Acceptance and Commitment Therapy Scott Clark

1950-60s 1st wave: Behaviour Therapy focus on direct behaviour change, classical

and operant conditioning 1970s 2nd wave: Cognitive Therapy

focus on changing content and frequency of cognitions

1980s 3rd wave: focus on changing relationship with thoughts and feelings – using mindfulness and acceptance strategies

Dialectical Behavior Therapy, Acceptance and Commitment Therapy, Functional Analytic Psychotherapy, Integrative Behavioral Couples Therapy, Mindfulness Based Cognitive Therapy (Hayes and De May, in press)

ACT (Hayes, Masuda & De Mey, in press)

ACT (Morris & Oliver 2009) Psychotherapy technique that:

Attempts to expand a person’s behavioural repertoire by increasing the ability to respond flexibly in response to the opportunities presented by each situation for valued living.

Involves a degree of being in the present moment, connection with the direction given by values, and a letting go of or distancing from the rules and assumptions that can function as barriers to doing what matters. Some of these rules and assumptions are a by product of/

are inherent in the use of language as thinking and communication.

Attempts to change the social and verbal contexts that link thoughts and feelings with overt action

Russ Harris intro video

ACT Developed by Stephen Hayes - 1984

Evolution from behaviourism Classical and Instrumental conditioning Learnt verbal and rule-governed behaviour

Functional contextualism (Hayes, Masuda & De Mey, in press) “ACT conceptualizes psychological events as a set of

ongoing actions of a whole organism interacting with historically and situationally defined contexts”.

……. Learning Theory…at mercy of learned associations…focusing on changing cognitions is not enough or can actually be counter productive by reinforcing dysfunctional thinking…..

Relational Frame Theory (www.contextualpsychology.org)

Language allows humans to link neutral stimuli such

as words/thoughts with events. Pairings/networks can generalise (derived relationships) with reinforcement to become relational frames applied in an arbitary fashion. Relational networks: If A = B and B = C then A = C A child experiences seasickness on a boat and then

associates the word boat with seasickness. The child may then learn at school that a "Car Ferry" is a

type of boat. Later, on hearing that she is going on a car ferry, the

child may show signs of anxiety despite having had no direct experience with car ferries.

Respondently acquired (conditioned) function of "boat" and the derived relation between "boat" and "car ferry".

The child does not need to experience the possibly aversive consequences of traveling on a car ferry in rough seas, in order to show signs of anxiety.

ACT Core Priniciples (Harris 2006) Goal is psychological flexibility Defusion

Thoughts/language are not truth/rules/threatening events….person not fused with thoughts….able to observe them….”leaves in the stream”

versus Fusion (Hayes et al. in press) Behavior is guided more by inflexible verbal networks than by the

contingencies of reinforcement in the environment…..reality focus on:

Literality - treating symbols (e.g.“life is hopeless”) as one would their referents (i.e., a truly hopeless life)

Reason-giving (i.e., basing action or inaction excessively on the constructed “causes” of ones own behavior, especially when these processes point to non-manipulable “causes” such as conditioned private events)

Emotional control (i.e., focusing on proper manipulation of emotional states as a primary goal and metric of successful living)…..? In contrast to CBT

ACT Core Priniciples (Harris 2006) Acceptance

Moment by moment process of actively embracing the private events evoked in the moment without unnecessary attempts to change their frequency or form, especially when doing so would cause psychological harm (Vs avoidance)

Contact with the present moment Bringing full awareness to your here- and-now experience,

with openness, interest, and receptiveness The “Observing Self”

“A transcendent sense of self encourages clients to experience their own thoughts and feelings and to shift from identifying with the conceptualized self (“I am a bad person”, “I am depressed”)”.

Values Clarifying what is most important to you; what sort of person

you want to be Committed action

setting goals, guided by your values, and taking effective action to achieve them

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

HEXAFLEX DIAGRAM

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

HEXAFLEX DIAGRAM

1. Given a distinction between Context you and the stuff you are struggling with and trying to change …

2. … are you willing to have that stuff, fully and without defense …

3. … as it is, and not as what it says it is …

4. … and do what takes you in the direction …

5. … of your chosen values …

6. … at this time, in this situation?

Acceptance and mindfulness

Commitment and behaviour change

HEXAFLEX DIAGRAM

Techniques (Harris 2006)

Less confrontational manner and less directive forms of verbal interaction, such as metaphor, paradoxes, and experiential exercises, to loosen the entanglement of language/thoughts and the self.

Identify unworkable behaviours and develop suitable metaphors

Homework exercises that highlight the cost of unworkable solutions in respect to valued living

Stages (Hayes, Masuda, & De Mey (in press)) Creative hopelessness – explore current strategies in

motivational interviewing style - bring client toward new options.

Man in the hole metaphor Control is the problem, not the solution

Polygraph metaphor Acceptance as an alternative agenda

Two scales metaphor Imagine an anxiety provoking situation

Notice its effects on the body Examine these effects at a distance, “like a scientist” Allow it to be there regardless of its aversive nature Highlights the futility of struggle for control and undermines

avoidance Russ Harris exmples

Accepting emotions Demons on a ship

Stages (Hayes, Masuda, & De Mey (in press)) A transcendent sense of self

Safe to expose yourself to fears Chessboard metaphor – separated self and avoided psyc

hological content Defusing language and cognition

Mindfulness exercises: locate self in here and now “AND” not “BUT” (which implies something is wrong) Dealing with an unpleasant thought

Simply observe it with detachment Repeat it over and over, out aloud, until it just becomes a

meaningless sound Imagine it in the voice of a cartoon character Sing it to the tune of ‘Happy Birthday’ Silently say ‘Thanks, mind’ in gratitude for such an interesting

thought Exercise: Think of a negative self-judgement “(x)” – notice its

effect. Compare to “I am having the thought (x)”

Stages (Hayes, Masuda, & De Mey (in press)) Values

Choose life directions in various domains (e.g. family, career, spirituality) while undermining verbal processes that might lead to choices based on avoidance, social compliance, or fusion (e.g. “I should value X” or “A good person would value Y” or “My mother wants me to values x”) (Hayes et al. in press).

The “Bulls eye” (Tobias Lundgren) Formal assessment of ability to live life according to ones

values in: Work/education Leisure Personal Growth/Health Relationships

Assessment of barriers in each area Valued action plan addressing each area

Stages (Hayes, Masuda, & De Mey (in press)) Willingness and commitment

Development of larger and larger patterns of effective action linked to chosen values.

Identify barriers to achieving values Similar to traditional behavior therapy

Select the appropriate components: exposure skills acquisition shaping methods goal setting,

The ACT therapeutic relationship Two mountains metaphor

Studies of efficacy (Powers et al. (2009)) Metanalysis of 18 (n = 917) randomized controlled ACT trials Range of conditions:

Psychosis, worksite stress, chronic pain, anxiety and depression, smoking, borderline personality disorder, diabetes self management, polysubstance abuse, weight, drug refractory epilepsy, trichotillomania, math anxiety.

Mixed comparators and outcome measures ACT better than control (effect size = 0.42).

The average ACT-treated participant was more improved than 66% of the participants in the control conditions.

ACT was superior to: Waiting lists and psychological placebos (effect size = 0.68) Treatment as usual (effect size = 0.42)

ACT was not more effective than: Established treatments - e.g CBT (effect size = 0.18, p = 0.13).

Studies of efficacy

Cohen’s convention of small (0.2), medium (0.5), and large (0.8) effects

Studies of efficacy (Powers et al. (2009)) When viewed individually only 4 studies had confidence intervals

not crossing 0: Smoking cessation Supplementation of TAU for borderline PD Treatment resistant epilepsy Trichotillomania

Study quality poor Jadad Scale 0-5

0=1; 1 = 7; 2 = 5; 3 = 5

Studies of efficacy Since 2008 (Smout et al. 2012)

Improved coherence and competence montoring Good studies provide Level II RCT evidence for chronic pain,

obsessive–compulsive disorder, and a subset of other anxiety disorders (panic disorder, social phobia, and generalised anxiety disorder)

The majority of studies demonstrated that ACT significantly improved primary outcomes but used comparison conditions that did not rule out therapy-unspecific factors, including use of concurrent treatments, as explanations for the improvements.

Use of treatment as usual unmatched for contact and unmonitored for competence, and unmonitored use of concurrent treatments are the primary factors preventing the attribution of better outcomes for ACT recipients to therapy-specific effects

References Chris Cullen (2008) Acceptance and Commitment Therapy (ACT): A Third Wave Behaviour

Therapy Behavioural and Cognitive Psychotherapy, 36, 667–673. Fletcher L, Hayes S (in press) Relational Frame Theory, Acceptance and Commitment Therapy,

and a Functional Analytic Definition of Mindfulness Harris R (2006) Embracing Your Demons: an Overview of Acceptance and Commitment

Therapy. Psychotherapy in Australia 12 (4): 2-8. Hayes S, Luoma, J, Bond S, Masuda A, and Lillis J (in press) Acceptance and Commitment

Therapy: Model, Processes and Outcomes. Hayes S, Masuda A, and De May (in press) Acceptance and Commitment Therapy and the

Third Wave of Behavior TherapyRelational Frame Theory, Acceptance and Commitment Therapy, and a Functional Analytic Definition of Mindfulness

Morris E & Oliver J (2009)ACT Early: Acceptance and Commitment Therapy in early intervention. Power point presentation

Powers M, Vording M, Emmelkamp P (2009) Acceptance and Commitment Therapy: A Meta-Analytic Review. Psychother Psychosom 78:73–80.

Webster, M. (2011) Introduction to Acceptance and Commitment Therapy. Advances in Psychiatric Treatment 17:309-316.

Wilson, K. G. & Murrell, A. R. (In Preparation). Values-Centered Interventions: Setting a Course for Behavioral Treatment. In S. C. Hayes, V. M.. Follette, & M. Linehan (Eds.) (in preparation). The new behavior therapies: Expanding the cognitive behavioral tradition. New York: Guilford Press.

The empirically supported status of acceptance and commitment therapy: An update Smout, M, Louise Hayes, Atkins, PWB, Klausen, J and Duguid, J E (2012) The empirically

supported status of acceptance and commitment therapy: An update. Clinical Psychologist 16 (2012) 97–109

www.contextualpsychology.org Relational frame theory simplified Bulls eye values assessment