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Debate continues about the extent to which postulated mechanisms of action of cognitive behavior therapies (CBT), including standard CBT (i.e., Beckian cognitive therapy [CT]) and acceptance and commitment therapy (ACT) are supported by mediational analyses. Moreover, the distinctiveness of CT and ACT has been called into question. One contributor to ongoing uncertainty in this arena is the lack of time-varying process data. In this study, 174 patients presenting to a university clinic with anxiety or depression who had been randomly assigned to receive either ACT or CT completed an assessment of theorized mediators and outcomes before each session. Hierarchical linear modeling of session-by-session data revealed that increased utilization of cognitive and affective change strategies relative to utilization of psychological acceptance strategies mediated outcome for CT, whereas for ACT the mediation effect was in the opposite direction. Decreases in self-reported dysfunctional thinking, cognitive "defusion" (the ability to see one's thoughts as mental events rather than necessarily as representations of reality), and willingness to engage in behavioral activity despite unpleasant thoughts or emotions were equivalent mediators across treatments. These results have potential implications for the theoretical arguments behind, and distinctiveness of, CT and ACT.

Over 80% of people with social anxiety disorder (SAD) do not receive any type of treatment, despite the existence of effective evidence-based treatments. Barriers to treatment include lack of trained therapists (particularly in nonmetropolitan areas), logistical difficulties (e.g., cost, time, transportation), concerns regarding social stigma, and fear of negative evaluation from health care providers. Interventions conducted through electronic communication media, such as the Internet, have the potential to reach individuals who otherwise would not have access to evidence-based treatments. Second Life is an online virtual world that holds great promise in the widespread delivery of evidence-based treatments. We assessed the feasibility, acceptability, and initial efficacy of an acceptance-based behavior therapy in Second Life to treat adults with generalized SAD. Participants (n=14) received 12 sessions of weekly therapy and were assessed at pretreatment, midtreatment, posttreatment, and follow-up. Participants and therapists rated the treatment program as acceptable and feasible, despite frequently encountered technical difficulties. Analyses showed significant pretreatment to follow-up improvements in social anxiety symptoms, depression, disability, and quality of life, with effect sizes comparable to previously published results of studies delivering in-person cognitive behavior therapy for SAD. Implications and future directions are discussed.