WorldCon XIII Reno, NV June 19-26, 2010

1. WorldCon XIIIReno, NVJune 19-26, 2010

2. Contextual Behavioral Scienceand the Role of RFT Steven C. Hayes University of Nevada

3. Our Society By consensus of the group, our association is not named for ACT, or RFT, or 3rd generation CBT This talk is about what it is named for and why it matters. I want to suggest that the approach this group is taking is coherent, and potentially important to the field at large

4. When Behavior Therapy Started • During the first wave of behavior therapy which involved "operationally defined learning theory and conformity to well established experimental paradigms" (Franks & Wilson, 1974) • This contained a model of how to produce progress, and what it would look like: empirical validation AND a link to basic processes and coherent theory

5. And When Behavior Analysis Started • It embraced a bottom up, inductive vision • Begin with the individual, non-verbal organism and scale into human complexity • Move toward the largest prize: projecting behavioral science into every aspect of human functioning (think Walden II)

6. Changes in Behavior Therapy • Clinicians soon thought they needed a better way to deal with cognition than basic behavioral principles • And they could not figure out how to do so using basic cognitive science so they began to create clinical theories of cognition • With the advent of traditional CBT the vision of progress changed

7. Meanwhile in Behavior Analysis • Unable to overcome the problems of human verbal behavior, ABA began to focus more on children, DD or institutionalized populations • Verbal behavior became much more a matter of interpretative adoption of Skinner’s approach • But with that its original vision became lost or merely rhetorical

8. An Alternative Path In the early-1980s we did 7-8 component and basic studies on what accounted for CBT effects – none of the results fit with a traditional cognitive model and we abandoned that line of work We wanted a general theory that would work: bottom up, coherent, broadly applicable And we tried to find a way forward by tweaking a behavior analytic strategy

9. Behavior Analysis • Its contextual and pragmatic nature (“prediction and influence” as a goal) fits with clinical goals and it contains readily manipulable independent variables • And it’s inductive strategy did work … until it hit the issue of cognition • We thought we might be able to overcome that and to modernize the strategy

10. The Oft-Told Tale • What happened from 1985 until 1999 was not just the development of RFT, or the maturing of ACT • We ended up with a strategy for progress: CBS

11. CBS In this talk I will describe the major features of contextual behavioral science as an approach to scientific development. I will argue that while it is slow, it is steady and can speed up as the group grows And like the story of the hare racing the turtle, a slow turtle may have some advantages in the long run

12. Contextual Behavioral Science Our mission is bold: creation of a comprehensive psychological science more adequate to the challenges of the human condition But our strategy is humble: contextual, inductive, pragmatic, participatory, and at times small n.

13. The Eight-Fold Path of Contextual Behavioral Science Philosophy

14. Philosophy: Functional Contextualism What is philosophy of science Why most empirical traditions in the behavioral sciences skip over this step Why we cannot

15. Philosophy: Functional Contextualism Monistic, radically pragmatic, contextualistic and a-ontological The world is one – our behavior partitions it “Truth” refers to what works: to consequences Like an arrow shot “true,” to determine what works we need your target – your goals An ontological leap adds nothing to knowledge claims

16. Philosophy: Functional Contextualism Psychological level of analysis: Act-in-context of whole organisms Our goal in CBS: Prediction and influence with precision, scope, and depth

17. The Eight-Fold Path of Contextual Behavioral Science Philosophy Basic account

18. Basic Account: Behavioral Principles as Extended by Relational Frame Theory (RFT) CBS strategy aims for an account that is bottom up, inductive, and yet broadly applicable That strategy requires a basic, technical account that continuously informs application and vice versa, based on a contextual behavioral approach What CBS adds is this: it is our responsibility as a whole community, applied folks included

19. Early Work in Rule-Governance Led to RFT • We showed in the early 1980’s that verbal interventions could undermine excessive control by verbal rules, but that led to … • What controls the impact of a verbal stimulus? • In fact, what is a verbal stimulus? • So “taking responsibility” meant that we started out with how to do psychotherapy and ended up with this question: “what is language and cognition?”

20. Limoo Betrang Seeds of an Answer:Normal Human Adults do this in Some Relational Contexts … Mutual entailment Combinatorial entailment But Why?

21. Betrang salivation salivation sour sour bumpy bumpy yellow yellow lemonade lemonade citrus citrus And They do This in Some Functional Contexts ….. But Why? Transformation of functions

22. Our Dumb Behavioral Idea • Maybe it is operant behavior • Could it be viewed as a contextual controlled overarching relational operant, based originally on multiple exemplar training? • If so “equivalence” is one of many such relational actions

23. 10 10 10 5 5 5 And thus that a dime is “bigger than” a nickel & is worth more Good good If then A Classic Example all Parents Know A child learns that a nickel is “smaller than” a dime

24. We Now Know Can Teach Them Berens & Hayes, 2007 4 year olds Teach (with “coins”) “This is more than that. Which would you use to buy candy?” Steps: A > B; A < B; mixed; A > B > C; A < B < C; mixed; A < B, C > A Test for generalization with novel sets

25. And They Generalize

26. We Now Know That • Without relational operants children do not develop language • Relational frames change how other behavioral processes work • We can model cognitive phenomena behavioral and neurobiologically using RFT

27. The Eight-Fold Path of Contextual Behavioral Science Philosophy Basic account Clinical model

28. Clinical Model: The Hexaflex A model of psychopathology / human growth and a model of treatment linked to behavioral principles and RFT It is an operating system: these are not basic principles, they are middle level processes linked to basic principles. It’s OSX, not C++ Why an operating system

29. Psychological Flexibility Hexagon Model of Treatment

30. The Eight-Fold Path of Contextual Behavioral Science Philosophy Basic account Clinical model Components

31. Components Manipulable processes linked to basic principles MUST lead to active treatment components, otherwise that part of the theory MUST be discarded These processes can be tested tightly, frequently, and early in experimental psychopathology and smaller clinical studies and inform treatment development

32. 38 Published Studies on ACT Components

33. Hedges's g and 95% CI Study Process Targeted Comparison Eifert & Heffner, 2003 -2.0 -1.0 0.0 1.0 2.0 Favors Control Favors ACT As an Example, a Partial List: Impact of ACT Mindfulness Components on Persistence and Willingness: Active Comparisons -2.0 -1.0 0.0 1.0 2.0 Acceptance Diaphragmatic Breathing Levitt et al., 2004 Acceptance Suppression Roche et al., 2007 Acceptance Perseverance Vowles et al., 2007 Acceptance Control Training Marcks & Woods, 2007 Defusion Suppression Cioffi & Holloway, 1993 Present Moment Distraction & Suppression Kingston et al., 2007 Present Moment Guided Imagery Hayes et al., 1999 Mindfulness Components CBT for pain Keogh et al., 2005 Mindfulness Components Distraction and Control Keogh et al., 2006 Mindfulness Components Distraction and Control Masedo & Esteve, 2007 Mindfulness Components Suppression

34. Hedges's g and 95% CI 0.0 -1.0 -.5 .5 1.0 Favors Control Favors ACT Impact on Persistence, Willingness, and Distress Persistence and Willingness g = .40 Active Comparison (n=692) g = .82 Inactive Comparison (n=440) Distress During Task g = .09 Active Comparison (n=693) g = .23 Inactive Comparison (n=564) Distress While Recovering From Task g = .38 Active Comparison (n=423) g = .31 Inactive Comparison (n=145) Persistence and Willingness g = 1.96 Full package (n=72) Rationale plus metaphor or exercise but not both (n=854) g = .69 Rationale alone (n=173) g = .03

35. Pain Tolerance McMullen et al., 2008 Instructions, Metaphor, Exercise Acceptance and Defusion Instructions Only Instructions, Metaphor, Exercise Distraction Instructions Only No Instructions 2 4 6 8 10 Shocks to Continue Task

36. The Eight-Fold Path of Contextual Behavioral Science Philosophy Basic account Clinical model Components Processes

37. Processes: Diagnosis, Mediation, and Moderation Develop process measures (experiential avoidance, psychological flexibility, values, defusion) Many specific versions now (in pain, weight, stigmas, diabetes, epilepsy, smoking, trauma, tinnitus, psychosis, etc) Looking at them correlationally, in case conceptualization and functional dimensional diagnosis, mediation, and moderation

38. Correlational Studies Well over 10,000 participants in nearly 50 studies show that ACT processes can account for a substantial portion (around 16-25%) of almost anything you can name ACT processes mediate many forms of coping and psychological adjustment including some very important ones such as cognitive reappraisal

39. the c’ path Mediator M the b path (controlling for X) the a path Treatment X Outcomes Y the c path Treatment Mediation Preferably M before Y; better: before Y changes

40. c’ a b c Meta-Analysis of ACT Mediation • 23 of the first 31 ACT RCTs used measures of ACT processes as mediators and are out, in press, or in preparation and we can get the complete data set • These are the first 18 studies we’ve walked through

41. Large effect size Follow up Change Outcomes; Post Mediators (3 studies no follow-up; 3 no post) Proportion Mediated 0 .25 .50 .75 1.0 Testing with bootstrapped cross product: All below p = .1 All but 3, p < .05 Average Proportion Mediated: .53 (unweighted by n); .47 (weighted); Total n = 903

42. The Eight-Fold Path of Contextual Behavioral Science Philosophy Basic account Clinical model Components Processes Breadth

43. Why Breadth? • Breadth and the claims of the model • Controlled studies in depression, stress, adjustment to psychosis, anxiety, chronic pain, burnout, trichotillomania, substance abuse, developmentally disabled/dually diagnosed, OCD, epilepsy, diabetes, weight control and maintenance, tinnitus, GAD, marijuana addiction, prejudice, learning, dealing with cancer, smoking, borderline personality disorder, fitness, prevention of depression and anxiety problems, adjusting to detoxification, skin picking, pornography addiction, self-stigma and shame in addiction, trauma, intercultural adjustment, body image concerns, adolescent depression, work effectiveness, adjusting to cancer, playing world class chess

44. Pediatric Chronic PainWicksell, Melin, Lekander, & Olsson, Pain, 2009 • 32 patients w/ longstanding pediatric pain • 25 female; ~ 15 y o, 32 mo pain duration • Randomly assigned to ACT or multidiscipinary Rx & medication (MDT). 2 drop outs. • Pre / post / 3.5mo f-up / 6.5 mo f-up • ACT = 12 session; MDT = 23

45. 4 6 2 Pain Interference Pain Interference (1-10) Pre Post 3.5 mo 6.5 mo

46. The Eight-Fold Path of Contextual Behavioral Science Philosophy Basic account Clinical model Components Processes Breadth Dissemination and training

47. Dissemination and Training Include from the very beginning. Why? Pragmatic view of truth Contextual view of behavior One of the things this does is to put the real world issues of end users and practitioners into a central role early, rather than as an afterthought

48. Dissemination and Training Three effectiveness trials including the first ACT study in the modern era Three trials on the use of ACT to train other things One on how to train ACT You can also include here trials on broadly disseminable methods such as books, tapes, or websites

49. Impact of an ACT Book on Depression Sub-analysis of 46 depressed teachers in a wellness program 8 weeks to read the book 4 month follow up Then the wait list reads the book. DASS-D cutoff: 20 or higher (clinical cut off and gives us an average like in patient population) Goal: 13 or lower (cutoff and the expected response to hospitalization)

50. Depressed Teacher Subsample Average for Hospitalized Depressed Patients Book Analysis of 0,2,6 month data: p eta sq = .25 (large effect size) Teacher Sample How about clinical significance? % who get across that green line Book O 2 6 8