A Review of Acceptance and Commitment Therapy (ACT) Empirical Evidence:
Correlational, Experimental,
Psychopathology, Component and Outcome Studies
By Francisco J. Ruiz (2010)
ACT
A psychological intervention Philosophically rooted in functional
contextualism Rooted in Relational frame theory (RTF) Treatment of experiential avoidance
disorder (EAD) Functional dimensional approach to
psychopathology
Functional contextualism
Generally contextualism observes actions in a context
Functional contextualism specific way of contextualism which undermines prediction and influence of events with precision, scope and depth.
Thoughts or actions are not seen correct or incorrect
It focuses on usefulness
RFT
Contextual behaviorism approach to human language and cognition
Based on laws Human beings learn to relate stimuli
under arbitrary contextual control It has three requisites for considering
the existence of relational frame
RFT
Mutual entailment
AB
BA
Combinational
Entailment
A>B, B>C
A>C
Transformation of
Functions(Depends on function)
RFT
Has large number of implication of area of psychopathology and psychotherapy
Briefly nature of language and cognition has more impact on changing attempts focused on the function of private events
Experiential Avoidance
Deliberate effort to avoid and/or escape from private events such as thoughts, memories and bodily sensations.
When EA combined with psychological inflexibility problems occur.
EA works in short run. In long run, it provokes patients’ life.
Essential ACT Principles and Methods
What does ACT provide ?
Generates psychological flexibility Contact the present moment
Proposes acceptance To involve oneself in valued action
Therapeutic Work in ACT
Promotes
Values clarification
and actionsDefusion
Values clarification and actions
Creative hopelessness
Values clarification
Promotion of the willingeness to experince
Defusion
To choose to behave in valued way
Cognitive defusion - weakining the tendency to treat them.
Self as a context - there is a YOU
behind all private events
How ACT obtaion its objectives
metaphors
paradoxes
Experiential exercises
Classical exposure therapies vs. ACT
Extinction of discomfort
Trains the patients to be present with their feared experince
Directs them to behave in a valued way.
ACT Empirical Reviews
First Critique: Corrigan (2001)
ACT has not been developed with the usual rationale--philosophical and theoretical roots were not used
First Review: Hayes et al (2006)• Correlation evidence• Experiential avoidance, experimental psychopathology and
ACT component studies, randomized controlled trials and processes of change studies
• ACT—superior to control conditions, wait-lists and treatment• ACT—superior to structured interventions
Other research:
Öst (2008): Qualitative and quantitative review of the ACT empirical evidence from RCT.
--Comparing ACT versus CBT (Cognitive Behavior Therapy)
--Conclusion: ACT showed lower scores in a methodological scale compared with CBT
--ACT does not fulfill the criteria for being considered as an empirical validated treatment.
Re-analysis of Öst review: Gaudiano (2009)
%38 of the ACT studies could not be matched with CBT study because:
--Studies were conducted over different disorders
--Different population
CBT studies were 4.5 more times funding than ACT studies
Recent Review: Powers, Vörding & Emmelkamp (2009) Meta-analytic review of ACT empirical evidence in
RCT studies--Conclusion: ACT is better than wait-lists,
placebo attention conditions BUT
not significantly better than established treatments
HOWEVER Re-analyzed the data base: Levin & Hayes (2009)
--Conclusion: ACT was better than established treatments
Emprical Evidence of ACT Model
separated as a correlational, experimental psycpath. and component studies, outcome studies and case studies.
Correlational Studies; Aim to study relationship among experiential
avoidance and psychological symptoms. ‘’Acceptance and Action Questionnaire’’ is used in
studies. it measures experiential avoidance Experiential avoidance is analyzed with different types
of psychological construct and symptoms . Chronic pain is one of them
Kratz, Davis,& Zatura (2007) have showed that acceptance of pain predicted posterior positive affect.
According to Wicksell, Renöfalt, Olsson, Bond & Melin (2008), acceptance predicted pain severity , pain interference in everyday life and physical and metal well-being.
In work setting, the level of experiential avoidance has predicted mental health and performance in learning a new software (Bond, & Flaxman, 2006).
Experiential avoidance has been a mediator between childhood psychological abuse and current mental health symptoms (Reddy, Picket, & Orcutt, 2005).
Experiential avoidance block the reduction of depression in the treatment of borderline personality disorder.
Experimental psychopathology and ACT component studies
3 types of studies : effect of experiental avoidance, effect of acceptance coping instructions, effect of brief ACT protocol
Studies about effect of experiental avoidance repertoire in experimental task:
Predictive power of the level experiental avoidance of
participants selecting participants with high and low scores in AAQ
Cold pressor task (Zettle et al.,2005)
-High score of AAQ had lower tolerance and kept their hand in cold water less time than participant with low AAQ score
Effect of being drunk (Zettle,Petersen,Hocker&Provines,2007) -Higher scores in AAQ were more discomforting and had worse performance on challenging perceptual-motor task than lower scores.
Carbon dioxide-enriched air challenge (Feldner, Zvolensky, Eifert &Spira (2003)
-High levels of AAQ showed more anxiety and emotional discomfort but not more phsysiological activation
- High AAQ score, received suppression protocols, showed higher levels of anxiety than those who received perceived acceptance control
Comparing emotional reactions (Sloan,2004) -participants with high level of experiental avoidance showed higher
emotional experience and higher heart rate with the pleasent and unpleasent films
THE EFFECT OF ACCEPTANCE COPING INSTRUCTIONS
Nihan Kaymaz
Several studies focused on the effects of acceptance coping instructions
Aim: to assess the psychopathology in terms of comparing acceptance coping instructions and other coping strategies
Aversive stimulation, intrusive thoughts, cardiovascular conditions, emotional contents
In terms of aversive stimulation:
Keogh, Bond, Hanmer & Tilston (2005): Cold-pressor task Acceptance coping instruction obtained better results than one
‘distraction coping instruction’ with women The same effect with men
In terms of intrusive thoughts: Marks & Woods (2005):
Acceptance instructions vs. suppression in the management of intrusive thoughts
Acceptance coping instruction group: less discomfort when experiencing the intrusive thoughts.
Suppression group: more intrusions, higher levels of anxiety, negative evaluation compared with acceptance
(while doing a task which consisted in saying aloud and imagining that
a loved one were having a traffic accident)
Najmi, Riemann & Wegner (2009): Similar effects with those with OCD Both acceptance and focused distraction coping instruction
groups had less distress than suppression group.
In terms of cardiovascular conditions:
Low, Stanton & Bower (2008): Acceptance-oriented processing vs. evaluative emotional
processing on cardiovascular habituation and recovery Task: writing about an ongoing stressful experience Better efficient heart rate habituation and recovery in
acceptance condition
In terms of emotional contents:
Campblell-Sills, Barlow, Brown & Hofmann (2006): Differential effect of suppression vs. acceptance instructions Task: viewing a highly emotional film Lower heart rate and less negative effect during the film in acceptance
condition than in suppression condition
Liverant, Brown, Barlow & Roemer (2008): Depressed participants used Suppression produced short-term reduction in sadness with low levels
of anxiety However, not effective at moderate and higher levels
In terms of emotional contents:
Hofmann, Heering, Sawyer & Asnaani (2009): Suppression vs. cognitive reappraisal vs. acceptance instruction Task: coping with an impromptu speech in front of a video-camera Higher heart rate in suppression condition than in others Also, subjective experience of anxiety was lower in cognitive
reappraisal than acceptance
Dunn, Billotti, Murphy & Dalgleish (2009): Suppression vs. acceptance on processing distressing materials Suppression showed better results However, suppression was accepted similar to cognitive reappraisal
coping instruction
Limitations ACT does not instruct acceptance
Metaphors and experiential exercises are used
Coping strategies have some similarities among them and there is still no a consensus about their verbal processes Both acceptance and cognitive reappraisal involve distancing
from thoughts
Acceptance coping protocols in these studies did not include valued oriented behaviors or any valued context. In ACT, acceptance is always at the services of values
Effects of ACT Protocols
Cold-pressor task experiments:
Hayes, Bissett, et al(1999): Acceptance-based protocol vs . Control-based protocol
Masedo& Esteve (2007):Acceptance-based protocol vs. Suppression-based protocol
Branstetter-Rost et al (2009):ACT-based acceptance with/without values
Pain-tolerance task experiments:
Takahashi et al (2002):ACT exercises vs. CBT exercises
Gutierrez et al (2004):Acceptance-based protocols vs. Cognitive-control-based
protocols
McMullen et al (2008):Acceptance-based coping strategies vs. Control-based strategies
Blarrina et al (2008):ACT values protocol vs. Control values protocol
OUTCOME STUDIES
CLINICAL PSYCHOLOGY
Depression Anxiety disorders Psychotic symptoms Personality disorders Addictive behaviors At-risk adolescents
CLINICAL PSYCHOLOGY Two studies: ACT and depression Zettle & Hayes, 1986:
Comprehensive distancing vs. two versions of cognitive therapy
ACT was better after therapy and after 2 month follow up.
• Zettle & Hayes, 1989: ACT in group format vs. the previous two CT
versions in groups Cognitive fusion mediated the results
(believability of depressive thoughs).
ANXIETY DISORDERS
Two studies: ACT and OCD Twohig, Hayes & Masuda, 2006b:
Positive results with all participants Twohig, 2007:
ACT vs. Progressive Relaxation Training Less compulsions with ACT group than
relaxation group at post-treatment and at 3 month follow-up.
ANXIETY DISORDERS
Four studies: ACT and Social Phobia Block, 2002:
ACT vs. CBT, participants with subclinical social anxiety
ACT group was better at public speaking• In general, ACT is a promising
treatment for social phobia
ANXIETY DISORDERS Generalized Anxiety Disorder
Roemer & Orsillo (2007): ACT obtained large effect sizes in reducing GAD symptoms.
• Hayes, Orsillo & Roemer (in press): Acceptance in private events and
engagement in meaningful activities related to responder status and quality of life at post-treatment.
Trichotillomania and skin picking: Studies reported positive results.
ANXIETY DISORDERS
Diverse symptoms related to anxiety and/or depression
ACT vs. CBT or CT ACT obtained more improvements at
post-treatment and at the 6 month follow-up
Decrease of experiential avoidance (Lappalainen et al., 2007).
PSYCHOTIC SYMPTOMS
Bach & Hayes (2002): 45 minute sessions of ACT and TAU vs.
only TAU to prevent rehospitalizations ACT and TAU condition decreased
rehospitalizations, hallucinations and delusions believability.
• Gaudiano & Herbert (2006a & 2006b): same results.
PERSONALITY DISORDERS
Gratz & Gunderson (2006): patients with borderline personality disorder. TAU vs. ACT and TAU Even though both conditions have
significant effects, the latter one reached normative functioning levels.
ADDICTIVE BEHAVIORS
Hayes, Wilson et al. (2004): polysubstance abusing individuals being maintained on methadone ACT, Intensive Twelve Step Facilitation
vs. Methadone Maintenance only ACT condition showed greater decrease
in total drug use at the 6 month follow-up
AT-RISK ADOLESCENTS
Gomez et al. (under review): In the treatment of at-risk adolescents
who are with a history of antisocial behavior and current legal issues (n=5)
Less impulsivity, higher self-control, more value oriented actions
Improvements increased in one year follow-up
AT-RISK ADOLESCENTS Luciano et al. (2009):
Adolescents with moderate or high risk (n=15) of having impulsivity or emotional problems
Values clarification protocol: promoting choosing and taking responsibility for own choices
Showed a large effect only for moderate-risk adolescents
Defusion protocol: discriminating private events Produced a large effect size for high-risk adolescents
and improved the effect of values protocol.
ACT in Health Psychology
Dahl, Wilson, & Nilsson (2004): Chronic pain, ACT vs. TAU Less sick days for ACT group at 6 month follow-up
Wicksell et al. (2008): On people with Longstanding Pain –> significant
improvements in functioning, life satisfaction, fear of movements and depression at 7 month follow-up.
Gifford et al. (2004): ACT>CBT -for chronic pain- (Smoking Cessation
ACT>Nicotine Replacement Therapy) at 1 year follow-up.
ACT in Health Psychology Branstetter et al. (2004):
Distress resulted from end-stage cancer ACT>CBT for alleviating distress levels
Lundgren et al. (2006): Epilepsy ACT condition vs. Attention Placebo Condition At 12 month follow-up Less seizures, higher quality of life
Forman et al. (2009): Weight loss in obese women At post-treatment 6.6% of body weight lost At 6 month follow-up 9.6% of body weight lost
ACT in Health Psychology Gregg et al. (2007):
Type II Diabetes Diabetes Education vs. ACT + Diabetes Education ACT condition was more succesful in promoting
self-management behaviours Hesser et al. (2009):
ACT reduced Tinnitus Distress At 6 month follow-up symptom reduction
Good outcomes in: Multiple Sclerosis (Sanchez & Luciano, 2005), Prevention of HIV (Gutiérrez et al., 2007), Systematic Lupus Erythematosus (Quirosa et al.,
2009)
Other Areas of Intervention
OTHER AREAS of INTERVENTION
Fernandez et al. (2004);
- sport performance enhancement
- carried out RCT
- ACT vs. hypnosis
RESULTs : ACT showed greater influence BUT without reaching a statistical significant differences.
OTHER AREAS of INTERVENTION
Chess players who showed the greatest improvement in their performance were the ones who had higher levels of experiental avoidance during competitions at pretreatment
OTHER AREAS of INTERVENTION
Work Settings ;Differential effect of ACT 3 hours session intervention vs.
Innovation Promotion Program and wait-list condition
ACT showed better effect in post treatment and in the 3 month follow-up in the improvement of general mental health
OTHER AREAS of INTERVENTION
Potential efficacy of ACT in reducing the resistance to the use of emprical validated treatments among professional councelors
Louma et al. (2007) compared the differential effect of 8 ACT sessions with a control condition
RESULTS: in the ACT condition, counselors followed using the empirical validated treatment at the 2 and 4 month follow-up more frequently than control condition
OTHER AREAS of INTERVENTION
Reducing prejudice and stigma Hyes et al. (2004)
Differential effect of ACT vs. Multicultural Training and Biological Education in diminishing the stigma and burnout among substance abuse counselors
RESULTs: ACT obtained better results than the other intervention of stigma, burnout and the believability of stigmatizing attitudes at post-treatment and 3 months follow-up
OTHER AREAS of INTERVENTION
• Masuda et al. (2007)
- effect of an ACT intervention vs. educational intervention in reducing stigma towards people with mental disorders
- differential effect of the protocols among participants with high and low AAQ scores
OTHER AREAS of INTERVENTION
RESULTS;
-in post-treatment and at the 1 month follow-up, ACT produced a decrease on stigma both in participants with high and low AAQ scores
-Higher effect in the high avoidant participants
-Educational intervention worked with participants with low AAQ scores
Published case studies:Depression GAD Anxiety Agoraphobia Panic disorder PSTD OCD Psychotic symptoms Anorexia nervosa Schizotipic personality disorder Familiar and couples problems Patients with intellectual disabilities Exhibitionism Sexual dysfunction and orientation Alcoholism Heroin addiction Chronic pain Cancer Swimming and weightliftingChess Lacrosse
Discussion
ACT is effective in a wide range of problems Typically better after follow-up Relevant effect when applied to extremely short
interventions The empirical evidence is compromising
Some studies show that: ACT and CBT have similar effects Better results for ACT
However;
Still needed for more controlled studies with larger
samples!
Coherent results with the literature of experiential psychopathology
The review of correlational studies strongly support the ACT model Experiential avoidance as a mediator
Some conclusions can be made out: Highly experiential avoidance participants responds
differently to several experimental challenges Acceptance values based protocols are effective in
improving the participants in the experimental challenges
More effect has been found in ACT protocols than in control based ones
DISCUSSION
Although the RFT state of evidence was out of the scope of the current study, it is called to be most differential characteristic between ACT and other second and third wave therapies.
DISCUSSION
Although RFT definition of acceptance, values, and cognitive defusion is in its beginnings, it is the most important area of research that needs to be done in order ro improve ACT results..
DISCUSSION
For example, consider 2 specific issues:
1. To better know what are the specific transformations of functions involved in cognitive defusion and values clarification exercises would allow to redefine or invent new exercises that become more powerful
DISCUSSION
2. İf the therapist know the specific verbal processes in the transformation of functions through analogical relations, he/she becomes using more effective methapors in practice
CONCLUSION
ACT seems to have strong support in view of the correlational, the experimental psychopathology, and the outcome evidence
It is worth nothing that ACT is a therapy with very singular characteristic.
CONCLUSION
Also, it is a good model of psychopathology of EAD or psychological flexibility
ACT also have similarity with CBT or between other types of therapies.