Contextual Methods and Contextual Methods and the Future of CBTthe Future of CBT

The Opportunity of The Opportunity of UpheavalUpheaval

Contextual Behavioral Science StrategyContextual Behavioral Science Strategy

From a clear philosophy of science, and with aFrom a clear philosophy of science, and with a General-process account that addresses cognition,General-process account that addresses cognition, Construct transdiagnostic processes, andConstruct transdiagnostic processes, and Organize them into a useful clinical model, with Organize them into a useful clinical model, with Components that derive from the model, andComponents that derive from the model, and Substantial breadth of application, andSubstantial breadth of application, and Successful mediators and moderators linked to those Successful mediators and moderators linked to those

process; extended by aprocess; extended by a Dissemination and training strategy, and theDissemination and training strategy, and the Construction of a development communityConstruction of a development community

Contextual Behavioral ScienceContextual Behavioral Science Philosophy: Functional contextualismPhilosophy: Functional contextualism General process account: Behavioral principles General process account: Behavioral principles

and Relational Frame Theory nested within an and Relational Frame Theory nested within an overall evolutionary science perspective overall evolutionary science perspective

Transdiagnostic processes: Experiential Transdiagnostic processes: Experiential avoidance, cognitive fusion, flexible attention to avoidance, cognitive fusion, flexible attention to now, perspective taking sense of self, values, now, perspective taking sense of self, values, committed actioncommitted action

Clinical model: Psychological flexibility model Clinical model: Psychological flexibility model

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Psychological Flexibility

Contextual Behavioral ScienceContextual Behavioral Science Functional ContextualismFunctional Contextualism Behavioral principles and RFT within EvoSBehavioral principles and RFT within EvoS EA, fusion, now, self, values, actionEA, fusion, now, self, values, action Psychological flexibility modelPsychological flexibility model ComponentsComponents Breadth of application, Breadth of application, Mediators and moderators, Mediators and moderators, Dissemination and training strategy, Dissemination and training strategy, Construction of a development communityConstruction of a development community

ComponentsComponentsAcceptance Defusion Contact

with Present

Self-as-Context

Combinations of Four Mindfulness Components

Values Other Combination

Campbell-Sills et al., 2006

Marcks & Woods, 2005

Cioffi & Holloway, 1993

Williams, 2007

Arch & Craske, 2006 Cohen et al., 2000 Gutiérrez et al., 2004

Eifert & Heffner, 2003

Marcks & Woods, 2007

Kingston et al., 2007

Broderick, 2005 Cohen et al., 2006 McMullen et al., 2008

Levitt et al., 2004

Masuda et al., 2004

Leventhal et al., 1989

Burns, 2006 Creswell et al., 2005

Paez-Blarrina et al., 2008

Low et al., 2008

Masuda et al., in press

Logan et al., 1995

Feldner et al., 2003 Crocker et al., 2008

Roche et al., 2007

Michael & Burns, 2004

Hayes et al., 1999 Harris et al., 2005

Vowles et al., 2007

Haythornthwaite et al., 2001

Fein et al., 1997

Keogh et al., 2005; 2006

Paez-Blarrina et al., 2007

Masedo & Esteve, 2007

Spencer et al., 2001

Takahashi et al., 2002

Forman et al., 2007

Kehoe et al., 2007

Pain Tolerance Pain Tolerance McMullen et al., 2008McMullen et al., 2008

108642

Acceptanceand Defusion

Distraction

No Instructions

Instructions,Metaphor, Exercise

Instructions,Metaphor, Exercise

Instructions Only

Instructions Only

Shocks to Continue Task

Hedges's g and 95% CI

-.5-1.00.0

1.0.5Favors ACTFavors Control

Active Comparison (n=692)

Persistence and Willingness

Impact of ACT Components on Persistence and Willingness

Inactive Comparison (n=440)

Subjective Distress During Task

Active Comparison (n=693)

Inactive Comparison (n=564)

Inactive Comparison (n=145)

Subjective Distress While Recovering From Task

g = .13

g = .69

g = .48

g = .37

g = .47

g = .38

Active Comparison (n=423)

Breadth of ApplicationBreadth of Application

RCTsRCTs DepressionDepression 33 StressStress 44 PsychosisPsychosis 22 AnxietyAnxiety 11 PainPain 44 BurnoutBurnout 11 TrichTrich 11 Substance Substance 22

abuseabuse DD/DDDD/DD 11

RCTs

• OCD 1

• Epilepsy2

• Diabetes1

• Weight 3

• Prejudice 2

• Learning 2

• Cancer 2

• Smoking 3

• BPD 2

• Fitness 1

0 .25 .50

.75

1.0

Study Problem Comparison Mediator 

Tapper, 2009 Weight Diet PF/EA

Woods, 2006 Trichotillomania Wait list PF/EA

Gaudiano, 2009 Psychosis Enhanced TAU Defusion

Bond, 2000 Work stress Wait list PF/EA

Wicksell, 2009 Pain MDT + medication Defusion

Wicksell, 2008 Pain TAU PF/EA

Lazzaroni, 2009 Work stress Wait list PF/EA

Zettle, 1986 Depression CT Defusion

Hayes, 2004 Stigma Psychoeducation Defusion

Lappalainen, 2007 Outpatient misc CBT PF/EA

Lillis, 2009 Weight Wait list PF/EA

Lillis, 2007 Ethnic prejudice Education PF/EA

Gifford, under review Smoking Medications PF/EA

Lundgren, 2008 Epilepsy Supportive treatment PF/EA

Gregg, 2007 Diabetes Education PF/EA/Self-Manage

Varra, 2008 Resistance to ESTs Psychoeducation PF/EA/Defusion

Zettle, in press Depression CT Defusion

Gratz, 2006 BPD TAU PF/EA

Average Proportion Mediated: .53 (unweighted by n); .47 (weighted); Total n =

903

Follow up Change Outcomes; Post Mediators(3 studies no follow-up; 3 no post)

Testing with bootstrapped cross product:

All below p = .1All but 3, p

< .05

Large effect size

Proportion Mediated

The CBT Future? My The CBT Future? My GuessGuess

Down: syndromes, brute force empiricism, Down: syndromes, brute force empiricism, EBP based only on packages. EBP based only on packages.

Up: EB processes, EB procedures, functional Up: EB processes, EB procedures, functional analysis, transdiagnostic models. Why? analysis, transdiagnostic models. Why? More progressive and more functional.More progressive and more functional.

I believe general functional contextual I believe general functional contextual perspectives will compete with more perspectives will compete with more structural, special process, or mentalistic structural, special process, or mentalistic accounts accounts

… … and I expect more of …and I expect more of …

Contextual CBT (“Third Contextual CBT (“Third Wave”)Wave”)

Is grounded in an empirical, principle-Is grounded in an empirical, principle-focused approach, that is particularly focused approach, that is particularly sensitive to the context and functions sensitive to the context and functions of psychological phenomena more so of psychological phenomena more so than their validity or form, and thus than their validity or form, and thus tends to emphasize contextual and tends to emphasize contextual and experiential change strategies in experiential change strategies in addition to more direct and didactic addition to more direct and didactic onesones

Seeks the construction of broad, Seeks the construction of broad, flexible and effective repertoires flexible and effective repertoires over an eliminative approach to over an eliminative approach to syndromes, symptoms, or narrowly syndromes, symptoms, or narrowly defined problems;defined problems;

Emphasizes the relevance of these Emphasizes the relevance of these issues for clinicians as well as issues for clinicians as well as clients; clients;

Contextual CBT Contextual CBT

Reformulates and synthesizes what is Reformulates and synthesizes what is already known in behavioral and already known in behavioral and cognitive therapy, rather than rebelling cognitive therapy, rather than rebelling against it; andagainst it; and

Carries the behavioral and cognitive Carries the behavioral and cognitive therapy tradition forward into deeper or therapy tradition forward into deeper or more complex questions, issues, and more complex questions, issues, and domains that were previously addressed domains that were previously addressed primarily by other, less empirical primarily by other, less empirical traditions. traditions.

Contextual CBTContextual CBT

Context Over ContentContext Over Content

““unlike CBT, there is little emphasis in unlike CBT, there is little emphasis in MBCT on changing the content of thoughts; MBCT on changing the content of thoughts; rather, the emphasis is on changing rather, the emphasis is on changing awareness of and relationship to thoughts.” awareness of and relationship to thoughts.” (2004, p. 54). (2004, p. 54).

Behavioral activation “interventions address Behavioral activation “interventions address the the functionfunction of negative or ruminative of negative or ruminative thinking, in contrast to CT’s emphasis on thinking, in contrast to CT’s emphasis on thought thought contentcontent, [through] attention-to-, [through] attention-to-experience interventions” (Dimidjian et al., experience interventions” (Dimidjian et al., 2006, p. 668). 2006, p. 668).

Context Over ContentContext Over Content

““MCT does not advocate challenging MCT does not advocate challenging of negative automatic thoughts or of negative automatic thoughts or traditional schemas.” (Wells, 2008, traditional schemas.” (Wells, 2008, p. 651); while “p. 651); while “CBT is concerned CBT is concerned with testing the validity of thoughts with testing the validity of thoughts (…) MCT is primarily concerned with (…) MCT is primarily concerned with modifying the way in which thoughts modifying the way in which thoughts are experienced” (p. 652). are experienced” (p. 652).

A Content Focus is Not Buying Us MuchA Content Focus is Not Buying Us Much

25

0

10

15

20

30

ADMADM CTCTBehavioralBehavioral

ActivationActivation

Pre

to P

ost

Dec

reas

es in

BD

I

5

Psychological Flexibility

Open

Aware

Active

Defusion

Pre

sent

Mom

ent Perspective taking

ValuesAcceptance

Com

mitted

Action

(modified from Harris, 2009)

Simplified Psychological Simplified Psychological Flexibility ModelFlexibility Model

Psychological Flexibility

Open

Aware

Active

(modified from Harris, 2009)

Is This Becoming a Is This Becoming a Consensus Consensus

Contextual CBT Model?Contextual CBT Model?

The Triflex as a The Triflex as a Consensus Consensus

Contextual CBT Model?Contextual CBT Model?

Expos

ure

with

resp

onse

pre

vent

ion

Bec

k’s

Cog

nitiv

e Th

erap

y

Dialectical B

ehavior Therapy

Min

dful

ness

Bas

ed C

ogni

tive

Ther

apy

Rational E

motive B

ehavior Therapy

Acceptance and C

omm

itment Therapy

Sch

ema T

herap

y

Barlo

w’s U

nified

Pro

toco

l

Behav

iora

l Act

ivat

ion

Func

tiona

l Ana

lytic

Psy

chot

hera

py

Man

y oth

ersAp

praisal w

ork

Mindfulness B

ased Stress R

eduction

C B T

Mot

ivat

iona

l Int

ervi

ewin

g

Met

acog

nitiv

e Th

erap

y

The Big Tribal Umbrella

C B T

Emotion Cognition

Sense of SelfOvert Behavior

With Shared Targets

Social Functioning

Spirituality

C B T

Neo-Behavioral Information Processing

Behavior Analytic

Social Learning

But Varied Foundations

Hypothetico-Deductive

Inductive

Contextual Behavioral Science

Relational Frame Theory

C B T

Functional Contextualism

Elemental Realism

OrganicismConstructivism

And Philosophies

A C T

Functional Contextualism

Behavior Analytic

Inductive

Contextual Behavioral Science

Relational Frame Theory

And Distinct Features, e.g.

CBTCBT