Acceptance and Commitment Therapy Scott Clark
ACT (Hayes, Masuda & De Mey, in press) • 1950-60s 1stwave: Behaviour Therapy • focus on direct behaviourchange, classical and operant conditioning • 1970s 2ndwave: 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 (Morris & Oliver 2009) • Psychotherapy technique that: • Attempts to expand a person’s behaviouralrepertoire by increasing the ability to respond flexibly in response to the opportunities presented by each situation for valuedliving. • 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 verbalcontexts 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 importantto you; what sort of person you want to be • Committed action • setting goals, guided by your values, and taking effective action to achieve them
HEXAFLEX DIAGRAM 6. … at this time, in this situation? Acceptance and mindfulness Commitment and behaviour change 2. … are you willing to have that stuff, fully and without defense … 5. … of your chosen values … 3. … as it is, and not as what it says it is … 4. … and do what takes you in the direction … 1. Given a distinction between Context you and the stuff you are struggling with and trying to change …
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 psychological 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 (Smoutet 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 generalisedanxiety 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, Vörding M, Emmelkamp P (2009) Acceptance and Commitment Therapy: A Meta-Analytic Review. PsychotherPsychosom78:73–80. • 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