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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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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 Clinical Psychology

  • 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)


Evidence base for ACT Clinical Psychology

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


Evidence base for ACT Clinical Psychology

Experimental & Theoretical Work:

Questionnaire studies using the Acceptance & Action Questionnaire:

There are now 27 studies using the AAQ, involving 5,616 participants


AAQ Scores Are Associated With …. Clinical Psychology

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


Evidence base for ACT Clinical Psychology

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


Evidence base for ACT Clinical Psychology

The first RCT: Depression

Zettle and Hayes, 1987

Done at the Centre for Cognitive Therapy in Philadelphia with Aaron T. Beck

Surprisingly…


Significantly Better Outcomes Clinical Psychology

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


Not only that, but process too! Clinical Psychology

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 %


ACT For Psychosis Clinical Psychology

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


ACT Clinical Psychology

Treatment as Usual

Impact on Rehospitalization

1.0

.9

.8

Proportion Not Hospitalized

.7

.6

40

80

120

Days After Initial Release


Processes of Change: Symptoms Clinical Psychology

100

ACT

Percentage Reporting Symptoms

75

50

Control

25

Pre

F-up

Phase


Processes of Change: Clinical PsychologyBelievability

80

Control

Literal Believability of Psychotic Symptoms

(0-100)

60

ACT

40

Pre

F-up

Phase


Chronic Pain Clinical PsychologyMcCracken, 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


Chronic Pain Clinical PsychologyMcCracken, Vowles, & Eccleston, BRAT, 2005


Chronic Pain Clinical PsychologyMcCracken, Vowles, & Eccleston, BRAT, 2005


Refractory Epilepsy Clinical PsychologyLundgren, 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.


Refractory Epilepsy Clinical PsychologyLundgren, 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:


Refractory Epilepsy Clinical PsychologyLundgren, Dahl, Melin & Kies (2006) Epilepsia

Interestingly the seizures reduce before the delivery of the behavioural technologies.


Evidence base for ACT: Clinical Psychology

Overall effect sizes across all RCT’s


Evidence base for ACT Clinical Psychology

“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


Evidence base for ACT Clinical Psychology

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)


Evidence base for ACT Clinical Psychology

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)


Evidence base for ACT Clinical Psychology

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)


Evidence base for ACT Clinical Psychology

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)


Evidence base for ACT Clinical Psychology

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)


Evidence base for ACT Clinical Psychology

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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