A Review of Acceptance and Commitment Therapy (ACT) Empirical Evidence:

1. A Review of Acceptance and Commitment Therapy (ACT) Empirical Evidence: Correlational,Experimental, Psychopathology,Component and Outcome Studies By Francisco J. Ruiz (2010)

2. ACT A psychological intervention Philosophically rooted in functional contextualism Rooted in Relational frame theory (RTF) Treatment of experiential avoidance disorder (EAD) Functional dimensional approach to psychopathology

3. Functional contextualism Generally contextualism observes actions in a context Functional contextualism specific way of contextualism which undermines prediction and influence of events with precision, scope and depth. Thoughts or actions are not seen correct or incorrect It focuses on usefulness

4. RFT Contextual behaviorism approach to human language and cognition Based on laws Human beings learn to relate stimuli under arbitrary contextual control It has three requisites for considering the existence of relational frame

6. RFT Has large number of implication of area of psychopathology and psychotherapy Briefly nature of language and cognition has more impact on changing attempts focused on the function of private events

7. Experiential Avoidance Deliberate effort to avoid and/or escape from private events such as thoughts, memories and bodily sensations. When EA combined with psychological inflexibility problems occur. EA works in short run. In long run, it provokes patients’ life.

8. Essential ACT Principles and Methods

9. What does ACT provide ? Generates psychological flexibility  Contact the present moment Proposes acceptance  To involve oneself in valued action

10. Therapeutic Work in ACT

11. Values clarification and actions Creative hopelessness Values clarification Promotion of the willingeness to experince

12. Defusion To choose to behave in valued way Cognitive defusion - weakining the tendency to treat them. Self as a context - there is a YOU behind all private events

13. How ACT obtaion its objectives

14. Classical exposure therapies vs. ACT Extinction of discomfort Trains the patients to be present with their feared experince Directs them to behave in a valued way.

15. ACT Empirical Reviews

16. First Critique: Corrigan (2001) First Review: Hayes et al (2006) • Correlation evidence • Experiential avoidance, experimental psychopathology and ACT component studies, randomized controlled trials and processes of change studies • ACT—superior to control conditions, wait-lists and treatment • ACT—superior to structured interventions ACT has not been developed with the usual rationale --philosophical and theoretical roots were not used

17. Other research: Öst (2008): Qualitative and quantitative review of the ACT empirical evidence from RCT. --Comparing ACT versus CBT (Cognitive Behavior Therapy) --Conclusion: ACT showed lower scores in a methodological scale compared with CBT --ACT does not fulfill the criteria for being considered as an empirical validated treatment.

18. Re-analysis of Öst review: Gaudiano (2009) %38 of the ACT studies could not be matched with CBT study because: --Studies were conducted over different disorders --Different population CBT studies were 4.5 more times funding than ACT studies

19. Recent Review: Powers, Vörding & Emmelkamp (2009) Meta-analytic review of ACT empirical evidence in RCT studies --Conclusion: ACT is better than wait-lists, placebo attention conditions BUT not significantly better than established treatments HOWEVER Re-analyzed the data base: Levin & Hayes (2009) --Conclusion: ACT was better than established treatments

20. Emprical Evidence of ACT Model • separated as a correlational, experimental psycpath. and component studies, outcome studies and case studies. Correlational Studies; • Aim to study relationship among experiential avoidance and psychological symptoms. • ‘’Acceptance and Action Questionnaire’’ is used in studies. • it measures experiential avoidance • Experiential avoidance is analyzed with different types of psychological construct and symptoms . • Chronic pain is one of them

21. Kratz, Davis,& Zatura (2007) have showed that acceptance of pain predicted posterior positive affect. According to Wicksell, Renöfalt, Olsson, Bond & Melin (2008), acceptance predicted pain severity , pain interference in everyday life and physical and metal well-being. In work setting, the level of experiential avoidance has predicted mental health and performance in learning a new software (Bond, & Flaxman, 2006). Experiential avoidance has been a mediator between childhood psychological abuse and current mental health symptoms (Reddy, Picket, & Orcutt, 2005). Experiential avoidance block the reduction of depression in the treatment of borderline personality disorder.

22. Experimental psychopathology and ACT component studies 3 types of studies : effect of experiental avoidance, effect of acceptance coping instructions, effect of brief ACT protocol Studies about effect of experiental avoidance repertoire in experimental task: Predictive power of the level experiental avoidance of participants  selecting participants with high and low scores in AAQ • Cold pressor task (Zettle et al.,2005) -High score of AAQ had lower tolerance and kept their hand in cold water less time than participant with low AAQ score

23. Effect of being drunk (Zettle,Petersen,Hocker&Provines,2007) -Higher scores in AAQ were more discomforting and had worse performance on challenging perceptual-motor task than lower scores. • Carbon dioxide-enriched air challenge (Feldner, Zvolensky, Eifert &Spira (2003) -High levels of AAQ showed more anxiety and emotional discomfort but not more phsysiological activation - High AAQ score, received suppression protocols, showed higher levels of anxiety than those who received perceived acceptance control • Comparing emotional reactions (Sloan,2004) -participants with high level of experiental avoidance showed higher emotional experience and higher heart rate with the pleasent and unpleasent films

24. THE EFFECT OF ACCEPTANCE COPING INSTRUCTIONS Nihan Kaymaz

25. Several studies focused on the effects of acceptance coping instructions Aim: to assess the psychopathology in terms of comparing acceptance coping instructions and other coping strategies Aversive stimulation, intrusive thoughts, cardiovascular conditions, emotional contents

26. In terms of aversive stimulation: • Keogh, Bond, Hanmer & Tilston (2005): • Cold-pressor task • Acceptance coping instruction obtained better results than one ‘distraction coping instruction’ with women • The same effect with men

27. In terms of intrusive thoughts: • Marks & Woods (2005): • Acceptance instructions vs. suppression in the management of intrusive thoughts • Acceptance coping instruction group: less discomfort when experiencing the intrusive thoughts. • Suppression group: more intrusions, higher levels of anxiety, negative evaluation compared with acceptance (while doing a task which consisted in saying aloud and imagining that a loved one were having a traffic accident) • Najmi, Riemann & Wegner (2009): • Similar effects with those with OCD • Both acceptance and focused distraction coping instruction groups had less distress than suppression group.

28. In terms of cardiovascular conditions: • Low, Stanton & Bower (2008): • Acceptance-oriented processing vs. evaluative emotional processing on cardiovascular habituation and recovery • Task: writing about an ongoing stressful experience • Better efficient heart rate habituation and recovery in acceptance condition

29. Interms of emotional contents: • Campblell-Sills, Barlow, Brown & Hofmann(2006): • Differential effect of suppression vs. acceptance instructions • Task: viewing a highlyemotional film • Lower heart rate and less negative effect during the film in acceptance condition than in suppression condition • Liverant, Brown, Barlow & Roemer (2008): • Depressed participants used • Suppression produced short-term reduction in sadness with low levels of anxiety • However, not effective at moderate and higher levels

30. In terms of emotional contents: • Hofmann, Heering, Sawyer & Asnaani (2009): • Suppression vs. cognitive reappraisal vs. acceptance instruction • Task: coping with an impromptu speech in front of a video-camera • Higher heart rate in suppression condition than in others • Also, subjective experience of anxiety was lower in cognitive reappraisal than acceptance • Dunn, Billotti, Murphy & Dalgleish (2009): • Suppression vs. acceptance on processing distressing materials • Suppression showed better results • However, suppression was accepted similar to cognitive reappraisal coping instruction

31. Limitations • ACT does not instruct acceptance • Metaphors andexperiential exercises are used • Coping strategies have some similarities among them and there is still no a consensus about their verbal processes • Both acceptance and cognitive reappraisal involve distancing from thoughts • Acceptance coping protocols in these studies did not include valued oriented behaviors or any valued context. • In ACT, acceptance is always at the services of values

32. Effects of ACT Protocols Cold-pressor task experiments: Hayes, Bissett, et al(1999): Acceptance-based protocol vs . Control-based protocol Masedo& Esteve (2007): Acceptance-based protocol vs. Suppression-based protocol Branstetter-Rost et al (2009): ACT-based acceptance with/without values

33. Pain-tolerance task experiments: Takahashi et al (2002): ACT exercises vs. CBT exercises Gutierrez et al (2004): Acceptance-based protocols vs. Cognitive-control-based protocols McMullen et al (2008): Acceptance-based coping strategies vs. Control-based strategies Blarrina et al (2008): ACT values protocol vs. Control values protocol

34. OUTCOME STUDIES

35. CLINICAL PSYCHOLOGY • Depression • Anxiety disorders • Psychotic symptoms • Personality disorders • Addictive behaviors • At-risk adolescents

36. CLINICAL PSYCHOLOGY • Two studies: ACT and depression • Zettle & Hayes, 1986: • Comprehensive distancing vs. two versions of cognitive therapy • ACT was better after therapy and after 2 month follow up. • Zettle & Hayes, 1989: • ACT in group format vs. the previous two CT versions in groups • Cognitive fusion mediated the results (believability of depressive thoughs).

37. ANXIETY DISORDERS • Two studies: ACT and OCD • Twohig, Hayes & Masuda, 2006b: • Positive results with all participants • Twohig, 2007: • ACT vs. Progressive Relaxation Training • Less compulsions with ACT group than relaxation group at post-treatment and at 3 month follow-up.

38. ANXIETY DISORDERS • Four studies: ACT and Social Phobia • Block, 2002: • ACT vs. CBT, participants with subclinical social anxiety • ACT group was better at public speaking • In general, ACT is a promising treatment for social phobia

39. ANXIETY DISORDERS • Generalized Anxiety Disorder • Roemer & Orsillo (2007): ACT obtained large effect sizes in reducing GAD symptoms. • Hayes, Orsillo & Roemer (in press): • Acceptance in private events and engagement in meaningful activities related to responder status and quality of life at post-treatment. • Trichotillomania and skin picking: Studies reported positive results.

40. ANXIETY DISORDERS • Diverse symptoms related to anxiety and/or depression • ACT vs. CBT or CT • ACT obtained more improvements at post-treatment and at the 6 month follow-up • Decrease of experiential avoidance (Lappalainen et al., 2007).

41. PSYCHOTIC SYMPTOMS • Bach & Hayes (2002): • 45 minute sessions of ACT and TAU vs. only TAU to prevent rehospitalizations • ACT and TAU condition decreased rehospitalizations, hallucinations and delusions believability. • Gaudiano & Herbert (2006a & 2006b): same results.

42. PERSONALITY DISORDERS • Gratz & Gunderson (2006): patients with borderline personality disorder. • TAU vs. ACT and TAU • Even though both conditions have significant effects, the latter one reached normative functioning levels.

43. ADDICTIVE BEHAVIORS • Hayes, Wilson et al. (2004): polysubstance abusing individuals being maintained on methadone • ACT, Intensive Twelve Step Facilitation vs. Methadone Maintenance only • ACT condition showed greater decrease in total drug use at the 6 month follow-up

44. AT-RISK ADOLESCENTS • Gomez et al. (under review): • In the treatment of at-risk adolescents who are with a history of antisocial behavior and current legal issues (n=5) • Less impulsivity, higher self-control, more value oriented actions • Improvements increased in one year follow-up

45. AT-RISK ADOLESCENTS • Luciano et al. (2009): • Adolescents with moderate or high risk (n=15) of having impulsivity or emotional problems • Values clarification protocol: promoting choosing and taking responsibility for own choices • Showed a large effect only for moderate-risk adolescents • Defusion protocol: discriminating private events • Produced a large effect size for high-risk adolescents and improved the effect of values protocol.

46. ACT in Health Psychology • Dahl, Wilson, & Nilsson (2004): • Chronic pain, ACT vs. TAU • Less sick days for ACT group at 6 month follow-up • Wicksell et al. (2008): • On people with Longstanding Pain –> significant improvements in functioning, life satisfaction, fear of movements and depression at 7 month follow-up. • Gifford et al. (2004): • ACT>CBT -for chronic pain- (Smoking Cessation ACT>Nicotine Replacement Therapy) at 1 year follow-up.

47. ACT in Health Psychology • Branstetter et al. (2004): • Distress resulted from end-stage cancer • ACT>CBT for alleviating distress levels • Lundgren et al. (2006): • Epilepsy • ACT condition vs. Attention Placebo Condition • At 12 month follow-up • Less seizures, higher quality of life • Forman et al. (2009): • Weight loss in obese women • At post-treatment 6.6% of body weight lost • At 6 month follow-up 9.6% of body weight lost

48. ACT in Health Psychology • Gregg et al. (2007): • Type II Diabetes • Diabetes Education vs. ACT + Diabetes Education • ACT conditionwas more succesful in promoting self-management behaviours • Hesser et al. (2009): • ACT reduced Tinnitus Distress • At 6 month follow-up symptom reduction • Good outcomes in: • Multiple Sclerosis (Sanchez & Luciano, 2005), • Prevention of HIV (Gutiérrez et al., 2007), • Systematic Lupus Erythematosus (Quirosa et al., 2009)

49. Other Areas of Intervention

50. OTHER AREAS of INTERVENTION Fernandez et al. (2004); - sport performance enhancement - carried out RCT - ACT vs. hypnosis RESULTs : ACT showed greater influence BUT without reaching a statistical significant differences.