1 Understanding the Clinical Processes in ACT Yvonne Barnes-Holmes & Dermot Barnes-Holmes.

1

Understanding the Clinical Processes in ACT

Yvonne Barnes-Holmes &

Dermot Barnes-Holmes

2

Co-Authors

Ian Stewart Louise McHugh Kelly Wilson Barbara Johnson Brandy Fink Andy Cochrane Anne Kehoe Hilary-Anne Healy Claire Keogh Jenny McMullen

Carmen Luciano Francisco J. Molina Cobos Olga Gutiérrez Sonsoles Valdivia Marisa Páez Miguel Rodríguez Francisco Cabello Carmelo Visdómine José Ortega Francisco Montesinos Mónica Hernández Laura Sánchez

3

Introduction There is no theory behind therapy, the former is a coherent set

of theoretical constructs that hang together and make predictions, the latter is a coherent set of techniques that make a different set of predictions

Almost never in the history of psychology have they come together in a manner that was both theoretically consistent and technologically effective

ACT is no different, but as the field develops, there is growing reason to believe that there is considerable overlap between Relational Frame Theory (RFT) and ACT and that the former can make sound predictions about why the latter works, and to some extent about what the latter should look like

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Overview The current talk will review some of the predictions and

empirical evidence that support processes and techniques identified in ACT

For the sake of simplicity, and in order to be consistent with the evidence, we will divide ACT into the following:

Acceptance vs. Avoidance

Acceptance vs. Cognitive Control

Values

Defusion

5


6

Our first place to start looking at ACT (Study 1) was to analyse the distinction between acceptance and avoidance – if this was not clear-cut, then the basic terminology might need to be reconsidered

ACT’s emphasis on the dichotomy between acceptance and avoidance and the development of the AAQ suggested that we might be able to functionally differentiate individuals in terms of their propensity towards acceptance or avoidance

We took 15 undergraduates who were low in acceptance (at least 1 SD below the mean on the AAQ) and 14 high in acceptance (at least 1 SD above the mean)


7

Participants were exposed to a simple automated task that required them to match nonsense syllables

During the task, however, matching on some trials resulted in the presentation of a horrible aversive image (e.g. mutilated bodies) for 6 seconds

Participants were required to rate each aversive picture

But, primarily we wanted to determine how long it took them to do the task when they had discriminated which type of picture would come next

Our prediction was that low accepters/high avoiders would take longer to complete tasks, which they had learned would be followed by an aversive picture

This, for us, was a type of avoidance


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During the task, High Acceptance produced similar reaction times whether they expected to see either an aversive or a neutral image next, so anticipation or avoidance was limited

But, Low Acceptance exhibited significantly longer reaction times when they expected to see an aversive image (p = 0.015)

0

0.5

1

1.5

2

2.5

3

High Low

Median Reaction Times

A N A N

But could this be simply because the Low Acceptance Group perceived the neutral pictures to be more unpleasant and

thus legitimtely more avoidable than the High Acceptance group?

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No, because High Acceptance rated the aversive images as more unpleasant and more emotionally intense than Low Acceptance

But yet, Low Acceptance were less willing to look at either images than High

Acceptance

Pleasant Unpleasant

0 50 100

0 50 100

0 50 100

High

Low

Mild Intense

Willing Unwilling

Self-Report Ratings

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Discussion So, the outcomes were consistent with ACT predictions

regarding acceptance and avoidance and their dichotomy

Individuals low in acceptance/high in avoidance showed greater anticipatory avoidance of the negative pictures than those high in acceptance/low in avoidance

This avoidance was consistent with their own ratings of willingness to look at the pictures

Furthermore, this avoidance occurred even though these individuals rated the pictures as less unpleasant and less intense than the other group

The high acceptance groups, therefore, showed less avoidance and greater experiential willingness in the face of adversity – outcomes that are consistent with ACT predictions

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Study 2 replicated Study 1, but incorporated Event Related Potentials (ERP’s) during the task with:

6 High Acceptance

6 Low Acceptance

6 Mid-Range Acceptance

Once again, we predicted that level of avoidance would differentiate and we hoped it would be detected by the ERP’s

ERP’s and Avoidance

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Identical to Study 1, High and Mid Acceptance produced similar reaction times for both aversive and neutral images, showing no anticipation or avoidance

But, Low Acceptance again emitted longer reaction times when they expected to see an aversive, rather than a neutral, image (p = 0.0431)

0

0.5

1

1.5

2

2.5

3

3.5

High Mid

Low

Median Reaction Times

A N A N A N

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Again, this was not because the pictures were less unpleasant, because the High and Mid Acceptance rated the aversive images as more unpleasant and emotionally intense than Low Acceptance

But, Low and Mid Acceptance were less willing to look at the images

0 50 100

Pleasant Unpleasant

0 50 100

0 50 100

HighLow

Mid

Mild Intense

Willing Unwilling

Self-Report Ratings

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ERP’s Recordings As expected, the ERP’s recordings discriminated between

the two types of pictures, with the unpleasant pictures producing significantly more positive wave forms than the neutral pictures for all groups

And an interesting finding emerged with regard to the scalp locations . . .

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Low Acceptance

-12500

-7500

-2500

2500

7500

12500

Left Middle Right

High Acceptance

-12500

-7500

-2500

2500

7500

12500

Left Middle Right

Are

a D

imen

sion

s (

V •

ms)

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The fact that the Low Acceptance group showed greater negative activation for left hemisphere electrodes could suggest greater verbal activity for this group, which might indicate the use of verbal avoidance strategies (e.g. “This is not real, think of something else,” etc.)

ERP’s Recordings

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So again, the avoidance groups could be distinguished from one another on several predictable counts -- Low Acceptance showed greater anticipation of the aversive images than the others and were less willing to look at them -- and yet, they rated the pictures as less unpleasant

Some willingness distinctions even emerged between mid and high range accepters

The unwillingness and tolerance avoidance for Low Acceptance was associated with greater negative activation for left hemisphere electrodes, suggesting the activation of verbal areas

Again, the former outcomes are consistent with ACT’s emphasis on acceptance, avoidance and willingness and the ERP’s data were consistent with RFT’s emphasis on verbal behaviour

Discussion

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Acceptance vs. Cognitive Control

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Acceptance Up until the mid-90’s, CBT was still insistent that explicit

attempts to control cognitive events directly would reduce their frequency and impact, and thus be associated with positive clinical outcomes

ACT has always offered a counter-approach because of its contextualistic underpinnings that argues that the only way to change verbal events is to change the context in which they occur and acceptance is the term we use to describe this broader target

In this regard, though not intentionally, ACT is more in line with Eastern traditions that emphasise acceptance/mindfulness

But Eastern traditions are not sciences and thus cannot be relied upon to provide scientific argument or evidence

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Acceptance Although in Eastern traditions and in ACT, we had reason to

believe that acceptance was an active ingredient in positive clinical outcomes and psychological well-being generally, there was almost no empirical evidence to attest to this

Furthermore, positive empirical evidence for the impact of acceptance would to some extent undermine positivity for the main existing alternative that was cognitive control – which functionally may be seen as the opposite of acceptance

It should also be added that empirical evidence for cognitive control as an active ingredient in CBT is relatively scarce, in spite of its wide usage

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So, thus far, we had some comfort in the terminology that suggested a dichotomy between acceptance and avoidance

But, acceptance as a clinical tool was something else

In our first empirical analysis of acceptance as a mechanism of change, we set out with a very simple aim -- to see if we could construct a short, but potent, acceptance intervention that would be functionally similar to what is presented in therapy, but which might just work in an experimental context

This was demonstration research of the simplest kind

Acceptance

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During Study 3, ‘normal’ participants were simply presented with a computerised task in which they were asked to match a lot of neutral pictures and a small number of horrible aversive pictures (e.g. mutilated bodies)

The former pictures simply represented an experimental control, while the latter represented our core effort to provide participants with a clinical strategy they could use to deal with unpleasant

psychological/visual content

Study 3

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Because the matching was too simple to function as a dependent variable, we targeted participants’ willingness to look at the aversive pictures by: (1) giving them the option to avoid the pictures altogether before the trial and counting how many they looked at and (2) observing how long they would endure them on screen

Avoiding Negative Images

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Participants were exposed to the baseline matching task, the intervention, and then the task again

Both interventions involved the presentation of a vignette in which participants were asked to -- imagine that they had witnessed a horrific car accident in which they had to rescue the badly injured and bloodied victims from the car and to imagine that they found the sight of blood extremely aversive

They were then given a coping strategy/intervention to help them deal with the vignette (and to influence their subsequent performances on the negative pictures)

Acceptance or Control

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Participants in Cognitive Control were instructed to try to control their emotional reactions and to avoid feelings of discomfort (e.g. by imaging that the blood was just like tomato ketchup)

Participants in Acceptance were instructed to fully embrace their feelings of discomfort (i.e. to fully accept that trying to save the bloodied and mutilated victims would be the most horrific experience of their lives)

Acceptance vs. Control

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Experimenter influence were also manipulated by altering the instructions and the extent to which the experimenter monitored the matching performances

During the No Instruction/No Monitoring conditions, participants were informed that it did not matter whether they looked at the negative pictures (i.e. no instruction) and the experimenter sat approximately 30 feet away and pretended to read a book (no monitoring)

During the Instruction/Monitoring conditions, participants were told that it was very important to look at the negative pictures (instruction) and the experimenter walked around actively monitoring performances (monitoring)

Experimenter Influence

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The results of the study failed to differentiate between the two groups on the number of aversives observed

However, they did differ in their mean response latencies while the aversives were on the screen (i.e. aversive tolerance time)

Results

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Mean Response Times: Neutral Pictures

On the neutral pictures, there were no changes at all between Baseline and Post-intervention, as expected

Baseline Post-Intervention

1000

1200

1400

1600

1800

2000

2200 T

oler

ance

Tim

e in

ms.

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Mean Response Times: Aversive Pictures

But, on the aversive pictures, Acceptance and Control differed significantly when combined with Instruction/Monitoring (p = 0.002)

Strategy and Experimenter Influence interacted significantly

Accept/Instruct

Accept/No Instruct

Control/No Instruct

Control/Instruct

1000

1200

1400

1600

1800

2000

2200

Baseline Post-Intervention

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Discussion The Acceptance strategy increased participants’ tolerance time in

the presence of the aversive pictures (when combined with active experimenter influence)

Control did not and decreased tolerance in both cases

While both strategy outcomes appeared to be influenced by the social context, further analyses indicated that this primarily affected the extent to which participants applied the strategies, rather than affecting the strategies directly (i.e. the strategies were applied more when the experimenter attended)

This was our first empirical evidence that acceptance could be delivered as a brief therapeutic intervention in an experimental context and was associated with positive outcomes

Cognitive control was in fact counter-productive in terms of altering aversive tolerance when the images were present

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In Study 4, we were concerned that the data so far would not generalise to physical pain and the psychological content associated with that – perhaps different outcomes would emerge relative to coping with aversive visual imagery

So, we exposed participants to systematic electric shocks

This was based on a previous study by Gutierrez, Luciano, Rodriguez, and Fink who compared acceptance and control as coping interventions with electric shock with 40 undergraduates

They reported that Acceptance not only increased shock tolerance, but also reduced participants’ believability of their own subjective pain ratings

Acceptance vs. Control with Pain

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Although the original study was entirely consistent with our own findings thus far, there was increasing concern within the community about experimental precision – but this was hard to offset against external validity

So in Study 4, we tried to come up with a format that was fully automated (hence experimentally ‘clean’), but that would still allow the interventions to be impactful

We did some refinement of the Acceptance and Control exercises and metaphors to remove possible confounds

And we began to look at values as an active addition to acceptance

Our Study

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40 ‘normal’ participants were assigned to four conditions

Design

Intervention Values Context

Pre-Intervention

Post-Intervention

Acceptance High

Low

Control High

Low

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Play Video 1 Play Video 2 Play Video 3 Play Video 4 Play Video 5 Play Video 6 Play Video 7 Play Video 8

Delivery

The entire procedure was automated through a program containing a series of video clips

Participants progressed through the clips at their own pace, individually and alone

Clips were rated first by independent observers, for consistency, adherence and empathy and were found to not differ in any capacity

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Delivery

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A Participants were provided with metaphors and experiential exercises indicating that the best way to deal with pain related thoughts and feelings was to accept

them in the context of whatever action is being taken

HV Participants were asked to imagine that they suffered from chronic pain and that the task involving shock was one which they must do in order to support their family

LV Participants were told that the aim of the experiment was to contribute to research on the relation between voltage level and perception of shock

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C Participants were given metaphors and experiential exercises designed to teach them that the best way to deal with pain related thoughts and feelings was to distract themselves by imagining pleasant images

HV Participants were asked to imagine that they suffer from chronic pain and that the task involving shock was one which they must do in order to support their family

LV Participants were told that the aim of the experiment was to contribute to research on the relation between voltage level and perception of shock

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Shock Tolerance Data

The Acceptance participants significantly increased their shock tolerance from pre- to post-intervention

Control produced no change

0

3

6

9

12

15

Pre-Intervention Post-Intervention

Control

Acceptance

No.

of

Sh

ock

s T

aken

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Self-Report Data

There was an interesting effect for values – although there was no significant main effect, High Values participants rated the pain as greater across time, whereas Low Values rated it as less

40

50

60

70

80

90

100


Low Value

High Value

High Pain

Low Pain

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Tolerating High Pain We wanted to check whether some of the effects were

driven by people who had different perceptions of how much pain they were in -- so we examined only those reporting great pain more closely

100% of participants in Acceptance who reported greater experienced pain Post-Intervention showed an increase in tolerance levels, compared to only 50% of the same sub-set of Control (significant: p = 0.0455)

We also analysed the number of trials for which participants continued in the Post-Intervention task after reporting high levels of pain (>= 80) and found that the median number of trials for Acceptance was 4, compared to 2 for Control (significant: p = 0.0069)

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So as an intervention, Acceptance worked better than Control in the context of experimentally physical pain in the form of electric shock

Changes in tolerance were particularly strong for participants experiencing a lot of pain and using Acceptance

The effects were the same as those reported by other researchers even in a highly structured automated experimental environment

While the Values manipulation did not have a significant effect on shock tolerance, it did affect self-reports of pain, in that participants in High Values reported more pain subsequent to the intervention (perhaps the values component oriented them more towards their pain, but not in an avoidant way)

Discussion

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One issue that had been emerging across experiments was the possibility that participants were not really engaging with the various features of the interventions (i.e. the exercises and metaphors), but that they were simply generating or following simple rules

So, in Study 5, we compared the full Acceptance and Control interventions used before, but added two new interventions that simply comprised of an Acceptance Rule and a Control Rule -- a brief and simple rule for accepting or distracting

In this study, we also employed a Placebo Condition

Study 5: Simple Rules

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Acceptance Rule

Acceptance Rule,

Metaphor & Exercise

Control

Rule

Control Rule, Metaphor &

Exercise

Placebo

Experimental Conditions

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Only Full Acceptance increased tolerance significantly from Pre- to Post-Intervention, but none of the other four

Distraction-Rule actually decreased tolerance significantly

Tolerance Data

0123456789

10


Rule DistractionRule AcceptancePlaceboDistractionAcceptance

Se

lf-D

eli

ve

red

Sh

oc

ks

(p < .002)

(p < .03)

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Again, we looked at those participants who reported more pain and still took more shocks and found that these were mostly in the Acceptance Conditions

0

20

40

60

80

100

Acceptance Distraction Placebo RuleAcceptance

RuleDistraction

Per

cen

tag

e o

f P

arti

cip

an

ts

More Pain & More Shocks

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So, the positive acceptance outcomes thus far could not be explained in terms of simple rule following – the metaphors and exercises were essential

When these were absent, the moderate improvement in pain tolerance for an acceptance rule was non-significant

Although Distraction effects are again negligible

Distraction actually makes you worse when it comes in the form of a simple rule

Discussion

47

The next study (Study 6) was also concerned acceptance, but attempted to broaden the generality of the work by employing a new type of pain induction, that might circumvent criticisms that electric shock is not a good analogue of clinical pain

So, three groups of participants were assigned to:

Acceptance ControlPlacebo

And were exposed to the radiant heat pad in a fully automated procedure

Different Pain Same Outcome

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Heat Apparatus

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Results

At baseline, the groups did not differ on a series of psychological measures

And the amount of heat tolerance was tightly controlled

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Tolerance Data

0 1 2 3 4 5 6 7 8 9

Baseline Post-Intervention Reminder

Hea

t T

ime

Tol

eran

ce (

Sec

ond

s)

P = .005

Placebo Control Acceptance

Both Acceptance and Control increased pain tolerance, but only Acceptance was significant

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So, positive outcomes again for acceptance – now a total of six experiments

Acceptance is always significantly better than Control, which had negligible effects

Outcomes so far have included tightly controlled experimental environments, a range of populations and numerous experimental methodologies and types of pain

The data overall are highly consistent with ACT’s centrality for acceptance and its predictions on avoidance

The ERP’s data were consistent with both ACT and RFT and added legitimacy to the outcomes and methodologies

Discussion

52

But one thing troubled us and we had seen it in research by other labs

In some studies, there had been positive (albeit limited and never significant) outcomes for Cognitive Control

So, in the radiant heat research, we began to look more closely at our interventions and those used in other studies

In the heat study, in particular, we noticed that part of the Control intervention involved saying a pain-related thought aloud before participants tried to distract themselves from it

One Query?

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So, we thought that it might just be possible that this feature offered a type of defusion, or at least cognitive distancing, that may have attributed to the outcomes

And we set about modifying the Control intervention so as to eliminate this potential confound (Study 7)

Our new condition was called Control Revised

And we were amazed at what we found . . .

Revisions

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Tolerance Data

The effects for Acceptance were exactly the same But, Control had no effect at all, and in fact increased pain

tolerance was decreasing

0 1 2 3 4 5 6 7 8 9

Baseline Post-Intervention Reminder

Hea

t T

ime

Tol

eran

ce (

Sec

ond

s)

P = .005

Control Revised Acceptance

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So, even the small improvements that had been previously recorded for Cognitive Control may not have functioned in the way that was intended

Some of the experimental interventions had spurious features that enabled aspects of defusion to creep into the Control protocols

In our latter heat experiment in which this feature was addressed directly, the effects for Control could not be differentiated from Placebo

Discussion

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Values

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But, of course, there is more to ACT than acceptance and much of what we do in the therapy depends upon the combination of active ingredients rather than simply a series of incoherent or unintegrated steps

However, as much as possible, we try to isolate the components individually for experimental purposes to get a better understanding of outcomes and processes

So, we turned our attention next to Values

But note, that where we had looked at values before, the outcomes were mixed and it would be very difficult to deliver values as a solitary intervention

Investigating Values

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We have done only one study (Study 8) to date looking specifically at values

This study was conducted in Spain and attempted primarily to assess the influence of a values clarification exercise

Although two types of exposure to painful private events were also compared (writing down versus experiential exercise) across three conditions

Values

Values Clarification


+ Writing


+ Experiential Exercise

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10 participants were assessed on personal barriers, valuable actions and areas of valued living affected by problems and barriers

Values

Subject 2

0123456789

10

1 2 3 4

RE

PO

RT

VALUES CLARIF F/U


Barriers

Valued Living

Values Clarification alone quickly and steadily reduced barriers and improved reports of valued living and effect enhanced across time

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0123456789

10

1 2 3 4 5 6

REPO

RT

S.8

VC EXERCISE F/U

0123456789

10

1 2 3 4 5 6

RE

PO

RT

VC WRITING F/U

S.7

Barriers

Valued LivingValues Clarification + Writing

Values Clarification + Exercise

Values Clarification + Writing alone showed a similar outcome, but the decrease in barriers was less

Values Clarification + Exercise alone was similar

Overall, the type of exposure to private events did not matter greatly, and these even softened the effects relative to Values Clarification alone

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So, some positive effects for values clarification

No matter, how you do it, a simple values clarification exercise helps to increase the extent of actual valued living and decrease barriers to same

There were some minor differences in terms of how this can be done, but these were minimal

The data also identified what appeared to be a functional relationship between decreases in barriers and improvements in valued living

These are entirely consistent with ACT predictions regarding how private events can function as barriers and how these can be altered with values

Discussion

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Defusion

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But, no-one would think for a second that ACT would be ACT without defusion

In fact, defusion, it seems is the gel that glues the active ingredients together

In fact, acceptance is often difficult when defusion is not in place

Also, for RFT the deliteralisation effects that underpin defusion techniques are central to ACT’s outcomes, so in ways studying defusion is perhaps the best test of the relationship between the theory and the therapy

Defusion

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When we started looking at defusion, we had only one previous study by Masuda et al. (2004) to work from

They attempted to assess the impact of word repetition on believability and discomfort levels associated with negative self-relevant words (e.g. “anxious, anxious, anxious” etc.)

Their findings indicated that the use of a defusion rationale produced greater reductions in discomfort and believability about the words when compared to a thought suppression rationale or a distraction task

Defusion

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In this study (Study 9) , we automated the presentation of 20 positive and 20 negative self-statements

This generated a total of 60 statements because there were three exposures to each statement

After the appearance in screen of each statement, participants were asked to provide ratings regarding their reactions to the statements in terms of:

Comfort Believability Willingness

Defusion

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We manipulated defusion in two ways

(1) Defusion Instructions

The 80 undergraduates were randomly assigned to:

Defusion Condition (pro-defusion instructions)

Anti-Defusion Condition (anti-defusion instructions)

Neutral Condition (neutral-defusion instructions)

Defusion

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‘In the current experiment, we are interested in the emotional impact of unusual self-statements. The scientific literature in this area shows that if you rephrase a self-statement like “I am an awful

person” into “I am having the thought that I am an awful person”, then the emotional impact of the statement is reduced

In other words, thinking or saying words like “I am having the thought that I am an awful person” is easier to deal with than

simply thinking or saying “I am an awful person”’

Defusion Instructions

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(2) Defusion in Visual Format

We wanted to see the extent to which defusion within the visual presentation of the self-statements would give rise to defusion-predictable outcomes

To manipulate this, we employed three types of presentation format for each statement:

Normal

Defusion

Abnormal

Defusion

69

Normal Negative Self-Statement

Deep down there is something wrong with meDeep down there is something wrong with me

70

Defusion Negative Self-Statement

I am having the thought that deep down there I am having the thought that deep down there is something wrong with meis something wrong with me

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Abnormal Negative Self-Statement

I have a wooden chair and deep down there is I have a wooden chair and deep down there is something wrong with mesomething wrong with me

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Results: Comfort

0

50

100

150

200

250

300

350

400

450

500

Normal Abnormal Defusion

Anti-Defusion Instruction

Defusion Instruction

Neutral Instruction

Uncomfortable

Comfortable

The (pro) defusion instructions were correlated with less discomfort than the other two types of instruction

As was the defusion presentation format

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Results: Willingness

0

100

200

300

400

500

600




Neutral Instruction

Unwilling

Willing

The (pro) defusion instructions were correlated with more willingness than the other two types of instruction

As was the defusion presentation format – very similar results to comfort ratings

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Results: Believability

0

100

200

300

400

500

600

700

800

900




Neutral Instruction

Unbelievable

Believable

Contrary to predictions, the (pro) defusion instructions were correlated with more believability than the other two types of instruction

As was the defusion presentation format – very similar results to comfort and willingness ratings

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Discussion Although they looked impactful in the ratings, the defusion

instructions did not have a significant influence

However, the Defused presentation format significantly decreased discomfort, increased willingness, but unexpectedly increased believability

However, on closer inspection of the data and other information gathered from participants it may be the case that they were rating the believability of whole statements –”I am having the thought that . .” rather than the content itself – this is not unlike defusion

76

Discussion So, increases in willingness to having negative self-

referential content were consistent with ACT’s predictions regarding defusion

Believability ratings, upon closer inspection, suggested that the defused format decreased participants’ believability of the content directly

Decreases in discomfort were not directly predicted by ACT, but such outcomes are positive although they would not be targeted directly

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Defusion Interventions In the previous study, we had assessed simple impacts for

defusion and found that it generated positive and largely ACT consistent outcomes even when defusion occurred within the visual presentation of the content

But, if we employed defusion as an intervention, as had been the case for Masuda et al., would we find similar outcomes?

Study 10 attempted to address this question

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Study 10

Participants generated a personalised negative self-relevant thought that represented a summary of several related personal statements

They were then given a written protocol that contained an instruction followed by an exercise

The three protocols were:

Defusion Thought Control Placebo

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Rationale ExerciseDefusion Defusion

Thought Control Thought Control

Defusion Thought Control

Thought Control Defusion

Defusion Placebo

Thought Control Placebo

Placebo Defusion

Placebo Thought Control

Placebo Placebo

Experimental Conditions

80

Once again, the emotional impact of the negative self-referential statements was measured in terms of:

Discomfort

Believability

Willingness

Method

81

Results: Comfort

All interventions with a defusion component generated decreases in discomfort

But, the largest effects were DD and PD, suggesting activity in the defusion exercise

Condition

Uncomfortable

100

80

60

40

20

0

Pre-Intervention

Post-Intervention

DD TC/TC

D/TC

TC/D

D/P TC/P

P/D P/TC

P/PComfortable

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Results: Comfort

Interestingly, the only significant differences pre- and post-intervention emerged for the following conditions:

Placebo-Defusion Defusion-Placebo Defusion-Defusion Thought Control-Thought Control

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All effects were in the right direction of decreasing believability

But, D-D and TC-D showed largest decreases in believability

Believable

Condition

Pre-Intervention

Post-Intervention

Unbelievable

100

80

60

40

20

0DD TC/

TCD/TC

TC/D

D/P TC/P

P/D P/TC

P/P

84


The only significant differences pre- and post-intervention emerged for the following conditions:

Placebo-Defusion Placebo-Thought Control Defusion-Placebo Defusion-Defusion Defusion-Thought Control Thought Control-Defusion Thought Control-Thought Control

So, a very mixed bag overall

85

Results: Willingness

All effects were in the right direction of decreasing unwillingess

But, D-TC was the only significant outcome

Unwilling

Condition

Pre-Intervention

Post-Intervention

Willing

100

80

60

40

20

0

DD TC/TC

D/TC

TC/D D/P

TC/P

P/D P/TC P/P

86

Discussion

Quite a mixed bag overall

But, generally most positive effects in predicted directions for packages containing defusion features

Defusion exercise appeared to be somewhat more effective than a simple rationale

87

Concluding Comments

88

There are many more analogue studies completed and underway than those reported here

The effects for ACT components across the board are predominantly as predicted and compare favourably with substantively weaker outcomes generated by target comparisons

The range of issues generated by the studies shows the complexity of the effects and the difficulty in conducting high quality research in this modality

As studies progress, the standard of experimental rigour is exceptional

Concluding Comments

89

Automated interventions Balancing for gender Balancing for heat tolerance, acceptance etc. Pre-screening with relevant psychological assessments Including self-report measures Blind experimenter Use of different types of physical and psychological

stressors Use of non-clinical populations Very substantive N in some cases Interventions are very closely matched, topographically

and functionally Range of ACT components tested

Concluding Comments

90

We are now in a place where these types of analyses can be done effectively and with high levels of precision

The evidence is overwhelmingly positive . . .

Concluding Comments

1 Understanding the Clinical Processes in ACT Yvonne Barnes-Holmes & Dermot Barnes-Holmes.

Documents

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