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A Therapeutic ExchangeAcceptance and Commitment Therapy (ACT): 

A Therapeutic Exchange Acceptance and Commitment Therapy (ACT) Mark Webster Psychotherapist Personality Disorders and Addictions

Overview: 

Overview Background Theory Aims of ACT Research

ACT History: 

ACT History ACT is part of CBT ‘New Wave’ ACT is grounded in 25 years of basic research ACT emerges from Relational Frame Theory, over 400 published papers Promising evidence- 11 RCTs in last two years ACT increasingly applied to a wide range of complicated psychological disorders Flexible interventions

Relational Frame Theory (RFT): 

Relational Frame Theory (RFT) How can you turn the screw? Plastic Melts Pliable Forms a shape Cools Hardens Leverage

Slide5: 

Relations Transformation of Functions

Slide6: 

Example

Clinical example: an obsessive-compulsive client who avoided a carpeted area in her bedroom: 

Clinical example: an obsessive-compulsive client who avoided a carpeted area in her bedroom A mild insecticide had been used on a tree in the front garden She saw an insect in her garage and thought that it might have been on the tree Paint cans were stored in that corner of the garage When workmen painted her bedroom, they set paint cans in a cardboard box on the carpet, and; She concluded that the carpet was contaminated with the insecticide!

Slide8: 

toxic toxic toxic toxic toxic toxic

Human Suffering is Ubiquitous: 

Human Suffering is Ubiquitous Normal psychological processes are destructive We need to understand these processes and work within them to promote health Nominee: human language and cognition WORDS cause PAIN EXPERIENTIAL AVOIDANCE!

Experiential Avoidance: 

Experiential Avoidance Experiential avoidance (EA) is built into human language Experiential avoidance is the tendency to attempt to alter the form, frequency, or situational sensitivity of historically produced negative private experience (emotions, thoughts, bodily sensations) even when attempts to do so cause psychological and behavioral harm Experiential Avoidance is amplified by the culture

Experiential Avoidance is Harmful: 

Experiential Avoidance is Harmful Coping styles literature Psychotherapy process literature Thought suppression literature Emotional suppression literature Psychopathology literature Linked to other several behaviors such as violence and suicide Psychotherapy outcome literature

Experiential Avoidance is Harmful: 

Experiential Avoidance is Harmful Higher experiential avoidance is associated with: Higher anxiety More depression More overall pathology History of sexual abuse High risk sexual behavior Substance abuse BPD symptomatology and depression Thought suppression Alexithymia Anxiety sensitivity Sources: Hayes et al (under submission); Polusny (1997); Toarmino (1998); Pistorello (1997); Batten, Follette, & Aban (1998); Stewart, Zvolensky, & Eifert (1998);

Experiential Avoidance is Harmful: 

Experiential Avoidance is Harmful Thought and emotional suppression is often counterproductive Suppress Accept Source: Walser (1998)

Experiential Avoidance is Harmful: 

Experiential Avoidance is Harmful Thought and emotional suppression is often counterproductive This coping strategy is associated with psychopathology Examples Panic PTSD Depression OCD Suicide Source: Hayes, Wilson, Gifford, Follette, & Strosahl (1996)

Slide15: 

The Goals and Components of ACT Undermine experiential avoidance Creative hopelessness Control is the problem Provide alternatives Acceptance Exposure Contact with the present moment

Outcome Research: 

Outcome Research Psychosis Addiction Stigma Workplace Stress Epilepsy Primary Care- Depression, Anxiety, Smoking Cessation, Chronic Pain, OCD, Diabetes

Slide17: 

Coping with Psychotic Symptoms Bach & Hayes, JCCP, 2002 Could this work even with the most horrifying forms of private events? 80 S’s hospitalized with hallucinations and/or delusions randomized to either ACT or TAU 3 hours of ACT; all but one session in-patient ACT intervention focused on acceptance and defusion from hallucinations / delusions

Impact on Rehospitalization: 

Impact on Rehospitalization .6 .7 .8 .9 1.0 40 80 120 Days After Initial Release Proportion Not Hospitalized

Process of Change:Believability: 

Process of Change: Believability Pre F-up 80 60 Control ACT 40 Literal Believability of Psychotic Symptoms (0-100) Phase Level 2 process evidence

Coping with Psychosis #2Gaudiano & Herbert, BRAT, in press: 

Coping with Psychosis #2 Gaudiano & Herbert, BRAT, in press Psychotic inpatients (n = 42) ACT vs. Enhanced TAU 29% Homeless, only 12% with own home 86% Unemployed 58% Substance Misuse comorbid 82% Medical condition

Rehospitalization: 

Rehospitalization Post 4 mo Follow Up 100 90 50 Phase 80 70 60 ACT ETAU 40 % Not Readmitted

Hallucination Distress: 

Hallucination Distress Pre Post 8 Hallucination Distress (1-10) Phase 7 6 ACT ETAU 5

Slide23: 

Severe Substance Abuse Hayes et al., Behavior Therapy, 2004 124 abusing multiple drugs within the last 30 days while on methadone maintenance Three conditions (RCT) ACT + methadone maintenance ITSF + methadone maintenance Methadone maintenance

Slide24: 

Post 6 Mo Follow Up Percentage Negative QAs Phase Pre Subjectively Assessed Total Drug

Stigma Toward Our ClientsHayes et al, Behavior Therapy, 2004 (Nevada PIC, SAMHSA funded): 

Stigma Toward Our Clients Hayes et al, Behavior Therapy, 2004 (Nevada PIC, SAMHSA funded) 90 drug counselors randomly assigned to day long workshop on ACT Multicultural training Class on biological models of SA 3 Month Follow-up

Effects on Stigma: 

Effects on Stigma ACT Multicultural Control

Change in Burnout: 

Change in Burnout ACT Pre- Post Pre- F-up Multicultural Education 4 0 -4 Pre- Post Pre- F-up Pre- Post Pre- F-up

Slide28: 

Worksite Stress and Innovation Bond & Bunce, IJOHP, 2000 Study done at a large company Three treatment conditions (30 per condition) Acceptance and Commitment Therapy Behavioral Innovation Promotion Wait list control

Slide29: 

Stress Pre Mid Post F-Up 14 12 10 General Health and Stress Control Behavioral Innovation ACT

ACT for EpilepsyLundgren, Dahl, and Melin, soon to be under review : 

ACT for Epilepsy Lundgren, Dahl, and Melin, soon to be under review Randomized trial with 28 poor South African epileptics, not fully regulated by medication ACT vs. Attention Placebo 9 hours of therapy across 5 weeks: two three hour groups; two 1.5 hour individual sessions

Outcome: Seizure Time: 

Outcome: Seizure Time 600 400 200 Pre Post 6 mo 1 yr Seconds

Outcome: Seizure Time: 

Outcome: Seizure Time 600 400 200 Pre Post 6 mo 1 yr Seconds Cohen’s d at 1 yr = 1.25

Outcome: : 

Outcome:

In Conclusion: 

In Conclusion Overall ACT seems to be producing consistently positive gains, sometimes quickly, across an unusually broad range of problems including notably severe ones, and at times better than existing empirically supported procedures It seems to work through at least some of its theoretically specified processes and components, not just through general processes of change