Mindfulness and Behavior Change Processes in Acceptance and Commitment Therapy

Mechanisms of Change in Acceptance-Based Mechanisms of Change in Acceptance-Based InterventionsInterventions

Chair: Evan M. Forman, Drexel UniversityChair: Evan M. Forman, Drexel UniversityDiscussant: Steven C. Hayes, University of Nevada, RenoDiscussant: Steven C. Hayes, University of Nevada, Reno

Mindfulness and Behavior Change Processes in Acceptance and Mindfulness and Behavior Change Processes in Acceptance and Commitment TherapyCommitment Therapy

Akihiko Masuda & Steven C. Hayes, University of Nevada, RenoAkihiko Masuda & Steven C. Hayes, University of Nevada, Reno

The Relationship of Three Self-report Measures of Mindfulness to The Relationship of Three Self-report Measures of Mindfulness to Each Other and to Measures of Emotion, Cognition, and Each Other and to Measures of Emotion, Cognition, and

PsychopathologyPsychopathologyEmily A. Haigh, Shane A. Mares, Candace Croft, Michael T. Moore, & David M. Fresco, Emily A. Haigh, Shane A. Mares, Candace Croft, Michael T. Moore, & David M. Fresco,

Kent State UniversityKent State University

Differential Strategies in Coping with Induced Pain as a Function of Differential Strategies in Coping with Induced Pain as a Function of Experiential AvoidanceExperiential Avoidance

Robert D. Zettle, Tanya R. Hocker, Katherine A. Mick, Brett E. Scofield, Connie L. Robert D. Zettle, Tanya R. Hocker, Katherine A. Mick, Brett E. Scofield, Connie L. Petersen, Petersen,

Hyunsung Song & Ratna P. Sudarijanto, Wichita State UniversityHyunsung Song & Ratna P. Sudarijanto, Wichita State University

Learning is a Mechanism Through Which Psychological Acceptance Learning is a Mechanism Through Which Psychological Acceptance Affects Mental Health and Job PerformanceAffects Mental Health and Job Performance

Frank W. Bond, Goldsmiths College, University of London, United KingdomFrank W. Bond, Goldsmiths College, University of London, United Kingdom

Comparing Outcome and Mechanisms of Action in Cognitive Comparing Outcome and Mechanisms of Action in Cognitive Behavioral and Acceptance and Commitment TherapiesBehavioral and Acceptance and Commitment Therapies

Evan M. Forman, James D. Herbert, Peter D. Yeomans, Katie McGrath, Ethan Moitre & Evan M. Forman, James D. Herbert, Peter D. Yeomans, Katie McGrath, Ethan Moitre & Pamela A. Geller, Drexel UniversityPamela A. Geller, Drexel University

Comparing Outcome and Mechanisms Comparing Outcome and Mechanisms of Action in Cognitive Behavioral and of Action in Cognitive Behavioral and

Acceptance and Commitment Acceptance and Commitment TherapiesTherapies

Evan M. Forman, James D. Herbert, Peter D. Yeomans, Evan M. Forman, James D. Herbert, Peter D. Yeomans, Katie McGrath, Ethan Moitre & Pamela A. Geller, Katie McGrath, Ethan Moitre & Pamela A. Geller,

Drexel UniversityDrexel University

Corresponding Author:Evan M. Forman, Ph.D.Department of PsychologyDrexel University245 N 15th Street, MS 515Phila., PA 19102(215) [email protected]

Paper presented at the AABT, New Orleans, November 19, 2004Paper presented at the AABT, New Orleans, November 19, 2004

ACT vs CBTACT vs CBTCBTCBT ACTACT

FocusFocus reducing or eliminating reducing or eliminating distorted/unwanted distorted/unwanted thoughts, feelings, and thoughts, feelings, and bodily sensations bodily sensations

reducingreducing unwillingness unwillingness toto experience and experience and efforts to efforts to controlcontrol thoughts, feelings thoughts, feelings and sensationsand sensations

Efficacy studies:Efficacy studies:DepressioDepressionn

Numerous (cf. DeRubeis & Numerous (cf. DeRubeis & Crits-Christoph, 1998)Crits-Christoph, 1998)

Growing (e.g. (Zettle Growing (e.g. (Zettle & Hayes, 2002; Zettle & Hayes, 2002; Zettle & Rains, 1989)& Rains, 1989)

AnxietyAnxiety Numerous (cf. DeRubeis & Numerous (cf. DeRubeis & Crits-Christoph, 1998)Crits-Christoph, 1998)

Growing (e.g. Block & Growing (e.g. Block & Wulfert, 2000; Wulfert, 2000; Roemer & Orsillo, Roemer & Orsillo, 2002; Zettle, 2003)2002; Zettle, 2003)

Theorized Mechanisms of Theorized Mechanisms of ActionAction

Empirical EvidenceEmpirical EvidenceCBTCBT

Reducing dysfunctional Reducing dysfunctional attitudesattitudes

AgainstAgainst: Barber & DeRubeis, : Barber & DeRubeis, 1989; DeRubeis, Evans, 1989; DeRubeis, Evans, Hollon, Garvey, & et al., Hollon, Garvey, & et al., 1990; Teasdale et al., 2001 1990; Teasdale et al., 2001

Increasing Meta-Increasing Meta-cognitive awarenesscognitive awareness

ForFor: : Teasdale et al., 2001Teasdale et al., 2001

ACTACTDecreasing Experiential Decreasing Experiential AvoidanceAvoidanceIncreasing Increasing Psychological Psychological AcceptanceAcceptance

ForFor: Bond & Bunce, 2000; : Bond & Bunce, 2000; Zettle, 2003Zettle, 2003

Increasing DefusionIncreasing DefusionAwarenessAwareness

Study QuestionsStudy Questions Disseminability?Disseminability? Efficacy (RCT)?Efficacy (RCT)? Effectiveness in real-world setting (few Effectiveness in real-world setting (few

exclusion criteria, comorbidity, exclusion criteria, comorbidity, subthreshold diagnostically) subthreshold diagnostically) [Strosahl et al., [Strosahl et al., 1998]1998]

Mechanisms of action?Mechanisms of action?

… … of ACT relative to CBTof ACT relative to CBT

Study DesignStudy Design Setting: University counseling centerSetting: University counseling center Participants: health science students (nursing, Participants: health science students (nursing,

medicine, physical therapy, etc.)medicine, physical therapy, etc.) Therapists: Doctoral students (n = 13) in a Therapists: Doctoral students (n = 13) in a

CBT-oriented clinical psychology programCBT-oriented clinical psychology program Therapist Training/SupervisionTherapist Training/Supervision

– CBT: 4 weekly 2-hour trainingsCBT: 4 weekly 2-hour trainings– ACT: 6 weekly 2-hour trainingsACT: 6 weekly 2-hour trainings– 1-hour weekly ongoing group supervision1-hour weekly ongoing group supervision– 1-hour weekly ongoing individual supervision1-hour weekly ongoing individual supervision

Random assignment of participants to CBT / Random assignment of participants to CBT / ACTACT

Each therapist administered both CBT & ACTEach therapist administered both CBT & ACT

MeasuresMeasures Collection: Baseline & 3-mo follow-up Collection: Baseline & 3-mo follow-up (±8 sessions)(±8 sessions)

MediatorsMediatorsExper. Exper. AvoidanceAvoidance

AAQAAQ

MindfulnessMindfulness–ObserveObserve–AwarenessAwareness–DescribeDescribe–AcceptanceAcceptance

KIMKIMSS

Negative Negative ThoughtsThoughts

–FrequencyFrequency–BelievabilityBelievability

ATQATQ

Symptom/FunctioningSymptom/FunctioningDepressionDepression BDIBDI-II-II

AnxietyAnxiety BAIBAIFunctioning Diff.Functioning Diff. OQOQ-45-45

Global Global FunctioningFunctioning

CGICGI

Well-beingWell-beingQuality of LifeQuality of Life QOLIQOLILife SatisfactionLife Satisfaction SLSSLSSelf-EsteemSelf-Esteem RSESRSES

Participant Recruitment & Participant Recruitment & EnrollmentEnrollment

102 Subjects Screened102 Subjects Screened• 84 (82%) eligible84 (82%) eligible

• 74 (78%) administered 74 (78%) administered consentconsent• 51 (61%) agreed51 (61%) agreed

• 7 (14%) could not be assigned 7 (14%) could not be assigned • 22 (43%) assigned to ACT22 (43%) assigned to ACT

• 20 (91%) active20 (91%) active• 2 (9%) dropped out2 (9%) dropped out

• 22 (43%) assigned to CBT22 (43%) assigned to CBT• 19 (86%) active19 (86%) active• 3 (14%) dropped out3 (14%) dropped out

Reached 3-mo follow-

up10 ACT

8 CBT

Intake DemographicsIntake Demographics AgeAge: M=27.6 yrs., Min = 19, Max = 46: M=27.6 yrs., Min = 19, Max = 46

GenderGender: 8 Males (18%), 36 Females (82%): 8 Males (18%), 36 Females (82%) Marital StatusMarital Status:: Single = 22 (50%), Divorced = 1 (2%), Single = 22 (50%), Divorced = 1 (2%), Married/Partnered = 12 (27%), Married/Partnered = 12 (27%), Not Living with current spouse/partner = 9 (21%)Not Living with current spouse/partner = 9 (21%)

EthnicityEthnicity: Caucasian = 32 (73%), : Caucasian = 32 (73%), African American/Black = 4 (9%), African American/Black = 4 (9%), Latino = 1 (2%), Asian = 7 (16%)Latino = 1 (2%), Asian = 7 (16%)

Participants Reaching Time 2Participants Reaching Time 2 AgeAge: M=28.7 yrs., Min = 21, Max = 46: M=28.7 yrs., Min = 21, Max = 46

GenderGender: 7 Males (39%), 11 Females (61%): 7 Males (39%), 11 Females (61%) Marital StatusMarital Status:: Single = 9 (50%), Divorced = 1 (6%), Single = 9 (50%), Divorced = 1 (6%), Married/Partner = 5 (28%), Married/Partner = 5 (28%), Not Living with current spouse/partner = 3 (17%)Not Living with current spouse/partner = 3 (17%)

EthnicityEthnicity: Caucasian = 13 (72%), : Caucasian = 13 (72%), African American/Black = 1 (6%), African American/Black = 1 (6%),

Asian = 4 (22%)Asian = 4 (22%)

Baseline Diagnoses/Symptom LevelsBaseline Diagnoses/Symptom Levels

DiagnosiDiagnosiss

NN %%

Anxiety Anxiety DisordersDisorders

66 33%33%

Major Major Depressive Depressive DisorderDisorder

55 28%28%

Other Mood Other Mood DisordersDisorders

66 33%33%

Eating Eating DisordersDisorders

11 6%6%

No No DiagnosisDiagnosis

77 39%39%

MeasureMeasure MM SDSDBeck Depression Beck Depression Inventory (BDI)Inventory (BDI)

17.017.0 11.211.2

Beck Anxiety Beck Anxiety Inventory (BAI)Inventory (BAI)

10.710.7 11.011.0

Beck Beck Hopelessness Hopelessness Scale (BHS)Scale (BHS)

7.27.2 6.06.0

Problem Checklist: Main Problem Checklist: Main ConcernsConcerns

– Worried about my grades or academic workWorried about my grades or academic work– Concerned about my primary relationshipsConcerned about my primary relationships– Feel easily irritated, frustrated, and/or angryFeel easily irritated, frustrated, and/or angry– Feeling depressed or unhappyFeeling depressed or unhappy– Not feeling close/connected to othersNot feeling close/connected to others– Worried about my physical healthWorried about my physical health– Concerned about my eating habits/nutritionConcerned about my eating habits/nutrition– Having fears/worries that occupy my mindHaving fears/worries that occupy my mind

ResultsResultsHighlyHighly Preliminary Preliminary

Enrollment Slowdowns Enrollment Slowdowns 18 participants have 18 participants have reached time 2reached time 2– Effect sizes > p valuesEffect sizes > p values– Clinical SignificanceClinical Significance

Groups not equal at baseline (randomization Groups not equal at baseline (randomization failure)failure)– Repeated measures compares Repeated measures compares slopes slopes of change not of change not

simple differencesimple difference– Stratification by symptom (BDI, BAI, BHS, OQ) threshold; Stratification by symptom (BDI, BAI, BHS, OQ) threshold;

participants with minimal symptoms discardedparticipants with minimal symptoms discarded No midpoint assessment (No midpoint assessment (mediational analyses)mediational analyses)

Depression (BDI)Depression (BDI)Repeated Measures ANOVARepeated Measures ANOVA

F F (1,12)(1,12) pp pp22

TimeTime 19.919.944

.001.001**

.624.624

Time x Time x GroupGroup 4.964.96

ACTACT.046.046

**.293.293

BaselineBaseline 3 mo3 mo ReliableReliable ImprovemImprovem

ntnt

RecoverRecovereded

CBTCBT 14.6714.67(3.13)(3.13)

8.008.00(3.14)(3.14)

50%50% 50%50%

ACTACT 32.1332.13(2.71)(2.71)

12.112.188

(2.96)(2.96)

88%88% 50%50%

Clinical Significance

0

5

10

15

20

25

30

35

Baseline 3 mo

CBT ACT

Anxiety (BAI)Anxiety (BAI)Repeated Measures ANOVARepeated Measures ANOVA

F F (1,8)(1,8) pp pp22

TimeTime 33.533.588

.000.000**

.808.808


ACTACT.298.298 .134.134


ntnt

RecoverRecovereded

CBTCBT 20.5020.50(4.49)(4.49)

10.510.500(3.16)(3.16)

50%50% 0%0%

ACTACT 19.5019.50(2.25)(2.25)

4.754.75(1.58)(1.58)

63%63% 63%63%


0

5

10

15

20

25

Baseline 3 mo

CBT ACT

Functioning Difficulties (OQ-45)Functioning Difficulties (OQ-45)Repeated Measures ANOVARepeated Measures ANOVA

F F (1,14)(1,14) pp pp22

TimeTime 11.411.477

.004.004**

.450.450


ACTACT.062.062

°°.227.227


ntnt

RecoverRecovereded

CBTCBT 75.0075.00(9.20)(9.20)

68.868.800(7.37)(7.37)

0%0% 0%0%

ACTACT 91.4691.46(6.20)(6.20)

66.866.800

(4.97)(4.97)

46%46% 0%0%


6065

7075

8085

9095

100

Baseline 3 mo

CBT ACT

Therapists’ Clinical Global Impression Therapists’ Clinical Global Impression (CGI)(CGI)

Repeated Measures ANOVARepeated Measures ANOVAF F (1,10)(1,10) pp pp

22

TimeTime 8.008.00 .018.018**

.444.444


CBTCBT.189.189 .167.167

BaselineBaseline 3 mo3 moCBTCBT 3.833.83

(.401)(.401)2.332.33(.459)(.459)

ACTACT 4.174.17(.401)(.401)

3.663.6677

(.459)(.459)

1

1.52

2.53

3.5

44.5

5

Baseline 3 mo

CBT ACT

Subjective Life Satisfaction Subjective Life Satisfaction (SLS)(SLS)

Repeated Measures ANOVARepeated Measures ANOVAF F (1,12)(1,12) pp pp

22

TimeTime 4.414.41 .058.058°°

.269.269


ACTACT.190.190 .138.138


(2.48)(2.48)12.612.6

00(3.09)(3.09)

ACTACT 6.116.11(1.85)(1.85)

12.012.000

(2.30)(2.30)

02468

101214161820

Baseline 3 mo

CBT ACT

Quality of Life (QOLI)Quality of Life (QOLI)Repeated Measures ANOVARepeated Measures ANOVA

F F (1,16)(1,16) pp pp22

TimeTime .421.421 .526.526 .026.026Time x Time x GroupGroup 1.931.93

CBTCBT.473.473 .033.033

BaselineBaseline 3 mo3 mo

CBTCBT 2.762.76(.333)(.333)

3.153.15(.371)(.371)

ACTACT 2.772.77(1.85)(1.85)

2.752.75(.296)(.296)

1

2

3

4

5

Baseline 3 mo

CBT ACT

Self-Esteem (RSES)Self-Esteem (RSES)Repeated Measures ANOVARepeated Measures ANOVA

F F (1,16)(1,16) pp pp22

TimeTime .023.023 .881.881 .001.001Time x Time x GroupGroup .001.001 .973.973 .000.000


(1.04)(1.04)20.720.7

11(.55)(.55)

ACTACT 20.6420.64(.83)(.83)

20.720.733

(.44)(.44)

10

15

20

25

Baseline 3 mo

CBT ACT

Mediational AnalysesMediational Analyses1.1. Does mediational variable decrease Does mediational variable decrease

as a function of treatment and as a function of treatment and differentially by treatment type (CBT differentially by treatment type (CBT vs ACT)?vs ACT)?

2.2. Does change in mediational variable Does change in mediational variable covary with change in outcome?covary with change in outcome?

3.3. Is treatment effect attenuated—Is treatment effect attenuated—differentially by treatment type—differentially by treatment type—when mediational variable is when mediational variable is statistically controlled?statistically controlled?

Automatic Thoughts – Believability Automatic Thoughts – Believability (ATQ-B)(ATQ-B)

BDIBDI BAIBAI OQOQ

pp22

CBTCBT ACTACT CBTCBT ACTACT CBTCBT ACTACT

Nothing Nothing covariedcovaried

.813.813 .694.694

ATQ CovariedATQ Covaried .748.748 .336.336% decrease% decrease 8%8% 52%52%

F F (1,12)(1,12)

pp pp22

TimeTime 8.1228.122 .01.0155

.404.404

T x GroupT x Group 3.9853.985 .06.0699

.249.249

Repeated Measures analysis before and after covarying ATQ-B

ATQ-B Outcome Var?Treatment ATQ-B?Yes, particularly for ACT

Regrssn ATQ ATQ

BetaBeta ppIntrctIntrct

n n BetaBeta

pp

BDIBDI .30.30 .58.58 .32.32 .1.199 ACTACT

BAIBAI .69.69 .37.37 -.43-.43 .6.622 ----

OQOQ .70.70 .14.14 .01.01 .9.988 ----

Repeated Measures analysis, DV = ATQ-B

ATQ-B attenuates tx effect?

Decreases in believability are associated with decreases in depression, but only in the ACT condition.

Summary of Mediating Summary of Mediating EffectsEffectsTreatment mediator

mediator Outcome Var

mediator attenuates tx effect?

ATQATQBelievabilityBelievability Yes Yes (ACT)(ACT) BDI BDI (ACT)(ACT) BDI BDI (ACT)(ACT)

FrequencyFrequency very similar to ATQ-Bel; r = .91very similar to ATQ-Bel; r = .91AAQAAQ Yes?Yes? (ACT)(ACT) BDI BDI (ACT)(ACT)

KIMKIMSS

ObserveObserve Yes?Yes? (ACT)(ACT) BDI BDI (ACT)(ACT)

BAI BAI (ACT)(ACT)BAI BAI (ACT)(ACT)

DescribeDescribe Yes?Yes? (ACT)(ACT) BDI BDI ((ACTACT))OQOQ (ACT) (ACT)

AwarenessAwareness NoNoAcceptanceAcceptance Yes Yes (ACT)(ACT) OQ OQ (ACT)(ACT) OQOQ (ACT) (ACT)

SummarySummary DisseminableDisseminable EffectiveEffective Efficacious relative to CBTEfficacious relative to CBT

– DepressionDepression– FunctioningFunctioning– Subjective Life SatisfactionSubjective Life Satisfaction

Mechanisms of ActionMechanisms of Action– BelievabilityBelievability, for ACT, not CBT, on , for ACT, not CBT, on depressiondepression– ObserveObserve, for ACT, not CBT, on , for ACT, not CBT, on anxietyanxiety– AcceptanceAcceptance, for ACT, not CBT, on , for ACT, not CBT, on functioningfunctioning

( CGI )

FutureFuture Increase nIncrease n Consider specific diagnosesConsider specific diagnoses Session-by-session data (BSQ)Session-by-session data (BSQ) Diffusion as a mechanism of actionDiffusion as a mechanism of action

Mindfulness and Behavior Change Processes in Acceptance and Commitment Therapy

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