(Gun et al., 2011). Participants self-reported ratings of acceptability were complemented
by examining drop-out rate throughout the treatment phase of the study. The low drop-out
rate in the current study serves as an additional measure of acceptability, and also suggests
that participants found the intervention to be tolerable. The level of drop-out found in the
current study is consistent with meta-analytic reviews of drop-out during traditional CBT,
but may be somewhat lower than for traditional CBT (519%; Otto & Deveney, 2004).
To better understand treatment acceptability and how it may vary between different
groups of individuals, we examined whether acceptability ratings differed by demographic
variables. Overall, acceptability was consistent across groups, with few differences based on
demographics. However, some differences in acceptability emerged across age, race, income
 Cognitive Behaviour Therapy 11

levels, and relationship status. Specifically, we found higher levels of acceptability among
older adults, African-Americans, those with lower income, and those who were not in a
committed relationship. Some of these findings are inconsistent with previous research on
traditional CBT. For example, a review of CBT for anxiety disorders found that older aged,
minority, and lower income individuals were more likely to discontinue treatment (Santana
& Fontenelle, 2011). As such, our findings are promising, considering that this intervention
was rated as more acceptable to groups who may be difficult to reach through other, more
traditional forms of treatment.
Additionally, we found that veterans rated the treatment as more acceptable than non-
veterans. To our knowledge, there is a lack of clinical trials of CBT including both veterans
and non-veterans, which would enable an examination of differences between these two
groups on acceptability. As such, this finding is novel and is difficult to compare to prior
research. However, many studies have specifically examined treatment acceptability among
veterans, and found that veterans rate cognitive behavioral treatments such as prolonged
exposure (PE; Foa, Hembree, & Rothbaum, 2007) as acceptable treatments (Kehle-Forbes,
Polusny, Erbes, & Gerould, 2014). Despite this, it has been noted that veterans face several
obstacles in seeking treatment (Mittal et al., 2013), such as stigma, lack of time, and nega-
tive perceptions about treatments, suggesting an increased need for examining treatment
acceptability in this population.
Finally, we compared measures of acceptability based on clinical variables. Surprisingly,
treatment acceptability did not differ based on symptom severity, number of diagnoses,
type of symptoms, or suicidality. This is promising as it suggests that this treatment may
be acceptable across transdiagnostic categories and severity levels. In terms of previous
research, these results are somewhat inconsistent with meta-analyses of dropout rates across
diagnostic categories, which suggest that, of those with anxiety disorders, individuals with
PTSD are the most likely to drop-out of treatment, while those with panic disorder are the
least likely to do so (Otto & Deveney, 2004). However, in our sample, PTSD symptoms
were not associated with decreased levels of treatment acceptability. Additionally, some
studies have found that general symptom severity impacts acceptability, with some par-
ticipants reporting their symptoms may be too severe for a computer-based treatment
(egWootton et al., 2011); however, an association between severity (ie by symptoms or num-
ber of comorbid diagnoses) and acceptability was not found in our sample. Taken together,
the AS-focused intervention was deemed to be acceptable by participants demonstrating a
variety of anxiety and mood symptom types and severity levels.
The current study has several clinical implications. First, acceptability ratings were
comparable to traditional CBT, suggesting that this computerized intervention would be a
viable clinical alternative to traditional CBT for individuals who either do not have access
to traditional CBT or are not interested in participating in such treatments. Second, the
current study suggests that this could be an appropriate first step intervention in a stepped-
care treatment model (Bower & Gilbody, 2005), as the high acceptability demonstrates
this intervention would be unlikely to deter clients from progressing to the next treatment
step if necessary. Third, as the current study showed higher acceptability among certain
populations that find traditional CBT to be less acceptable (eg older adults, lower income
individuals), it is possible that using this treatment in a clinical setting could help to reduce
treatment dropout among those populations. Fourth, our analysis of qualitative data was not
based on empirically and theoretically recommended techniques. Considering this was only
12 N. A. Short et al.

a small goal of the study and that our questions were very open-ended and broad, this was
a reasonable first step. However, future studies should consider using more advanced tech-
niques, such as the grounded theory approach (Corbin & Strauss, 2014). Finally, considering
that prior research has suggested AS interventions may be a brief, portable, and inexpen-
sive method for reducing risk for and experience of anxiety-related symptoms (Keough &
Schmidt, 2012; Schmidt et al., 2014; Schmidt et al., 2007); however, the effectiveness of an
intervention is irrelevant if consumers are unwilling to utilize it. Thus, we believe this study
is an important next step in the literature as potential consumers must find an intervention
to be acceptable, tolerable, and related to their current functioning or perceived problems
in order for them to be motivated to engage with it (Kazdin, 2000).
Though these results are promising, the current study should be considered in the context
of several limitations. First, the use of a non-standard measure of treatment acceptability
makes it difficult to directly compare the results of this study with some prior acceptability
studies. However, as this measure was specifically designed to assess characteristics relevant
to this intervention, it provided valuable feedback for this specific intervention. Along these
lines, future work should attempt to incorporate participant feedback, such as making the
intervention more interactive or providing more coping tools, to increase acceptability.
However, considering this measure is not a standard measure of treatment acceptability,
it is imperative for future research to either validate this measure or to further investigate
acceptability of this treatment using a standard measure of acceptability. Similarly, the lack of
a direct comparison group makes it more difficult to put these acceptability ratings in context
of other treatments. Future studies should investigate in a repeated measures design how
the acceptability of this intervention compares to other brief, computerized interventions.
Despite these limitations, the current study takes an important step in establishing the
acceptability of a brief, computerized treatment for anxiety pathology that has already
demonstrated efficacy in reducing anxiety symptoms (Schmidt et al., 2014). Improving the
dissemination of these treatments is crucial to reducing the public health burden associated
with anxiety pathology. Future research must attend to improving patient acceptability as this
is a critical component to increasing engagement in, and completion of, these treatments.

Disclosure statement
The authors have no conflicts of interest to disclose.

Funding
This work was in part supported by the Military Suicide Research Consortium (MSRC) [grant number
W81XWH-10-2-0181], Department of Defense, and VISN 19 Mental Illness Research, Education,
and Clinical Center (MIRECC), but does not necessarily represent the views of the Department of
Defense, Department of Veterans Affairs, or the United States Government. Support from the MSRC
does not necessarily constitute or imply endorsement, sponsorship, or favoring of the study design,
analysis, or recommendations.

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