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Contextual Methods and Contextual Methods and the Future of CBTthe Future of CBT
The Opportunity of The Opportunity of UpheavalUpheaval
Contextual Behavioral Science StrategyContextual Behavioral Science Strategy
From a clear philosophy of science, and with aFrom a clear philosophy of science, and with a General-process account that addresses cognition,General-process account that addresses cognition, Construct transdiagnostic processes, andConstruct transdiagnostic processes, and Organize them into a useful clinical model, with Organize them into a useful clinical model, with Components that derive from the model, andComponents that derive from the model, and Substantial breadth of application, andSubstantial breadth of application, and Successful mediators and moderators linked to those Successful mediators and moderators linked to those
process; extended by aprocess; extended by a Dissemination and training strategy, and theDissemination and training strategy, and the Construction of a development communityConstruction of a development community
Contextual Behavioral ScienceContextual Behavioral Science Philosophy: Functional contextualismPhilosophy: Functional contextualism General process account: Behavioral principles General process account: Behavioral principles
and Relational Frame Theory nested within an and Relational Frame Theory nested within an overall evolutionary science perspective overall evolutionary science perspective
Transdiagnostic processes: Experiential Transdiagnostic processes: Experiential avoidance, cognitive fusion, flexible attention to avoidance, cognitive fusion, flexible attention to now, perspective taking sense of self, values, now, perspective taking sense of self, values, committed actioncommitted action
Clinical model: Psychological flexibility model Clinical model: Psychological flexibility model
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
Psychological Flexibility
Contextual Behavioral ScienceContextual Behavioral Science Functional ContextualismFunctional Contextualism Behavioral principles and RFT within EvoSBehavioral principles and RFT within EvoS EA, fusion, now, self, values, actionEA, fusion, now, self, values, action Psychological flexibility modelPsychological flexibility model ComponentsComponents Breadth of application, Breadth of application, Mediators and moderators, Mediators and moderators, Dissemination and training strategy, Dissemination and training strategy, Construction of a development communityConstruction of a development community
ComponentsComponentsAcceptance Defusion Contact
with Present
Self-as-Context
Combinations of Four Mindfulness Components
Values Other Combination
Campbell-Sills et al., 2006
Marcks & Woods, 2005
Cioffi & Holloway, 1993
Williams, 2007
Arch & Craske, 2006 Cohen et al., 2000 Gutiérrez et al., 2004
Eifert & Heffner, 2003
Marcks & Woods, 2007
Kingston et al., 2007
Broderick, 2005 Cohen et al., 2006 McMullen et al., 2008
Levitt et al., 2004
Masuda et al., 2004
Leventhal et al., 1989
Burns, 2006 Creswell et al., 2005
Paez-Blarrina et al., 2008
Low et al., 2008
Masuda et al., in press
Logan et al., 1995
Feldner et al., 2003 Crocker et al., 2008
Roche et al., 2007
Michael & Burns, 2004
Hayes et al., 1999 Harris et al., 2005
Vowles et al., 2007
Haythornthwaite et al., 2001
Fein et al., 1997
Keogh et al., 2005; 2006
Paez-Blarrina et al., 2007
Masedo & Esteve, 2007
Spencer et al., 2001
Takahashi et al., 2002
Forman et al., 2007
Kehoe et al., 2007
Pain Tolerance Pain Tolerance McMullen et al., 2008McMullen et al., 2008
108642
Acceptanceand Defusion
Distraction
No Instructions
Instructions,Metaphor, Exercise
Instructions,Metaphor, Exercise
Instructions Only
Instructions Only
Shocks to Continue Task
Hedges's g and 95% CI
-.5-1.00.0
1.0.5Favors ACTFavors Control
Active Comparison (n=692)
Persistence and Willingness
Impact of ACT Components on Persistence and Willingness
Inactive Comparison (n=440)
Subjective Distress During Task
Active Comparison (n=693)
Inactive Comparison (n=564)
Inactive Comparison (n=145)
Subjective Distress While Recovering From Task
g = .13
g = .69
g = .48
g = .37
g = .47
g = .38
Active Comparison (n=423)
Breadth of ApplicationBreadth of Application
RCTsRCTs DepressionDepression 33 StressStress 44 PsychosisPsychosis 22 AnxietyAnxiety 11 PainPain 44 BurnoutBurnout 11 TrichTrich 11 Substance Substance 22
abuseabuse DD/DDDD/DD 11
RCTs
• OCD 1
• Epilepsy2
• Diabetes1
• Weight 3
• Prejudice 2
• Learning 2
• Cancer 2
• Smoking 3
• BPD 2
• Fitness 1
0 .25 .50
.75
1.0
Study Problem Comparison Mediator
Tapper, 2009 Weight Diet PF/EA
Woods, 2006 Trichotillomania Wait list PF/EA
Gaudiano, 2009 Psychosis Enhanced TAU Defusion
Bond, 2000 Work stress Wait list PF/EA
Wicksell, 2009 Pain MDT + medication Defusion
Wicksell, 2008 Pain TAU PF/EA
Lazzaroni, 2009 Work stress Wait list PF/EA
Zettle, 1986 Depression CT Defusion
Hayes, 2004 Stigma Psychoeducation Defusion
Lappalainen, 2007 Outpatient misc CBT PF/EA
Lillis, 2009 Weight Wait list PF/EA
Lillis, 2007 Ethnic prejudice Education PF/EA
Gifford, under review Smoking Medications PF/EA
Lundgren, 2008 Epilepsy Supportive treatment PF/EA
Gregg, 2007 Diabetes Education PF/EA/Self-Manage
Varra, 2008 Resistance to ESTs Psychoeducation PF/EA/Defusion
Zettle, in press Depression CT Defusion
Gratz, 2006 BPD TAU PF/EA
Average Proportion Mediated: .53 (unweighted by n); .47 (weighted); Total n =
903
Follow up Change Outcomes; Post Mediators(3 studies no follow-up; 3 no post)
Testing with bootstrapped cross product:
All below p = .1All but 3, p
< .05
Large effect size
Proportion Mediated
The CBT Future? My The CBT Future? My GuessGuess
Down: syndromes, brute force empiricism, Down: syndromes, brute force empiricism, EBP based only on packages. EBP based only on packages.
Up: EB processes, EB procedures, functional Up: EB processes, EB procedures, functional analysis, transdiagnostic models. Why? analysis, transdiagnostic models. Why? More progressive and more functional.More progressive and more functional.
I believe general functional contextual I believe general functional contextual perspectives will compete with more perspectives will compete with more structural, special process, or mentalistic structural, special process, or mentalistic accounts accounts
… … and I expect more of …and I expect more of …
Contextual CBT (“Third Contextual CBT (“Third Wave”)Wave”)
Is grounded in an empirical, principle-Is grounded in an empirical, principle-focused approach, that is particularly focused approach, that is particularly sensitive to the context and functions sensitive to the context and functions of psychological phenomena more so of psychological phenomena more so than their validity or form, and thus than their validity or form, and thus tends to emphasize contextual and tends to emphasize contextual and experiential change strategies in experiential change strategies in addition to more direct and didactic addition to more direct and didactic onesones
Seeks the construction of broad, Seeks the construction of broad, flexible and effective repertoires flexible and effective repertoires over an eliminative approach to over an eliminative approach to syndromes, symptoms, or narrowly syndromes, symptoms, or narrowly defined problems;defined problems;
Emphasizes the relevance of these Emphasizes the relevance of these issues for clinicians as well as issues for clinicians as well as clients; clients;
Contextual CBT Contextual CBT
Reformulates and synthesizes what is Reformulates and synthesizes what is already known in behavioral and already known in behavioral and cognitive therapy, rather than rebelling cognitive therapy, rather than rebelling against it; andagainst it; and
Carries the behavioral and cognitive Carries the behavioral and cognitive therapy tradition forward into deeper or therapy tradition forward into deeper or more complex questions, issues, and more complex questions, issues, and domains that were previously addressed domains that were previously addressed primarily by other, less empirical primarily by other, less empirical traditions. traditions.
Contextual CBTContextual CBT
Context Over ContentContext Over Content
““unlike CBT, there is little emphasis in unlike CBT, there is little emphasis in MBCT on changing the content of thoughts; MBCT on changing the content of thoughts; rather, the emphasis is on changing rather, the emphasis is on changing awareness of and relationship to thoughts.” awareness of and relationship to thoughts.” (2004, p. 54). (2004, p. 54).
Behavioral activation “interventions address Behavioral activation “interventions address the the functionfunction of negative or ruminative of negative or ruminative thinking, in contrast to CT’s emphasis on thinking, in contrast to CT’s emphasis on thought thought contentcontent, [through] attention-to-, [through] attention-to-experience interventions” (Dimidjian et al., experience interventions” (Dimidjian et al., 2006, p. 668). 2006, p. 668).
Context Over ContentContext Over Content
““MCT does not advocate challenging MCT does not advocate challenging of negative automatic thoughts or of negative automatic thoughts or traditional schemas.” (Wells, 2008, traditional schemas.” (Wells, 2008, p. 651); while “p. 651); while “CBT is concerned CBT is concerned with testing the validity of thoughts with testing the validity of thoughts (…) MCT is primarily concerned with (…) MCT is primarily concerned with modifying the way in which thoughts modifying the way in which thoughts are experienced” (p. 652). are experienced” (p. 652).
A Content Focus is Not Buying Us MuchA Content Focus is Not Buying Us Much
25
0
10
15
20
30
ADMADM CTCTBehavioralBehavioral
ActivationActivation
Pre
to P
ost
Dec
reas
es in
BD
I
5
Psychological Flexibility
Open
Aware
Active
Defusion
Pre
sent
Mom
ent Perspective taking
ValuesAcceptance
Com
mitted
Action
(modified from Harris, 2009)
Simplified Psychological Simplified Psychological Flexibility ModelFlexibility Model
Psychological Flexibility
Open
Aware
Active
(modified from Harris, 2009)
Is This Becoming a Is This Becoming a Consensus Consensus
Contextual CBT Model?Contextual CBT Model?
The Triflex as a The Triflex as a Consensus Consensus
Contextual CBT Model?Contextual CBT Model?
Expos
ure
with
resp
onse
pre
vent
ion
Bec
k’s
Cog
nitiv
e Th
erap
y
Dialectical B
ehavior Therapy
Min
dful
ness
Bas
ed C
ogni
tive
Ther
apy
Rational E
motive B
ehavior Therapy
Acceptance and C
omm
itment Therapy
Sch
ema T
herap
y
Barlo
w’s U
nified
Pro
toco
l
Behav
iora
l Act
ivat
ion
Func
tiona
l Ana
lytic
Psy
chot
hera
py
Man
y oth
ersAp
praisal w
ork
Mindfulness B
ased Stress R
eduction
C B T
Mot
ivat
iona
l Int
ervi
ewin
g
Met
acog
nitiv
e Th
erap
y
The Big Tribal Umbrella
C B T
Emotion Cognition
Sense of SelfOvert Behavior
With Shared Targets
Social Functioning
Spirituality
C B T
Neo-Behavioral Information Processing
Behavior Analytic
Social Learning
But Varied Foundations
Hypothetico-Deductive
Inductive
Contextual Behavioral Science
Relational Frame Theory
C B T
Functional Contextualism
Elemental Realism
OrganicismConstructivism
And Philosophies
A C T
Functional Contextualism
Behavior Analytic
Inductive
Contextual Behavioral Science
Relational Frame Theory
And Distinct Features, e.g.
CBTCBT