A Review of Acceptance and Commitment Therapy (ACT) Empirical Evidence:

Correlational, Experimental,

Psychopathology, Component and Outcome Studies

By Francisco J. Ruiz (2010)

ACT

A psychological intervention Philosophically rooted in functional

contextualism Rooted in Relational frame theory (RTF) Treatment of experiential avoidance

disorder (EAD) Functional dimensional approach to

psychopathology

Functional contextualism

Generally contextualism observes actions in a context

Functional contextualism specific way of contextualism which undermines prediction and influence of events with precision, scope and depth.

Thoughts or actions are not seen correct or incorrect

It focuses on usefulness

RFT

Contextual behaviorism approach to human language and cognition

Based on laws Human beings learn to relate stimuli

under arbitrary contextual control It has three requisites for considering

the existence of relational frame

RFT

Mutual entailment

AB

BA

Combinational

Entailment

A>B, B>C

A>C

Transformation of

Functions(Depends on function)

RFT

Has large number of implication of area of psychopathology and psychotherapy

Briefly nature of language and cognition has more impact on changing attempts focused on the function of private events

Experiential Avoidance

Deliberate effort to avoid and/or escape from private events such as thoughts, memories and bodily sensations.

When EA combined with psychological inflexibility problems occur.

EA works in short run. In long run, it provokes patients’ life.

Essential ACT Principles and Methods

What does ACT provide ?

Generates psychological flexibility Contact the present moment

Proposes acceptance To involve oneself in valued action

Therapeutic Work in ACT

Promotes

Values clarification

and actionsDefusion

Values clarification and actions

Creative hopelessness

Values clarification

Promotion of the willingeness to experince

Defusion

To choose to behave in valued way

Cognitive defusion - weakining the tendency to treat them.

Self as a context - there is a YOU

behind all private events

How ACT obtaion its objectives

metaphors

paradoxes

Experiential exercises

Classical exposure therapies vs. ACT

Extinction of discomfort

Trains the patients to be present with their feared experince

Directs them to behave in a valued way.

ACT Empirical Reviews

First Critique: Corrigan (2001)

ACT has not been developed with the usual rationale--philosophical and theoretical roots were not used

First Review: Hayes et al (2006)• Correlation evidence• Experiential avoidance, experimental psychopathology and

ACT component studies, randomized controlled trials and processes of change studies

• ACT—superior to control conditions, wait-lists and treatment• ACT—superior to structured interventions

Other research:

Öst (2008): Qualitative and quantitative review of the ACT empirical evidence from RCT.

--Comparing ACT versus CBT (Cognitive Behavior Therapy)

--Conclusion: ACT showed lower scores in a methodological scale compared with CBT

--ACT does not fulfill the criteria for being considered as an empirical validated treatment.

Re-analysis of Öst review: Gaudiano (2009)

%38 of the ACT studies could not be matched with CBT study because:

--Studies were conducted over different disorders

--Different population

CBT studies were 4.5 more times funding than ACT studies

Recent Review: Powers, Vörding & Emmelkamp (2009) Meta-analytic review of ACT empirical evidence in

RCT studies--Conclusion: ACT is better than wait-lists,

placebo attention conditions BUT

not significantly better than established treatments

HOWEVER Re-analyzed the data base: Levin & Hayes (2009)

--Conclusion: ACT was better than established treatments

Emprical Evidence of ACT Model

separated as a correlational, experimental psycpath. and component studies, outcome studies and case studies.

Correlational Studies; Aim to study relationship among experiential

avoidance and psychological symptoms. ‘’Acceptance and Action Questionnaire’’ is used in

studies. it measures experiential avoidance Experiential avoidance is analyzed with different types

of psychological construct and symptoms . Chronic pain is one of them

Kratz, Davis,& Zatura (2007) have showed that acceptance of pain predicted posterior positive affect.

According to Wicksell, Renöfalt, Olsson, Bond & Melin (2008), acceptance predicted pain severity , pain interference in everyday life and physical and metal well-being.

In work setting, the level of experiential avoidance has predicted mental health and performance in learning a new software (Bond, & Flaxman, 2006).

Experiential avoidance has been a mediator between childhood psychological abuse and current mental health symptoms (Reddy, Picket, & Orcutt, 2005).

Experiential avoidance block the reduction of depression in the treatment of borderline personality disorder.

Experimental psychopathology and ACT component studies

3 types of studies : effect of experiental avoidance, effect of acceptance coping instructions, effect of brief ACT protocol

Studies about effect of experiental avoidance repertoire in experimental task:

Predictive power of the level experiental avoidance of

participants selecting participants with high and low scores in AAQ

Cold pressor task (Zettle et al.,2005)

-High score of AAQ had lower tolerance and kept their hand in cold water less time than participant with low AAQ score

Effect of being drunk (Zettle,Petersen,Hocker&Provines,2007) -Higher scores in AAQ were more discomforting and had worse performance on challenging perceptual-motor task than lower scores.

Carbon dioxide-enriched air challenge (Feldner, Zvolensky, Eifert &Spira (2003)

-High levels of AAQ showed more anxiety and emotional discomfort but not more phsysiological activation

- High AAQ score, received suppression protocols, showed higher levels of anxiety than those who received perceived acceptance control

Comparing emotional reactions (Sloan,2004) -participants with high level of experiental avoidance showed higher

emotional experience and higher heart rate with the pleasent and unpleasent films

THE EFFECT OF ACCEPTANCE COPING INSTRUCTIONS

Nihan Kaymaz

Several studies focused on the effects of acceptance coping instructions

Aim: to assess the psychopathology in terms of comparing acceptance coping instructions and other coping strategies

Aversive stimulation, intrusive thoughts, cardiovascular conditions, emotional contents

In terms of aversive stimulation:

Keogh, Bond, Hanmer & Tilston (2005): Cold-pressor task Acceptance coping instruction obtained better results than one

‘distraction coping instruction’ with women The same effect with men

In terms of intrusive thoughts: Marks & Woods (2005):

Acceptance instructions vs. suppression in the management of intrusive thoughts

Acceptance coping instruction group: less discomfort when experiencing the intrusive thoughts.

Suppression group: more intrusions, higher levels of anxiety, negative evaluation compared with acceptance

(while doing a task which consisted in saying aloud and imagining that

a loved one were having a traffic accident)

Najmi, Riemann & Wegner (2009): Similar effects with those with OCD Both acceptance and focused distraction coping instruction

groups had less distress than suppression group.

In terms of cardiovascular conditions:

Low, Stanton & Bower (2008): Acceptance-oriented processing vs. evaluative emotional

processing on cardiovascular habituation and recovery Task: writing about an ongoing stressful experience Better efficient heart rate habituation and recovery in

acceptance condition

In terms of emotional contents:

Campblell-Sills, Barlow, Brown & Hofmann (2006): Differential effect of suppression vs. acceptance instructions Task: viewing a highly emotional film Lower heart rate and less negative effect during the film in acceptance

condition than in suppression condition

Liverant, Brown, Barlow & Roemer (2008): Depressed participants used Suppression produced short-term reduction in sadness with low levels

of anxiety However, not effective at moderate and higher levels

In terms of emotional contents:

Hofmann, Heering, Sawyer & Asnaani (2009): Suppression vs. cognitive reappraisal vs. acceptance instruction Task: coping with an impromptu speech in front of a video-camera Higher heart rate in suppression condition than in others Also, subjective experience of anxiety was lower in cognitive

reappraisal than acceptance

Dunn, Billotti, Murphy & Dalgleish (2009): Suppression vs. acceptance on processing distressing materials Suppression showed better results However, suppression was accepted similar to cognitive reappraisal

coping instruction

Limitations ACT does not instruct acceptance

Metaphors and experiential exercises are used

Coping strategies have some similarities among them and there is still no a consensus about their verbal processes Both acceptance and cognitive reappraisal involve distancing

from thoughts

Acceptance coping protocols in these studies did not include valued oriented behaviors or any valued context. In ACT, acceptance is always at the services of values

Effects of ACT Protocols

Cold-pressor task experiments:

Hayes, Bissett, et al(1999): Acceptance-based protocol vs . Control-based protocol

Masedo& Esteve (2007):Acceptance-based protocol vs. Suppression-based protocol

Branstetter-Rost et al (2009):ACT-based acceptance with/without values

Pain-tolerance task experiments:

Takahashi et al (2002):ACT exercises vs. CBT exercises

Gutierrez et al (2004):Acceptance-based protocols vs. Cognitive-control-based

protocols

McMullen et al (2008):Acceptance-based coping strategies vs. Control-based strategies

Blarrina et al (2008):ACT values protocol vs. Control values protocol

OUTCOME STUDIES

CLINICAL PSYCHOLOGY

Depression Anxiety disorders Psychotic symptoms Personality disorders Addictive behaviors At-risk adolescents

CLINICAL PSYCHOLOGY Two studies: ACT and depression Zettle & Hayes, 1986:

Comprehensive distancing vs. two versions of cognitive therapy

ACT was better after therapy and after 2 month follow up.

• Zettle & Hayes, 1989: ACT in group format vs. the previous two CT

versions in groups Cognitive fusion mediated the results

(believability of depressive thoughs).

ANXIETY DISORDERS

Two studies: ACT and OCD Twohig, Hayes & Masuda, 2006b:

Positive results with all participants Twohig, 2007:

ACT vs. Progressive Relaxation Training Less compulsions with ACT group than

relaxation group at post-treatment and at 3 month follow-up.

ANXIETY DISORDERS

Four studies: ACT and Social Phobia Block, 2002:

ACT vs. CBT, participants with subclinical social anxiety

ACT group was better at public speaking• In general, ACT is a promising

treatment for social phobia

ANXIETY DISORDERS Generalized Anxiety Disorder

Roemer & Orsillo (2007): ACT obtained large effect sizes in reducing GAD symptoms.

• Hayes, Orsillo & Roemer (in press): Acceptance in private events and

engagement in meaningful activities related to responder status and quality of life at post-treatment.

Trichotillomania and skin picking: Studies reported positive results.

ANXIETY DISORDERS

Diverse symptoms related to anxiety and/or depression

ACT vs. CBT or CT ACT obtained more improvements at

post-treatment and at the 6 month follow-up

Decrease of experiential avoidance (Lappalainen et al., 2007).

PSYCHOTIC SYMPTOMS

Bach & Hayes (2002): 45 minute sessions of ACT and TAU vs.

only TAU to prevent rehospitalizations ACT and TAU condition decreased

rehospitalizations, hallucinations and delusions believability.

• Gaudiano & Herbert (2006a & 2006b): same results.

PERSONALITY DISORDERS

Gratz & Gunderson (2006): patients with borderline personality disorder. TAU vs. ACT and TAU Even though both conditions have

significant effects, the latter one reached normative functioning levels.

ADDICTIVE BEHAVIORS

Hayes, Wilson et al. (2004): polysubstance abusing individuals being maintained on methadone ACT, Intensive Twelve Step Facilitation

vs. Methadone Maintenance only ACT condition showed greater decrease

in total drug use at the 6 month follow-up

AT-RISK ADOLESCENTS

Gomez et al. (under review): In the treatment of at-risk adolescents

who are with a history of antisocial behavior and current legal issues (n=5)

Less impulsivity, higher self-control, more value oriented actions

Improvements increased in one year follow-up

AT-RISK ADOLESCENTS Luciano et al. (2009):

Adolescents with moderate or high risk (n=15) of having impulsivity or emotional problems

Values clarification protocol: promoting choosing and taking responsibility for own choices

Showed a large effect only for moderate-risk adolescents

Defusion protocol: discriminating private events Produced a large effect size for high-risk adolescents

and improved the effect of values protocol.

ACT in Health Psychology

Dahl, Wilson, & Nilsson (2004): Chronic pain, ACT vs. TAU Less sick days for ACT group at 6 month follow-up

Wicksell et al. (2008): On people with Longstanding Pain –> significant

improvements in functioning, life satisfaction, fear of movements and depression at 7 month follow-up.

Gifford et al. (2004): ACT>CBT -for chronic pain- (Smoking Cessation

ACT>Nicotine Replacement Therapy) at 1 year follow-up.

ACT in Health Psychology Branstetter et al. (2004):

Distress resulted from end-stage cancer ACT>CBT for alleviating distress levels

Lundgren et al. (2006): Epilepsy ACT condition vs. Attention Placebo Condition At 12 month follow-up Less seizures, higher quality of life

Forman et al. (2009): Weight loss in obese women At post-treatment 6.6% of body weight lost At 6 month follow-up 9.6% of body weight lost

ACT in Health Psychology Gregg et al. (2007):

Type II Diabetes Diabetes Education vs. ACT + Diabetes Education ACT condition was more succesful in promoting

self-management behaviours Hesser et al. (2009):

ACT reduced Tinnitus Distress At 6 month follow-up symptom reduction

Good outcomes in: Multiple Sclerosis (Sanchez & Luciano, 2005), Prevention of HIV (Gutiérrez et al., 2007), Systematic Lupus Erythematosus (Quirosa et al.,

2009)

Other Areas of Intervention

OTHER AREAS of INTERVENTION

Fernandez et al. (2004);

- sport performance enhancement

- carried out RCT

- ACT vs. hypnosis

RESULTs : ACT showed greater influence BUT without reaching a statistical significant differences.

OTHER AREAS of INTERVENTION

Chess players who showed the greatest improvement in their performance were the ones who had higher levels of experiental avoidance during competitions at pretreatment

OTHER AREAS of INTERVENTION

Work Settings ;Differential effect of ACT 3 hours session intervention vs.

Innovation Promotion Program and wait-list condition

ACT showed better effect in post treatment and in the 3 month follow-up in the improvement of general mental health

OTHER AREAS of INTERVENTION

Potential efficacy of ACT in reducing the resistance to the use of emprical validated treatments among professional councelors

Louma et al. (2007) compared the differential effect of 8 ACT sessions with a control condition

RESULTS: in the ACT condition, counselors followed using the empirical validated treatment at the 2 and 4 month follow-up more frequently than control condition

OTHER AREAS of INTERVENTION

Reducing prejudice and stigma Hyes et al. (2004)

Differential effect of ACT vs. Multicultural Training and Biological Education in diminishing the stigma and burnout among substance abuse counselors

RESULTs: ACT obtained better results than the other intervention of stigma, burnout and the believability of stigmatizing attitudes at post-treatment and 3 months follow-up

OTHER AREAS of INTERVENTION

• Masuda et al. (2007)

- effect of an ACT intervention vs. educational intervention in reducing stigma towards people with mental disorders

- differential effect of the protocols among participants with high and low AAQ scores

OTHER AREAS of INTERVENTION

RESULTS;

-in post-treatment and at the 1 month follow-up, ACT produced a decrease on stigma both in participants with high and low AAQ scores

-Higher effect in the high avoidant participants

-Educational intervention worked with participants with low AAQ scores

Published case studies:Depression GAD Anxiety Agoraphobia Panic disorder PSTD OCD Psychotic symptoms Anorexia nervosa Schizotipic personality disorder Familiar and couples problems Patients with intellectual disabilities Exhibitionism Sexual dysfunction and orientation Alcoholism Heroin addiction Chronic pain Cancer Swimming and weightliftingChess Lacrosse

Discussion

ACT is effective in a wide range of problems Typically better after follow-up Relevant effect when applied to extremely short

interventions The empirical evidence is compromising

Some studies show that: ACT and CBT have similar effects Better results for ACT

However;

Still needed for more controlled studies with larger

samples!

Coherent results with the literature of experiential psychopathology

The review of correlational studies strongly support the ACT model Experiential avoidance as a mediator

Some conclusions can be made out: Highly experiential avoidance participants responds

differently to several experimental challenges Acceptance values based protocols are effective in

improving the participants in the experimental challenges

More effect has been found in ACT protocols than in control based ones

DISCUSSION

Although the RFT state of evidence was out of the scope of the current study, it is called to be most differential characteristic between ACT and other second and third wave therapies.

DISCUSSION

Although RFT definition of acceptance, values, and cognitive defusion is in its beginnings, it is the most important area of research that needs to be done in order ro improve ACT results..

DISCUSSION

For example, consider 2 specific issues:

1. To better know what are the specific transformations of functions involved in cognitive defusion and values clarification exercises would allow to redefine or invent new exercises that become more powerful

DISCUSSION

2. İf the therapist know the specific verbal processes in the transformation of functions through analogical relations, he/she becomes using more effective methapors in practice

CONCLUSION

ACT seems to have strong support in view of the correlational, the experimental psychopathology, and the outcome evidence

It is worth nothing that ACT is a therapy with very singular characteristic.

CONCLUSION

Also, it is a good model of psychopathology of EAD or psychological flexibility

ACT also have similarity with CBT or between other types of therapies.