Feasibility Study of Acceptance Commitment Group Therapy on Social Anxiety

Symptom Reduction in Low Self-Esteem College Students

Fadhilah Eryanandaa* and Imelda Ika Dian Orizab

a
Faculty of Psychology, Universitas Indonesia, Depok, Indonesia; b Department of Clinical
Psychology, Faculty of Psychology, Universitas Indonesia, Depok, Indonesia

*Corresponding Author:
Fadhilah Eryananda
Faculty of Psychology, Universitas Indonesia
Jl. Lkr. Kampus Raya, Depok, Jawa Barat
Indonesia, 16424
Tel.: +62 217270004
e-mail address: fadhilah.erynd@gmail.com
Feasibility Study of Acceptance Commitment Group Therapy on Social Anxiety
Symptom Reduction on Low Self-Esteem College Students

Backgrounds. Social anxiety disorder is a mental disorder that is quite disturbing for college
students because the impact on performance is not only related to social but also academic.
Social anxiety levels in college students are related to problems in social abilities, difficulty
maintaining attention, and learning. Furthermore, individuals with social anxiety disorder
display hypersensitivity to processes related to self-assessment and dependence on social
approval as a form of low self- esteem. Students who have social anxiety disorder feel afraid
that they will embarrass themselves or be embarrassed in social situations and being in that
situation can increase anxiety which significantly interferes with functions in daily tasks and
activities. There is a significant influence of anxiety disorders on failure to complete school
thereby increasing the risk of failure in examinations and failure in graduation. Social anxiety
can occur because individuals attached to thoughts about fear of being embarrassed or
humiliated and chose to avoid the situation. In this study, we would like to examine the
feasibility of Acceptance Commitment Therapy (ACT) to reduce social anxiety and increase
self-esteem. ACT is a type of intervention based on full awareness of the present moment
(mindfulness), acceptance and values. Based on ACT's perspective, anxiety disorders develop
if individuals are very involved with cognitive activity to reduce or eliminate their
experiences related to anxiety. The assumption of the ACT approach to psychological
disorders is when there is rejection or avoidance of the unwanted internal experiences. This
internal experience is prevented and detained, and the inability to give way to experience
leads to the emergence of psychological vulnerabilities such as anxiety disorders. Handling
anxiety using ACT intervention does not aim to directly reduce individual anxiety but rather
help individuals to live in harmony with values without considering anxiety. This goal is
fulfilled through the six main processes of ACT namely acceptance, defusion, self-as-a-
context, contact with moments, values and behavioral committed exercise
Methods. The study uses a quasi-experimental one-group, pretest and post-test design and
involved four participants who were willing to follow the entire intervention process. The
intervention consisted of six sessions, including pre-test and post-test sessions with duration
of 120 minutes for each session. Participants consisted of three female and one male who
were undergraduate students aged 19-22 years who had problems related to social anxiety
measured by the Liebowitz Social Anxiety Scale (LSAS) score and had low self-esteem
measured by the Rosenberg Self Esteem Scale (RSES) score. The post-test session was
conducted to see the impact of the intervention. Qualitative measurements were also carried
out using unstandardized non-structured interviews before and after the intervention.
Quantitative data were analyzed using the Wilcoxon Signed Rank Test.
Results. The results of the study showed that there was a decrease in general social anxiety
(Z = -.1.826; p = 0.068) where the average decrease on the avoidance scale was higher than
the fear scale. Correspondingly, the self-esteem score also increased (Z = -.1.826; p = 0.068).
This big size effect size (r> 0.05) showed that group intervention with the ACT approach had
the potential to reduce social anxiety. The participants' median score on social anxiety
decreased and self-esteem measurements increased as well, even though the results were not
significant. However, participants reported that they were more able to accept the feelings of
anxiety they had and chose to carry out activities in accordance with the values they had.
Conclusions. Although the results were not significant to reduce social anxiety and increase
self-esteem, all the participants reported they could accept anxiety as a part of themselves and
chose to behave according to their values through ACT’s skills. The ACT is helped
individuals eliminate their need for avoidance through a process of mindfulness, being in the
present, and better acceptance and commitment. ACT also able to encourage the capacity of
individuals to realize that thoughts and feelings are part of the minds and are not facts about
themselves.
Added-values. Previous research has focused on behavioral and cognitive therapy in
reducing social anxiety disorder, but some results say that there is no significant impact of
change. So, researchers are interested in providing ACT as a new intervention approach that
helps participants to deal with thoughts and emotions that caused social anxiety.

Keywords: Acceptance Commitment Therapy (ACT); self-esteem; social anxiety

Introduction
Social anxiety disorder (SAD) is a common anxiety disorder characterized by excessive
anxiety in various social situations. In general, this anxiety begins during adolescents when
communication with others in a group of friends increases. On average, this disorder initially
appears at the age of 16-18 years and it is estimated that 8-13% of the total population suffer
from this social anxiety disorder (National Collaborating Center for Mental Health, 2013).

Social anxiety disorder is a mental disorder that is quite disturbing for students because the
impact on performance is not only related to social but also academic life. Bernstein et al.
(2007 in Russel & Topham, 2012) found that the severity of social anxiety levels in college
students was related to problems in social abilities, maintaining attention difficulties and
learning difficulties. The research of Amerigen and colleagues (2003 in Russell & Topham,
2012) also found that the proportion of individuals with anxiety disorders was reported to
drop out of school because of the anxiety they had. Other studies from Stein and Kean (2000
in Russell & Topham, 2012) also found a significant influence of anxiety disorders on failure
to complete school thereby increasing the risk of failure in examinations and failure in
graduation (Wittchen, et al., 1999 in Russell & Topham , 2012).

In college students, the support from others is one thing that is considered important. Support
from others in the form of social approval is highly correlated with self-esteem (Harter,
Stocker, & Robinson, 1996 in Nordstrom, Goguen & Hiester, 2014). Individuals with social
anxiety disorder display hypersensitivity to processes related to self-assessment and
dependence on social approval (Leary, 2001 in Nordstrom, Goguen & Hiester, 2014). This is
supported by research performed in higher education setting where it found students who
have high social anxiety report lower levels of self-esteem compared to students with low
social anxiety (Stopa, Brown, Luke & Hirsch, 2010). Furthermore, Kocovski and Endler
(2000) found that college students with low self-esteem reported higher fear of negative
assessment, which were predictors of social anxiety disorder.

As college students, many assignments must be delivered in front of the class in the form of
presentations. Students who have social anxiety disorder feel afraid that they will embarrass
themselves or be embarrassed in social situations or while working and being in those
situations can increase anxiety that significantly interferes with functions in daily tasks and
activities (Nordstrom, Goguen & Hiester, 2014) . Although in general students realize that
the fear that they felt does not make sense, but they still avoid the situation. The impact, they
will have difficulty in undergoing classes and lectures as a whole.

Those conditions encourage facilitators to design interventions that can reduce social anxiety
symptoms and increase self-esteem in students. Previously, there were many interventions
that developed to overcome social anxiety disorders such as behavioral and cognitive therapy.
However, many modern psychologists believe that traditional behavioral therapy does not
produce a significant change effect so that better methods are needed specifically in dealing
with thoughts and emotions, on the other hand, the main concept of cognitive behavioral
therapy-based interventions that claim cognitive changes are needed for clinical change have
not been well-verified (Hayes et al., 2003). For the purpose of developing, refining and
providing stronger theoretical alternatives in cognitive behavioral therapy-based
interventions, clinical researchers have shown an increasing interest in mindfulness-based
interventions and acceptance of psychological disorders.

Acceptance commitment therapy (ACT) is a type of intervention based on mindfulness

(awareness on things happening in the moment), acceptance and values that are the basis of
traditional cognitive behavioral based interventions (Hayes, et al., 2003). ACT has been
found to be effective in treating anxiety among clinical and non-clinical populations and has
been proven effective in individual and group therapy (Swain, et al., 2013 in Rahmani, &
Rahmani., 2015). Based on ACT's perspective, anxiety disorders develop if the individual is
very involved with cognitive activity to reduce or eliminate his experiences related to anxiety
(Orsillo Roemer, & Holowka, 2005 in Rahmani, & Rahmani., 2015). The assumption of the
ACT approach to psychological disorders is when there is rejection or avoidance of the
deepest emotions (such as thoughts, memories and sensations). This internal experience is
prevented and detained and the inability to give way to experience leads to the emergence of
psychological vulnerabilities such as anxiety disorders (Mennin, 2005 Rahmani, & Rahmani.,
2015). Handling anxiety using ACT intervention, does not aim to directly reduce individual
anxiety but rather helps individuals to live in harmony with values without considering
anxiety. This goal is fulfilled through the six main processes of ACT namely acceptance,
defusion, self as-a-context, contact with moments, values and behavioral committed exercise
(Twohig et al., 2005 Rahmani, & Rahmani., 2015).

Based on the description above, the research problem for this study is "Will the application of
ACT group therapy reduce the social anxiety symptoms and increase self-esteem in college
students with social anxiety problems?” The hypothesis of this study is that the application of
ACT in groups can reduce the social anxiety symptoms and increase self-esteem in college
students who have social anxiety problems. Furthermore, it is expected that ACT can help
participants to accept thoughts or experiences related to anxiety as part of themselves and
choose to do something in line with their values. Therefore, the purpose of this study is to
determine whether the application of ACT group therapy can reduce the social anxiety
symptoms and increase self-esteem in college students who have social anxiety problems?

Methods
Participants
Recruitment of participants was performed openly by spreading information related to the
implementation of the therapy and the required participant criteria. Criteria for participants in
this study were college students and having problems related to social anxiety. The problem
of social anxiety is characterized by above 30 Liebowitz Social Anxiety Scale (LSAS) score
(Mennin, Fresco, Heimberg, Schneiner, Davies, Liebowitz, 2002). Prospective participants
according to the criteria filled out an online form. The form contained questions related to
personal information, schedule availability and LSAS.

Open recruitment was held for one month and there were 24 participants who registered. Of
the 24 participants there were only 11 college students who met the criteria. Of the 13
potential participants remaining, there are only 5 participants who were willing to follow the
intervention according to a predetermined schedule. Of the five participants who expressed
their willingness, only 4 participants attended the precession and stayed in the entire
intervention session.

Research Design
The study used a quasi-experimental method with one group pre-post test design, where there
was only one intervention group received group intervention using acceptance-commitment
therapy. To evaluate the impact of applying interventions on participants' social anxiety
symptom and self-esteem, the researchers conducted quantitative and qualitative
measurements before and after the intervention was given. Quantitative measurements of
social anxiety symptoms were carried out using The Liebowitz Social Anxiety Scale (LSAS,
Liebowitz, 1987). LSAS consists of 24 items that will measure the level of fear and
avoidance in various social situations. While the measurement of self-esteem level use the
Rosenberg Self Esteem Scale (Rosenberg, et al., 1995). RSES consists of 10 items and is a
unidimensional measurement tool that measures global self-esteem (Bryne, in Schmitt &
Allik, 2005). In addition, qualitative measurements were also carried out using unstructured
interviews for each participant.

Procedure
There were two stages carried out in this study, namely the preparation stage and the
implementation stage. During the preparation stage, a literature study and phenomenon study
were conducted. After knowing the problems, the target participants and the intervention
techniques to be used, then the participants were recruited. Parallel with that, the researchers
modified the modules from Kocovski, Fleming and Rector (2009) and prepared all the
components for implementing interventions such as PowerPoint, logbooks for participants
and room to be used. After all components were complete, the study continued to the
implementation stage.

The interventions were carried out in 6 sessions divided into 1 session of pretest and
introduction, 4 sessions of material, 1 session of post test and evaluation with a duration of
120 minutes for each session. The time span of each session is one week (except for pre-test
and post-test sessions), namely on 22, 23, 30 July, 6, 13, 14 August. The interventions were
carried out at Room B110, 1st Floor, Building B, Faculty of Psychology, University of
Indonesia.

This group intervention was based on the modification of the Mindfulness and Acceptance
based Group Therapy for Social Anxiety Disorder: A treatment Manual Second Edition
module of Kocovski and Fleming (2014). Modifications were made related to the number of
sessions and material provided at each session. Based on the module in the Kocovski and
Fleming (2014) Manual the interventions were conducted in 10 sessions with sessions related
to training in the context of Taking VITAL Action made into four sessions. While in the
implementation of interventions in the participants of this study, VITAL action was discussed
in one session and other exercises were made in the form of homework assignments to be
discussed in the next session. Changes in the number of sessions were done to consider the
characteristics and schedule of participants. The modifications and adjustments in ACT
design for students with social anxiety problems can be found in Table 1.
Table 1.
ACT Modul for College Student with Social Anxiety
Session Objective
Pre-session Participants know each other in group members
Introduction of participants and explore issues Participants shared the conditions they
related to social anxiety, introduce the term of experienced related to social anxiety problems
social anxiety and a general explanation of ACT Participants know the term of social anxiety
therapy Participants know the general description of ACT
therapy

Session 1 Participants know the concept of safety mode

Identification of safety mode and the impact of Participants can identify the safety mode
performing safety mode performed
Participants can identify the impact they feel
from performing safety mode

Session 2 Participants can identify fusion

Identification of fusion and know the strategy for Participants understand the concept of acceptance
defusion of anxiety
Participants can do defusion

Session 3 Participants can practice mindfulness

Identification of values and goals and do Participants know the values and goals they have
mindfulness exercises

Session 4 Participants know the concept of VITAL Mode

Learn how to apply VITAL mode in daily life Participants practice "get to know conversation"

Post-session Therapist and participants can see the changes

Conduct a post-test and determine the long-term and growth in participants by sharing about
goals conditions before and after following the
interventions
Therapists and participants determine the long-
term goals and steps to be taken.

Data Analysis
Data analysis in this study used the qualitative and quantitative methods. Each participant
was measured qualitatively by the interview method before and after the intervention related
to the problem of social anxiety and self-esteem. Before the intervention began, researchers
conducted interviews about the problem of social anxiety, studied the problem and the impact
obtained due to the problem. After the intervention, we asked the participants to fill out the
final evaluation form and participate in a group discussion about the progress they made
during the intervention.

In addition, data analysis quantitatively was carried out. Quantitative analysis was carried out
to see the significance of the impact of the intervention on participants' social anxiety
symptoms and self-esteem. For that purpose, we compared each participant's social anxiety
and self-esteem score before and after the intervention. We used the Wilcoxon sign-ranked
statistical test to compare social anxiety and self esteem scores and to examine whether there
was a significant change in participants' scores. Both quantitative and qualitative data
analysis types would provide a basis for examining the impact of ACT group therapy on
reducing social anxiety symptoms and increasing self-esteem in college students with social
anxiety problems.
Results
The results of this study indicate that ACT therapy can reduce social anxiety symptoms and
increase self-esteem in college students. In Table 3. we can see changes in group’s mean
scores before and after intervention in the anxious domain, avoidance domain, LSAS score
and RSES score. The increase of the total mean scores was quite high, where the highest
change was the LSAS avoidance subscale score of 38% while the lowest change was the
LSAS fear subscale score of 11%.

Table 2.
Total Mean Score Difference of Pre-Post Test
Variable Min Max Mean Group Changes
LSAS Fear Subscale Pre Intervention 27 60 41.00
11%
LSAS Fear Subscale Post Intervention 21 58 36.50
LSAS Avoidance Subscale Pre Intervention 20 60 37.75
38%
LSAS Avoidance Subscale Post Intervention 11 48 23.25
LSAS Score Pre Intervention 47 120 78.85
24%
LSAS Score Post Intervention 32 106 59.75
RSES Score Pre Intervention 8 13 10.50
24%
RSES Score Post Intervention 10 16 13.00

In addition, it can be seen from table 4 where the Wilcoxon Signed-Rank test analysis
indicates the results of LSAS score for the post-test, the avoidance subscale and the fear
subscale are significantly lower than the pre-test results (Z = -1.826, p = 0.068; Z = - 1,826,
p = 0.068; Z = -1.841, p = 0.066). Furthermore, the Wilcoxon Signed-Rank test analysis
indicates that the RSES scores for post-test are potentially significantly higher than the pre-
test (Z = -1.826, p = 0.068). From this test, the intervention decreased the social anxiety
symptoms and increased self-esteem levels of college students with social anxiety problems.

Table 3.
the Wilcoxon Sign-Ranked Statistical Test
Variable n Z Sig
LSAS Fear Subscale 4 -1.841 0.066
LSAS Avoidance Subscale -1.826 0.068
LSAS Score -1.826 0.068
RSES Score -1.826 0.068

From the participants’ social anxiety scale scores and self esteem scores, there is an
indication that each participant experienced a score decrease for social anxiety symptoms and
score increase for self esteem score with different, individual marks. These differences can be
seen in Figure 1, Figure 2, Figure 3, Figure 4 and Table 5.
 Figure 1. Measurement Result of LSAS Score Fear Subscale Before and After Group
Intervention

Figure 2. Measurement Result of LSAS Score Avoidance Subscale Before and After Group
Intervention

Figure 3. Measurement Result of LSAS Score Before and After Group Intervention
 Figure 4. Measurement Result of RSES Score Before and After Group Intervention

Table 5.
Range of Changes in Each Participant’s Score
Result Result Result Result
Change Change in Change Change
Initial Different Different Different Different
in Fear Avoidance in LSAS in RSES
Participant Fear Avoidance LSAS RSES
Subscale Subscale Score Score
Subscale Subscale Score Score
SH 5 24 29 4 11% 59% 34% 44%
US 6 9 15 1 22% 45% 32% 8%
SM 5 13 18 3 16% 43% 29% 23%
AS 2 12 14 2 3% 20% 12% 25%

As seen in Figure 1, 2, 3, 4 and Table 5, the change in participants' LSAS scores ranged
between 14-29 points. The highest number indicates the most change at 29 points or 34%;
this score belongs to SH, which also has the highest change in RSES score, which is 4 points
or 44%. Furthermore, the lowest change was obtained by US with 14 point increase or 12%
where US had the highest LSAS score at the pretest.

Aside from changes that can be seen in the quantitative analysis, the benefits of the ACT
intervention group can be seen in the qualitative data as shown in Table 5. Each participant
felt cognitive changes, i.e knowing a new way of looking at his/her anxiety and strategies for
processing thoughts related to anxiety. All four participants expressed that knowledge related
to the acceptance of anxiety greatly affects the way they see the problem of anxiety. In terms
of behavior, participants also reported changes. SH reported that he had started doing
activities that he had previously avoided such as going to mall, and the rest participants
reported being able to be more open and acquainted with new people.

Table 5.
The Participants’ Condition Post Intervention
Post-Intervention Changes
Participant
Cognitive Behaviour
SH Having anxiety is a natural thing when he Doing activities that he had avoided
doesn't want to feel anxious, it makes him to befor (going to mall, playing tennis).
be more anxious. These thoughts make him
feel more comfortable in social situations
and can do activities that he really wants to
do.
SH feels the area that has the greatest
 change after attending the therapy session is
the acceptance of his emotions and
thoughts.

US After attending the therapy session, US She wants to share his problem to
feels more able to accept himself in full. new people, especially with people
Next, US realizes the things that are who have the same problem with her
important to him and begins to determine
the priorities he wants to achieve in life.
His anxiety no longer prevents him from
doing what he wants to do to achieve his
goals.
SM After following the intervention session, Focus more on the things she wants
SM learns new alternatives in managing the to do before without any desire to
anxiety problems she has. During this time, eliminate her anxiety
SM thinks that she should not feel anxious
in order to display maximum performance.
SM feels more able to sincerely accept the
anxious thoughts and feelings that she has
and shift her focus to something more
positive.
SA After attending the intervention session, SA Able to more open up (get
feels she has received the new social acquainted) with new people.
support she needed. Sharing sessions during
therapy make her more able to open up and
see new perspectives of her problems. In
addition, SA also gains new knowledge
about the way she views the problem of
social anxiety. Acceptance of her anxiety
and thoughts makes her comfortable to live
her everyday life.

Discussion
Based on quantitative results, the information obtained is decrease in the anxiety symptom
score of each participant in group therapy. This shows that group therapy with ACT approach
is effective in reducing social anxiety symptoms in college students who have social anxiety
problems in this group. These results are consistent with previous research by Hasheminiya
and Davodi (2016) which states that ACT therapy is an effective way to reduce social anxiety
and improve quality of life. Research from Azadeh, Karemi and Besharat (2016) also found
that ACT is effective in helping students who have interpersonal problems and increase
psychological flexibility.

Social anxiety is one disorder that can have negative effect on the life and performance of
students. Although students are aware of the illogical nature of fear that can cause
embarrassment, predicting confrontations with these situations creates an immediate anxiety
response. As a result, students tend to avoid such situations which cause problems in
performance and social relations (Ghayur, Sepehri, Mashhadi, Ghanaei, & Articlear, 2015).
Individuals with social anxiety problems need to be directed that instead of doing cognitive
and active avoidance of thoughts and situations that lead to social anxiety, they can accept the
thoughts and emotions that arise in social situations. After that, they can choose what they
want to do at the moment and act in a way that suits their values. These characteristics were
created during ACT by helping individuals eliminate their needs for avoidance through the
mindfulness process, being in the present and better acceptance and commitment. Finally,
this explanation can also explain about the findings that the average decrease in social
anxiety in the avoidance domain is higher than the average decrease in social anxiety in the
anxious or fear domain.

Furthermore, quantitative and qualitative results also show an increase in students’ self-
esteem levels in this group. This is consistent with the explanation of Segal, Williams, and
Teasdale (2002) which states that the mindfulness approach is effective for individuals who
have low self-esteem, because it is found that the content of mind is not the crucial thing but
individual's relationship with his/her mind is. In the ACT approach, individuals are trained to
develop open acceptance of their inner experiences independently. The assumption is, when
individuals shift their attention to current experiences and accept the mind, it is able to
encourage the capacity of individuals to realize that thoughts and feelings are part of the mind
and not a fact or truth about him/her.

As for some limitations in the implementation of the study include the background and
intensity of the social anxiety symptoms that are quite varied in each participant. This makes
it difficult for the facilitators to apply examples or tasks in some sessions. In addition,
limitations also relate to the number of participants. This might be due to the therapy sessions
took place during the term break and the selection of constructs related to social anxiety
problems so that the number of participants in this group therapy only reached the minimum
number for group therapy of 4 people.

Based on the results of the initial interview, it is known that the problem of social anxiety in
participants in this group is the impact of other problems such as childhood trauma or
bullying experiences. For this reason, further intervention is needed to overcome the
problems related to the causes or triggers of the emergence of social anxiety.

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