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Treatment of Anxiety Disorders from a Contextual Behavioral Viewpoint
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Transcript of Treatment of Anxiety Disorders from a Contextual Behavioral Viewpoint
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Treatment of Anxiety Disorders from a Contextual Behavioral
Viewpoint
Michael P. Twohig, Ph.D.Associate Professor of Psychology
Utah State University
Workshop at ACBS conference Minneapolis June 17, 2014
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My life
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Certain populations?
Age groups?
Empirical support?
Is this really any different than CBT?
I saw Hayes present on this and he’s nuts.
How does this fit with what I do?
Is this said A-C-T or “ACT”?
What do you want to get out of today?
Do I need to know about RFT?
Is it ethical to use ACT?
What is contextual behavioral science?
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25% = Basic aspects 75% = Applied aspects One favor
Please ask questions
Plan for the day
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Procedure (How you do it)? Process of change (What type of
learning do you hope is occurring)? Outcome (How do you know you are
helping the client)?
Exposure Therapy
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Extinction involves new leaning and not unlearning spontaneous recovery (passage of time) disinhibition (presentation of a novel
stimulus) reinstatement (presentation of the US
or reinforcer) renewal (a change in context) resurgence (new behavior introduced
during extinction places on extinction)
Example of the importance of basic sciences
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Important aspects of CBS
1 2
3
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Verbal humans are insensitive to environmental contingencies
Non-verbal ones are not How does this happen?
Rule Governed Behavior
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Stimuli Three-term contingency Meaning vs function
Relational Frame Theory
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Useful and interfering effects of this ability Grocery store My wife and our children, “getting older” We can apply this to our own thinking and
emotions
Language: The two-edged sword
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Experiential avoidance is the tendency to attempt to alter the form, frequency, or situational sensitivity of historically produced negative private experience (emotions, thoughts, bodily sensations) even when attempts to do so cause psychological and behavioral harm
Experiential Avoidance
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The ability to contact the present moment more fully as a conscious human being, and based on what the situation affords, to change or persist in behavior in order to serve valued ends
Psychological Inflexibility
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AAQ-II
Below you will find a list of statements. Please rate how true each statement is for you by circling a number next to it. Use the scale below to make your choice.
1 2 3 4 5 6 7 never true
very seldom true
seldom true
sometimes true
frequently true
almost always true
always true
1. My painful experiences and memories make it difficult for me to live a life that I would value. 1 2 3 4 5 6 7
2. I’m afraid of my feelings. 1 2 3 4 5 6 7
3. I worry about not being able to control my worries and feelings. 1 2 3 4 5 6 7
4. My painful memories prevent me from having a fulfilling life. 1 2 3 4 5 6 7
5. Emotions cause problems in my life. 1 2 3 4 5 6 7
6. It seems like most people are handling their lives better than I am. 1 2 3 4 5 6 7
7. Worries get in the way of my success. 1 2 3 4 5 6 7
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Social phobia Specific phobia Posttraumatic Stress Disorder Generalized anxiety Disorder Obsessive compulsive disorder
OC-spectrum disorders Health Anxiety
Anxiety disorders
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63 studies AAQ and all measures of anxiety r = .45
General anxiety symptoms r = .48 Specific anxiety disorder symptoms r
= .42 Specific disorders
GAD r = .61 Social phobia r = .41 PTSD r = .39 OCD r = .36 panic/agoraphobia r = .21
AAQ and Anxiety
Bluett et al. (in press). JAD
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ACT Targets Psychological Inflexibility
ACT targets the verbal context in which cognition occur Decreases literality
Behavior change occurs is in the service of values
Therapy is about helping people live meaningful, exciting lives
If these processes are core to pathology, targeting them should result in positive outcomes
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Accep-tance
Defusion Present Values Mindful Combo
Mindful+Values
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Effec
t siz
e
Effect size by component relative to inactive conditions
Large effect
Medium effect
Levin et al., 2012 Behavior Therapy
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Randomized Trials Effectiveness=4 Mixed Anxiety=2 GAD=2 PTSD= Social Phobia=0 Panic Disorder=0 Specific Phobia=2 OCD=2 OC-Spectrum=2
SS designs, cases, open
Mixed Anxiety=2 GAD=1 PTSD=4 Social Phobia=7 Panic Disorder=2 Specific Phobia=0 OCD=6 OC-Spectrum=6
Anxiety outcome research
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Within and between session fear reduction is associated with better clinical outcomes
Moving through the hierarchy in an orderly fashion is best
Can’t stop exposures without fear reduction
Exposure is about fear reduction Not fear toleration
“optimizing learning …. based on increasing tolerance for fear and anxiety” (Arch & Craske, 2009)
Some misconceptions about exposure work
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Procedure Contacting feared stimuli And/or engaging in valued activities While practicing ACT concepts
Process of change Psychological flexibility
Desired outcome Greater life functioning Change in internal experience not a
concern
ACT’s view on Exposure
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Expos
ure w
ith re
spon
se pr
even
tion
Beck
’s Co
gnitiv
e Th
erap
y
Dialectical Behavior Therapy
Mind
fulne
ss B
ased
Cog
nitive
The
rapy
Rational Em
otive Behavior TherapyAcceptance and C
omm
itment Therapy
Schema Therapy
Barlow’s U
nified Protocol
Wilh
elm an
d Stek
etee’s
Cog
nitive
The
rapy
for O
CD
Func
tiona
l Ana
lytic
Psyc
hoth
erap
y
Met
acog
nitiv
e Th
erap
y
Many othersAppraisal w
ork
Mindfulness Based Stress R
eduction
C B T
Motiva
tiona
l Inter
viewing
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Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
PsychologicalFlexibility
The Primary ACT Model of Treatment
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The Primary ACT Model of Psychopathology
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Quality of life vs symptom reduction Problem with “typical” outcome measures Behavior tracking May initially confuse clients
Outcomes
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Different Roller coaster Judge at end Outcome
How this is presented to clients
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Client and therapist are on equal ground Shy away from being literal
No models Confusing and paradoxical talk Exercises
Not explaining why Workability trumps accuracy
ACT specifics
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Ok with anxiety Focus on quality of life See thoughts for what they are Person experiencing the anxiety Being present Practicing following values
Act for anxiety