A Therapeutic Exchange Acceptance and Commitment Therapy ACT

1
A Therapeutic ExchangeAcceptance and Commitment
Therapy (ACT)

• Mark Webster
• Psychotherapist
• Personality Disorders and Addictions

2
Overview

• Background
• Theory
• Aims of ACT
• Research

3
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

4
Relational Frame Theory (RFT)

• How can you turn the screw?

Pliable
Plastic
Melts
Forms a shape
Cools
Hardens
Leverage
5
Relations
Transformation of Functions
6
Example
7
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!

8
toxic
toxic
toxic
toxic
toxic
toxic
9
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!

10
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

11
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

12
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)
13
Experiential Avoidance is Harmful

• Thought and emotional suppression is often
  counterproductive

Suppress
Accept
Source Walser (1998)
14
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)
15

• The Goals and Components of ACT

• Undermine experiential avoidance
• Creative hopelessness
• Control is the problem
• Provide alternatives
• Acceptance
• Exposure
• Contact with the present moment

16
Outcome Research

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

17
Coping with Psychotic Symptoms Bach Hayes,
JCCP, 2002

• Could this work even with the most horrifying
  forms of private events?
• 80 Ss 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

18
Impact on Rehospitalization
1.0
.9
.8
Proportion Not Hospitalized
.7
.6
40
80
120
Days After Initial Release
19
Process of ChangeBelievability
80
Level 2 process evidence
Control
Literal Believability of Psychotic Symptoms
(0-100)
60
ACT
40
Pre
F-up
Phase
20
Coping with Psychosis 2Gaudiano 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

21
Rehospitalization
100
ACT
90
80
70
Not Readmitted
ETAU
60
50
40
Post
4 mo Follow Up
Phase
22
Hallucination Distress
8
ETAU
7
Hallucination Distress (1-10)
6
ACT
5
Pre
Post
Phase
23
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

24
Subjectively Assessed Total Drug
Percentage Negative QAs
Post
6 Mo Follow Up
Pre
Phase
25
Stigma Toward Our ClientsHayes 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

26
Effects on Stigma
Control
Multicultural
ACT
27
Change in Burnout
Education
ACT
Multicultural
4
0
-4
Pre- Post
Pre- F-up
Pre- Post
Pre- F-up
Pre- Post
Pre- F-up
28
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

29
Stress
General Health and Stress
14
Behavioral Innovation
12
Control
ACT
10
Pre
Mid
Post
F-Up
30
ACT for EpilepsyLundgren, 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

31
Outcome Seizure Time
600
400
Seconds
200
Pre
Post
6 mo
1 yr
32
Outcome Seizure Time
600
400
Seconds
200
Pre
Post
6 mo
1 yr
Cohens d at 1 yr 1.25
33
Outcome
34
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