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Dr. David Gillanders University of Edinburgh / NHS Lothian Chronic Pain Service

University of Edinburgh / NHS Scotland Training Programme in Clinical Psychology. Acceptance & Commitment Therapy: Empirical Status. Dr. David Gillanders University of Edinburgh / NHS Lothian Chronic Pain Service. The Empirical Base for ACT. This is very brief and selective

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Dr. David Gillanders University of Edinburgh / NHS Lothian Chronic Pain Service

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  1. University of Edinburgh / NHS Scotland Training Programme in Clinical Psychology Acceptance & Commitment Therapy: Empirical Status Dr. David Gillanders University of Edinburgh / NHS Lothian Chronic Pain Service

  2. The Empirical Base for ACT • This is very brief and selective • There are references on the reading list to pursue to see more of the evidence base • In particular Hayes et. al., 2006 in BRAT and Ost (2008)

  3. Evidence base for ACT Experimental & Theoretical Work: Experimental work in experimental pain tolerance, panic induction, distressing thoughts, 7 published component and experimental psychopathology studies (N = 199) Several more are done and on the way and so far the results are quite supportive of the act model

  4. Evidence base for ACT Experimental & Theoretical Work: Questionnaire studies using the Acceptance & Action Questionnaire: There are now 27 studies using the AAQ, involving 5,616 participants

  5. AAQ Scores Are Associated With …. Higher anxiety More depression More overall pathology Poorer work performance Inability to learn Substance abuse Lower quality of life Trichotillomania History of sexual abuse High risk sexual behavior BPD symptomatology and depression Thought suppression Alexithymia Anxiety sensitivity Long term disability Worry

  6. Evidence base for ACT Outcome Studies Across diverse clinical areas: depression, anxiety, OCD, psychosis, chronic pain, smoking, substance abuse, diabetes, cancer, epilepsy 20 randomized controlled trials are now done containing 24 planned between group comparisons. 23 of the 24 favor ACT (not all significantly, just in terms of effect sizes). Several controlled time series designs Control conditions include minimal comparisons (placebo; TAU; wait list) as well as structured active treatment comparisons

  7. Evidence base for ACT The first RCT: Depression Zettle and Hayes, 1987 Done at the Centre for Cognitive Therapy in Philadelphia with Aaron T. Beck Surprisingly…

  8. Significantly Better Outcomes 20 15 CT 10 Cohen’s d at F-up = .92 ACT 5 Hamilton Rating Scale (BDI was similar) 0 Pre Post 2 mo Follow up

  9. Not only that, but process too! 0 % Pre-Post Reductions in the Believability of Depressive Thoughts 10 % CT ACT CT ACT 20 % 30 % 40 % 50 % Pre to Post Pre to Follow up 60 %

  10. ACT For Psychosis Bach & Hayes, 2002 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

  11. ACT Treatment as Usual Impact on Rehospitalization 1.0 .9 .8 Proportion Not Hospitalized .7 .6 40 80 120 Days After Initial Release

  12. Processes of Change: Symptoms 100 ACT Percentage Reporting Symptoms 75 50 Control 25 Pre F-up Phase

  13. Processes of Change:Believability 80 Control Literal Believability of Psychotic Symptoms (0-100) 60 ACT 40 Pre F-up Phase

  14. Chronic PainMcCracken, Vowles, & Eccleston, BRAT, 2005 108 chronic pain patients Average of 132 months of Chronic pain 6.3 treatment programs Multidisciplinary in-patient program Within subject analysis: Preassessment; 3.9 months later (on average) pretreatment assessment; 3-4 week residential program; 3 month follow-up

  15. Chronic PainMcCracken, Vowles, & Eccleston, BRAT, 2005

  16. Chronic PainMcCracken, Vowles, & Eccleston, BRAT, 2005

  17. Refractory Epilepsy Lundgren, Dahl, Melin & Kies (2006) Epilepsia • Small RCT: n = 27; 14 in ACT, 13 supportive therapy • ACT intervention: values, reasons, acceptance of seizure, defusing ‘self as stigmatised,’ contact with self, plus standard behavioural procedures • Supportive Therapy: Talking about epilepsy and its impact on living, what it means to have epilepsy etc.

  18. Refractory Epilepsy Lundgren, Dahl, Melin & Kies (2006) Epilepsia • Limitations: non blinded outcome measurers , small numbers. • Main outcome measure: nursing records of daily seizures frequency and length – multiplied to give seizure index. • Here’s the data:

  19. Refractory Epilepsy Lundgren, Dahl, Melin & Kies (2006) Epilepsia Interestingly the seizures reduce before the delivery of the behavioural technologies.

  20. Evidence base for ACT: Overall effect sizes across all RCT’s

  21. Evidence base for ACT “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” Steven Hayes, 2005

  22. Evidence base for ACT First external meta analysis of ACT versus CBT Effect Sizes: Overall 0.68 (15 studies) WL Control 0.96 (2 studies) TAU 0.79 (5 studies) Active Treatment 0.53 (8 studies) Lars Goran Ost (BRAT 2008)

  23. Evidence base for ACT Also: Background variables ACT CBT p value Numbers starting 52.1 76.5 NS Attrition (% starters) 15.4 16.1 NS No of weeks 8.2 17.2 <0.01 No of hours 10.7 22 NS Months follow up 4.2 9.6 NS Lars Goran Ost (BRAT 2008)

  24. Evidence base for ACT However: Using a scale to rate methodological rigour ACT studies on average are significantly poorer quality than recent CBT studies: Total quality score (max 44) ACT = 18.1 (SD = 5.0) CBT = 27.8 (SD = 4.2) p <0.0001 Lars Goran Ost (BRAT 2008)

  25. Evidence base for ACT ACT studies are poorer on criteria such as; Representativeness of the sample, reliability of diagnosis, reliability and validity of outcome measures, assignment to treatment, number of therapists, therapist training and experience, treatment adherence checks, control of other treatments. Lars Goran Ost (BRAT 2008)

  26. Evidence base for ACT ACT studies are equivalent on other criteria: clarity of sample description, severity / chronicity of disorder, specificity of measures, use of blind assessors, assessor training, design, power analysis, assessment points, manualised specific treatments, checks for therapist competence, handling of attrition, statistical analyses and presentation of results, clinical significance of results. Lars Goran Ost (BRAT 2008)

  27. Evidence base for ACT In conclusion; The ACT literature is promising, shows moderate to large effect sizes across a range of conditions in a notably briefer time scale than existing therapies. The literature is not yet as mature as existing psychotherapies literature and is not as methodologically rigorous in some areas. Future studies should benefit from Ost’s review as he gives specific guidance as to how RCT’s involving ACT could improve.

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