Acceptance and Commitment Therapy Steven C. Hayes University of Nevada.

Acceptance and Commitment

Therapy

Steven C. HayesUniversity of Nevada

Acceptance and Commitment Therapy

• It is said as one word, not letters

• A cognitive behavioral intervention that uses acceptance and mindfulness processes, and commitment and behavior change processes, to create psychological flexibility

Psychological Flexibility

… is consciously contacting the present more fully, without needless defense, and based on what the situation affords, changing or persisting in behavior in the service of chosen values.

ACTIs transdiagnostic: focused on

common core processes known to underlie many forms of psychopathology

This makes it broadly applicable, and especially well suited to multi-problem patients

Expanding avoidance

All animals escape and avoid aversive events

CAR

But only humans can readily bring aversive events into any setting

“Car”

So We Try to Avoid Pain Itself

• Experiential avoidance is built into human language and then amplified by the culture– 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

ACTThis is a logical step, but it tends to

amplify pain or at least its impact, not decrease it

Especially toxic for those with difficult histories or physiology

Why toxic?

Don’t be anxious

Don’t think of a white bear

Self-Amplifying

Puts Life on Hold

Increases Arousal and

Stress

Rep

erto

ire

Nar

row

ing

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Psychological Flexibility

The ACT Model

Defusion

Acceptance

EssentialComponents

of ACT

Open

Self asContext

Contact with the Present Moment

Defusion

Acceptance

EssentialComponents

of ACT

Centered

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

EssentialComponents

of ACT

Engaged

Empirically

• ACT is recognized as an evidence-based therapy by APA and SAMSHA (areas so far: depression; chronic pain; coping with psychosis; worksite stress; OCD)

• 40 RCTs

• 42 component studies; 38 mediation studies

• Over 150 studies on experiential avoidance and psychological flexibility

What is Remarkable about the ACT Literature

• The variety of problems it can help treat

• The range of formats that can be used

• Size and stability of outcomes in comparison to the extent of intervention

Controlled Studies in Mental Health

• Obsessive-compulsive disorder; generalized anxiety disorder; panic disorder; depression; polysubstance abuse; coping with psychosis; borderline personality disorder; trichotillomania; marijuana dependence; skin picking; eating disorders

Controlled Studies in Behavioral Medicine

• chronic pain; smoking; diabetes management; adjustment to cancer; epilepsy; whiplash associated disorders; chronic pediatric pain; weight-maintenance; exercise; work stress; adjustment to tinnitus;

ACT for Depression

ACT for COD

ACT / CBT Comparisons

• 8 ACT better

• 1 CBT better

• 3 Both are the same

• Change processes so far always different

ACT for Psychosis

ACT (etc) for BPD(Gratz et al 2006)

Small RCT (N = 22); patients with at least 5/9 DSM BPD features (8 or more on the RDIB)

History and current (last 6 mo) self-harm

In individual therapy (stayed in – the group was in addition)

14 weekly groups; 90 minutes each

ACT (etc) for BPD(Gratz et al 2006)

1. Function of self-harm behavior 2. Function of emotions 3-4. Emotional awareness 5. Primary vs. secondary emotions 6. Clear vs. cloudy emotions 7-8. Emotional avoidance vs. acceptance9. Nonavoidant emotion regulation strategies 10. Impulse control11-12. Valued directions 13-14. Commitment to valued actions

Self Harm

Pre Post

30M

ean

Sco

re

Phase

20

ACT etcACT etc

TAUTAU

10

Depression

Pre Post

30M

ean

Sco

re

Phase

20

ACT etcACT etc

TAUTAU

10

ACT for BPD(Morton et al., in press)

Small RCT (N = 41); patients with at least 4 DSM BPD features

Regular individual treatment contact (stayed in – the group was in addition)

12 weekly groups; 2 hours each

ACT for BPD(Morton et al in press)

1. Overview of ACT. Intro to mindfulness2. Cost of avoidance; beginning values3-4. Acceptance and defusion5. Mindfulness of pleasure6. Emotional awareness7-8. Health and relationship values9. Mindfulness in conflict10. Values and choice11. Mindfulness and acceptance12. Review and celebration

Borderline Severity

Pre Post

50M

ean

Sco

re

Phase

40

ACT ACT

TAUTAU

30

3 mo F-Up

Hopelessness

Pre Post

18M

ean

Sco

re

Phase

12

ACT ACT

TAUTAU

6

3 mo F-Up

Impact of ACT Self Help

Sub-analysis of 46 depressed teachers in a wellness program

8 weeks to read the book

Depressed Teacher Subsample

0

5

10

15

20

25

30

35

40

45

0 2 6

0

5

10

15

20

25

30

35

40

45

0 2 6 8

Months

Analysis of 0,2,6 month data: p eta sq = .25 (large effect size)

How about clinical

significance?

% who get across that green line

Average for Hospitalized Depressed Patients

Teacher Sample

Book

Book

O 2 6 8

Depressed Teacher Subsample

0%

10%

20%

30%

40%

50%

60%

0 2 6 8

Percentage Clinically Improved

Book

56.5%

ACT

Good books now available in Dutch, for example

Rokx, T.A.J.J. (2011). Het Leven is geen Feest; de mythe van het maakbare geluk. Amsterdam, Hogrefe.