Presentation on theme: "Supercharging therapy with values"— Presentation transcript:
1Supercharging therapy with values Dr. Joseph Ciarrochi,School of Psychology, University of WollongongSpecial thanks to natalie stefanic, for all her intellectual discussion and research on this topic
2Structure of talk Part 1 Theory Part II. Behavioral Activation Evidence behavioral Activation is effective.Part III: Values clarificationEvidence values clarification is effectiveHow to work with values
4What happens to people’s dreams? “The very great majority kill themselves long long before their time.Live as children; grow pale as adolescents; show a flash of life in love; die in their twenties and join the poor things that creep angry and restless about the earth” (O’Brian, 1991, p. 526).
5ACT as a Unified framework An extremely brief and pictorial description of Relational Frame Theory Fusion and Avoidance, two key processes that play a role in interfering with value-congruent living
6How do we lose touch with what we value How do we lose touch with what we value? Fusion is the dominance of particular verbal functions over other potentially available nonverbal and verbal functions (Hayes et al., 1999).
7Fusion and avoidance. Fusion makes it possible for our private experiences (the bees above) to seem like physical threats. It allows us to spend time avoiding our experiences, just as we would avoid an outside threat
8Avoidance takes a great deal of energy and is often inconsistent with other activities, e.g., distress provoking valued-activities
9Desire (or values) and fear are two sides of the same coin Desire (or values) and fear are two sides of the same coin. If can’t have distress, then you often must give up what you desire or value
10Acceptance and Commitment Therapy (ACT) and Behavioural Activation (BA) Shared philosophy of science: Functional ContextualismBehaviouristEmphasis on functional analysisEmphasis on context rather than contentShared therapeutic processesActivation of behaviourUndermining of harmful avoidance behaviorMindfulnessExposure
11Distinctions between ACT and BA ACT is based on a behavioral theory of language. Like traditional CBT, ACT views cognition as playing a key controlling role in suffering. However , ACT and traditional CBT differ in how they conceptualize and treat client problems (Ciarrochi & Bailey, 2008).Cognitive Defusion. ACT attempts to change the way one interacts with or relates to thoughts by creating contexts in which their unhelpful functions are diminished.Self-as-Context- ACT helps people to contact with the sense of self as a locus or perspective (e.g., the “observer” self). This self gives clients a place to observe their experience and learn to let go of unhelpful self-evaluations. They learn that they are not the same as their evaluations; they are not the same as their pain, their depression.
12Distinctions between ACT and BA Activities versus valuesACT tends to emphasize values more than traditional BA, which focuses a bit more on activity scheduling
14Study 1 supporting BA as“well-established” treatment for depression (Chambless et al., 1996) McLean and Hakstian (1979) JCCP. Behavior therapy superior to other therapies at immediate follow-up (9 of 10 indices), and marginally superior on follow-up (7 of 10 indices)Behaviour therapy had lowest dropout (5% compared to 26% to 36% for other treatments)
15Study 2 supporting BA as“well-established” treatment for depression (Chambless et al., 1996) Jacobson et al. , 1996, (JCCP) compared three conditions.ConditionsBehavioural Activation (BA)BA + automatic thought challenging (ATC)BA+ATC+ downward arrow/core beliefResultsBehavioral activation alone was as effective in treating depression as BA combined with cognitive interventions.Gortner et al showed effects held at 2 year follow-up
16More research supporting behavioural activation Dimidjian et al., 2006, JCCP. Study of Major DepressionCompared behavioural activation to Cognitive Therapy and Antidepressent medication (ADM)BA found to be comparable in efficacy to ADM, and more efficacious than CT.Differential treatment effects obtained only for most severely depressedFor more severly depressed participants, BA and ADM comparableCuijpers et al., 2007 CPR. Meta-analysisBA effective (effect size =.87) and effects fairly consistent across studies
17Is behavioral activation effective for other disorders, such as anxiety? ACT theory posits similar processes: fusion and avoidance.Approximately 50% of individuals with depression have a coexistant anxiety disorder ( Kessler et al., 1996; Mineka, Watson, and Clark, 1998)Anxiety and depression share many symptoms (e.g., difficulties concentrating, restlessness, fatigue, and sleep problems.Decrease in control and predictability may be common in both disordersAnxiety and mood disorders may be variable manifestations of similar neurobiological processes (See Hopko, et al., 2006, for review of similarities between anxiety and depression)
18Exposure in the service of activating valued behaviour
19Is behavioral activation useful in treating anxiety Small study of pure B.A. with PTSD shows B.A. was effective (Jakupac, et al., 2006)Social anxiety: Exposure is as effective as CT and full CBT package in treating social anxiety (Powers, et al., 2008)ACT, with big BA component, is effective in treating anxiety (Block, & Wulfert, 2000; Dalrymple & herbert, 2007; Forman et al,2007; Zettle, 2003)
21What are values?Wilson, Sandoz, Kitchens, and Roberts, 2008, under review1) Values are ongoing patterns of activityNot achievable, can’t be completedGoals are achievable and serve values
22What are values? 2) values are a special class of reinforcer Can me distant in time, and occur in tiny incrementsCan refer to benefits that , in principle , could never contact (e.g., afterlife)Animals driven more by primary reinforcers (food shelter, water) and events correlated with those reinforcers (secondary reinforcers). These reinforcers usually occur in close proximity and reasonably large magnitude to serve as reinforcers (Wilson, et al., 2008)
23What are values? 3) values are verbal Language makes present psychological functions without direct operant or classical conditioning processes
24What are values?Values are a special class of reinforcers that are verbally constructed, dynamic, ongoing patterns of activity, for which the predominant reinforcer is intrinsic in the correspondence between the individual behaviour and valued behavoural pattern (Wilson, et al., 2008)
25Values, what are they good for? Values have tremendous transformational powerTheoretically, values set up the possibility for behaviours to become more reinforcing or punishing because of their relation to value statementsReinforcing:“Washing dishes” can go from tedious to joyous if “washing dishes” is in the service of “being a loving partner.”Punishing: Working extra hours can become increaingly aversive if it is seen as inconsistent with “being a loving partner.”
26Empirical evidence: Values work is likely to be good for the client
27Values affirmation buffers the stress response All participants rank order values in terms of personal importanceTrier social stress task—involves telling subjects they will have to do stressful speech task and mental arithmetic.Cresswall et al., 2005, Psychological Science
28Values affirmation buffers the stress response Affirmation manipulationAnswer question like: Assuming that you have sufficient ability, would you prefer to be (a) a banker (b) a politicianExperimental condition. Answered questions relating to top-ranked valueControl. Answers questions relating to fifth ranked value
29Salivary cortisol response to stress in the value-affirmation and control groups
30Pretest and postest self-report stress measure, as function of self-resources (self-esteem and optimism)Values affirmation may exacerbate stress (at least self-report) in people with low self-resourcesAffirmation was sufficient to buffer participants neuroendocrine responses to stress, and this effect did not depend on dispositional self-resources.
31Value affirmation improves objective performance Cohen et al., 2006, ScienceTheoryPeople are motivated to maintain self-integrityNegative group characterizations (e.g., black stereotypes in U.S.) pose chronic threat to self-integrityThis threat, if too severe, can undermine performance
32Value affirmation improves objective performance Main study and replicationTreatment and control condition presented a list of valuesTreatment condition: indicate most important values. Write about why value important to youControl condition. Indicate least important value and why this value might be important to someone else
34Values clarification and tolerance for pain Is their benefit to connecting pain-related thoughts to actions in a valued direction?Paez-Blarrina, M. et al., 2007, Behavior Modification; Paez-Blarrina et al. ,2008, Behaviour Research and TherapyMarisa Paez-Blarrina…Coming out of Carmen Lucianos Act lab in spain
35Values clarification and tolerance for pain Pain taskPerform cognitive task. If do well, get points, which can be exchanged for a reward at the end of the task.Red asterisk appears on screen.If choose “finish”, then task ends and no shock.If continue, more chance for points but also a shock. (this is behavioural measure of pain tolerance)
36Values clarification and tolerance for pain Key ConditionsACT-values protocol—depicted pain as a part of valued actionControl-values protocol—pain is opposed to valued livingNo values protocol
37Values clarification and tolerance for pain Findings7/10 ACT-values intervention tolerated maximum number of shocks; Only 1/10 and 2/10 tolerated in the control and untrained condition, respectively.Pain believability. Do you keep going even when you think the task is causing you “very much pain.”9/10 kept going in ACT-values; Only 5/10 and 3/10 kept going in the control and untrained conditions respectivelyThese differences were significant
38Measuring and using values in therapy ACT interventionSurvey of Life Principles
39Past research in values Values work (Schwartz, et al., Rokeach et al.).What is most important to you?Are there Universal values?Personal strivings (Sheldon, Emmons, Deci).What do you strive forWhy do you strive? Is it for authentic or controlled reasons?We will call both of these “guiding principles” for ease of reference
40Towards a behavioural approach to values and goals: Recasting Needs Both value and striving literature seek to identify universal needs that underpin all guiding principlesNeed is identified by observing that positive psychological consequences result from conditions that allow its satisfaction and negative consequences accrue in situations that thrwart it (deci and ryan, 2001, pg 229)Instead of speaking in terms of “needs”, I will speak in terms of categories of reinforcer.
41Towards a behavioural approach to values and goals: type of rule following Pliance- rule governed behavior under control of apparent speaker-mediated consequences for a correspondence between the rule and the relevant behavior. (Zettle and Hayes, 1982; Hayes, Wilson, and Stroshal, 2001)Factors that impact plianceability of speaker to monitor compliance, and deliver consequencesimportance of consequences to listenerothers (history, credibility; Hayes and zettle)Problem with pliance. Excessive pliance, e.g., wanting to “be good” and please others, can dominate over ones direct, personal expeirence of what worksReinforcers are arbitraryNote: contercompliance the other side of the compliance coinArbitrary versus natural reinforcer. Natural reinforcer is dependent on the form of the behavior in that situation(e.g., kicking a glass results in it breaking)Other , more arbitrary things
42Towards a behavioural approach to values and goals: type of rule following Tracking- rule governed behavior under control of apparent correspondence between the rule and the way the world is arranged. (Zettle and Hayes, 1982)Factors that impact trackingListeners history with the rule giverCorrespondence between the rule and other rules or events in the listener’s historyImportance of the consequence implied by the ruleExtent rule successfully leads to reinforcement, avoid punishmentSpeaker does not mediate compliance (e.g., the rule could be conveyed by a book and have the same effect); (Hayes and Zettle, 1982)
43Recasting Self-Determination Theory in behavioural terms. Pliance TrackingDeci and Ryban, 2000, psychological science
44The ImPActS intervention model ImportanceImportant principles are expected to involve trackingACT can be used to help people discover what principles are or are not important to them.PressureACT can be used to undermine the power of unhelpful, pliance-based principlesActivityACT can be used to increase the amount of principle-congruent activity and the likelihood of contacting reinforcersSuccessACT can be used to increase people’s success at living principles (e.g., via overcoming barriers and reinforcing commitment)
45Research on valuesThe area emphasizes the Importance component of the ImPActS model.
46The structure of values (Schwarz) values as cognitive representations of three universal requirements: (a) biological needs, (b) interactional requirements for interpersonal coordination, and (c) societal demands for group welfare and survival.Therefore, in building a typology of the content domains of values, we theorized that values could be derivedfrom the universal human requirements reflected in needs (organism), social motives (interaction), and social institutionaldemands. Of course, particular value contents may be grounded in more than one type of universal requirement.Emphasis on importance.The survey of life principles sought to sample three items from each domain
47Values and behaviour ImPActS Values importance has predicted more than 15 different behaviourse.g., voting for political party, choosing a university courseOther predicted behaviours: delinquency, cooperation, competition, consumer purchasing, environmental behaviours, religious behaviours(See Bardi and Schwartz, 2003)
48Values and well-being ImPActS The following were positively related to subjective well-beingAchievement: Personal success through demonstrating competence according to social standards. (Successful, capable, ambitious, influential)Stimulation: Excitement, novelty, and challenge in life. (Daring, a varied life, an exciting life)Self-direction: Independent thought and action-choosing, creating, exploring. (Creativity, freedom, independent, curious, choosing own goals)Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc
49Values and well-being ImPActS The following were negatively related to well-beingConformity: Restraint of actions, inclinations, and impulses likely to upset or harm others and violate social expectations or norms. (Politeness, obedient, self-discipline, honouring parents and elders)Security: Safety, harmony and stability of society, of relationships, and of self. (Family security, national security, social order, clean, reciprocation of favors)Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc
50Values and well-being ImPActS The researchers failed to find a positive association of subjective well-being andUniversalism: Understanding, appreciation, tolerance and protection for the welfare of all people and for nature. (Broadminded, wisdom, social justice, equality, a world at peace, a world of beauty, unity with nature, protecting the environment)Benevolence: Preservation and enhancement of the welfare of people with whom one is in frequent personal contact. (Helpful, honest, forgiving, loyal, responsible)Seemed inconsistent with the notion that concern for others rather than self promotes subjective well-beingA false dichotomy?Sagiv and Schwarz, 2000, Eur. Jn., of Soc. Psyc
51Succeeding at what is important to you ImPActSCongruity between people's values and their environment promotes well-being, regardless of the particular values to which people ascribe importance.Power values were negatively associated with well-being amongst psychology students, and higher satisfaction amongst business administration students. The business folks were also happier the more they were into achievement values.Sagiv and Schwarz, 2000, Eur. Jn., of Soc. PsycThe survey of life principles contains10 items that get at various career related interests
52Succeeding at what is important to you ImPActSLife satisfaction influenced when satisfied in value-congruent domain.More specifically, global life satisfaction was strongly influenced by social life for individuals high in Benevolence values, whereas it was strongly influenced by family life for individuals high in Conformity values.Satisfaction with grades was a stronger predictor of global life satisfaction for individuals who stress achievement than for those who do not.Within-individual variation of day-to-day satisfaction is strongly influenced by daily success with the most valued domain.Oishi, et al., j of personality, 1999Domain satisfaction most highly related to domain success in our study
53Personal strivingsKey Researchers: Sheldon, Emmons, Elliot, and OthersIdiographic. People describe their own personal strivings and do not select from a set items, as in values workEmphasis on Self-concordance. To what extent do people pursue their goals because the goals fit with their underlying interests and values rather than because others pressure them to pursue the goal.
54Universal “needs, “ or categories of reinforcer Competence or “effectance—propensity to have an effect on the environment as well as to attain valued outcomes within it.Relatedness -- desire to feel connected to others, to love and care, and to be loved and careAutonomy refers to volition—the organisimic desire to self-organize experience and behavior and to have activity be concordant with one’s integrated sense of selfThese can be viewed as classes of reinforcers from a behavioral perspective
55Personal strivings: key findings Self concordance relates to subjective well-being across many cultures (Sheldon, 2002; Sheldon et al., 2004)Longitudinal study. Making progress towards goals predicted well-being. However, this depended on the “organismic congruence” of the goal. That is, goal achievement led to increased well-being for those people who pursued goals for more autonomous reasons, and those goals that are oriented towards more intrinsic outcomes (Sheldon and Kasser, 1998)This relates to Importance and Pressure in the ImPActS model
56Personal strivings: Avoidance goals Elliot and sheldon (1998) coded goals in terms of approach and avoidanceApproach goals: get in good shape, be more gentle and humbleAvoidance goals: avoid procrastination, don’t be lazyPeople with avoidance goals tend to feel less competent and in control and experience greater reporting of physical symptoms (Elliot and Sheldon, 1998)Elliot, Sheldon, and Church (1997) had students classify goals as approach oriented or avoidance oriented. Avoidance striving was deleterious to both retrospective and longitudinal well-being
57The survey of life principles (SLP) Ciarrochi and Bailey, in press; Stefanic and Ciarrochi, 2008; Frearson and Ciarrochi, 2008The SLP attempts to combine the best parts of the values literature and the personal strivings literature, and attempts to do so in a way that is useful to clinicSLP provides people with wide variety of principles to choose from. This has the advantage of prompting people to think about principles they might have not considered for awhile, or might have forgottenSLP measures extent principle is due to self versus other pressure
58The survey of life principles (SLP) 53 items, sampled to cover every major domain identified in values literature, goals literature, and job interests literature.Somewhat heavy emphasis on social principles, given their clinical relevance.Three items related to experiential control (e.g., “having a stress free life”)Principles written in a verb form, in keeping with the ACT definition of values as being “ongoing patterns of activity.”Principles were written to have maximal personal relevance (e.g., “A world of beauty” changed to “creating beauty”)
59The survey of life principles (SLP) Items are call “principles”, because they could refer to either values or abstract goals (e.g., “being honest” might be either value or goal)Two open end items for people to write down own principles
60Four dimensions of the SLP Importance. The extent a person finds princple to be personally imporantPressure. The extent person feels pressured to hold principle. Pressure can come from other people, groups, media, society, etc.Activity. Each principle is rated in terms of whether the person wanted to put it into playSuccess. If person wanted to put a principle into play, then they rated that principle in terms of their level of success.
61SLP: Early findings First study conducted with 300 University Students We focused on variables of interest to clinicians: e.g., measures of emotional well-being, psychological well-being, social support, and relationship satisfactionThe next study will be conducted later this year with 600 year 12 adolescents. We have been conducting a longitudinal study with these students for 7 years.Includes broad range of measures related to social and emotional well-beingInvolves ratings by peers and teachers
62Each SLP global score makes a distinctive contribution to well-being DescriptionLow ScoreMeanHigh ScoreImportanceLow scores indicate the person finds few principles to be important5.816.517.19Female5.906.577.24Male5.576.37.03PressureHigh scores indicate the person feels pressure from others to hold principles3.144.545.98ActivityLow scores indicate that the person is putting reduced number of principles into play23.6331.1838.73SuccessLow scores indicate that the person is not succeeding at principles3.053.483.91
63SLP Global scores and emotional well being Positive AffectSadnessHostilityImportance.10.08.11Pressure-.10.11*.12*Activity.22**.01-.09Success.36**-.34**-.31**Variance explained23%14%12%*p < .05; ** p< .01Note: These are the Betas from regression analysis. All variables were entered simultaneously, so Beta represents the unique variance explained by each global score, after controlling for the other scores
64SLP Global scores and Psychological well-being AutonomyRelations with othersPurposeImportance-.12*.08.27**Pressure-.25**-.15**Activity.11.04.14**Success.30**.36**.39**Variance explained18%29%*p < .05; ** p< .01Note: These are the Betas from regression analysis. All variables were entered simultaneously, so Beta represents the unique variance explained by each global score, after controlling for the other scores
65Predicting social wellbeing Global scoreRomantic relationship satisfactionSocial support numbersSocial support satisfact.Global Success.12.09.18*Prosocial Import..24**.07.12*Having genuine and close friends-success.00.20**.14*Having relationships involving love and affection-success.41**-.04.21**Variance explained32%7%20%*p < .05; ** p< .01Note: The global score “success” was the only one to uniquely predict each of the social well-beings. However, prediction was much improved by using the more specific social principles
67One needs to look at local as well as global indices Importance of power not related to well-being. Indeed , it is related to higher hostilityImportance of wealth was not related to well-being
68Top 10 most important values Having genuine and close friends2Being loyal to friends, family, and/or my group3Maintaining the safety and security of my loved ones4Having relationships involving love and affection5Feeling good about myself (experiential control item)6Striving to be a better person7Experiencing positive mood states (experiential control item)8Being Honest9Having an enjoyable, leisurely life10Being safe from danger
69Top 10 most pressured values Meeting my obligations2Being ambitious and hardworking3Being physically fit4Showing respect to parents and elders5Eating healthy food6Being honest7Being self-sufficient8Striving to be a better person9Being competent and effective10Being safe from danger
70Top 10 most successful values Being loyal to friends, family, and/or my group2Enjoying food and drink3Being safe from danger4Having genuine and close friends5Being honest6Maintaining the safety and security of my loved ones7Making sure to repay favors and not be indebted to people8Showing respect to parents and elders9Having relationships involving love and affection10Enjoying music, art, and/or drama
71Top 10 failures1Leading a stress free life (experiential control)2Having a sense of accomplishment and making a lasting contribution3Promoting justice and caring for the weak4Gaining wisdom and a mature understanding of life5Being wealthy6Being at one with god or the universe7Feeling good about myself (experiential control)8Striving to be a better person9Being physically fit10Having an enjoyable, leisurely life13Experiencing positive mood states (experiential control)Note: Failure index= Importance – success.
73Perceived compatibilities Perceived incompatibilities PrincipleHaving genuine and close friendsPerceived compatibilitiesBeing loyal to friends, family, and/or my groupHaving relationships involving love and affectionEmotion control principles (e.g., Leading a stress-free life, feeling good about myself)Perceived incompatibilitiesGaining wisdom and a mature understanding of lifeArtistic principlesCommentSurprising disconnect between many pro-social principles (e.g., honesty) and friendship
74Perceived Compatibilities Perceived incompatibilities PrincipleHaving relationships involving love and affectionPerceived CompatibilitiesHaving genuine and close friendsMaintaining the safety and security of my loved onesBeing sexually activeBeing safe from dangerPerceived incompatibilitiesSensation seeking principles (Having a life filled with adventure)Nonsocial activities (Building and repairing things; working outdoors)CommentWhere are the prosocial virtues? Honesty, loyalty, helping others
75Perceived Compatibilities Perceived incompatibilities PrincipleProsocial : Being loyal, honest, maintaining security and safety of loved ones, respecting parents and elders, helping othersPerceived CompatibilitiesBeing safe from dangerResolving disputesShowing respect for traditionPerceived incompatibilitiesPower (e.g., having influence; having authority, being in charge)Sensation seekingArtistic
76Perceived Compatibilities Perceived incompatibilities PrincipleBeing wealthyPerceived CompatibilitiesPower principlesSensation seeking principlesAchievement principlesBeing sexually active; being sexually desirable (both M and F)Emotion controlPerceived incompatibilitiesHelping othersBeing at one with natureBeing at one with godBeing artisticPromoting justice and caring for the weak
77Perceived Compatibilities Perceived incompatibilities PrinciplePower: having influence of people, having authority, being in chargePerceived CompatibilitiesAchievement principles (e.g., being ambitious and hard working)Being sexually desirablePerceived incompatibilitiesBeing honestRespecting parents and eldersHelping peopleBeing at one with natureBeing at one with god, practicing religionPromoting justice and caring for the weak
78Utilizing the SLP Importance ratings What do clients value most? What is likely to be the subject of therapyValues themes. Social. Power. Art? AchievmentLook out for low global values ratings. Might suggest a client has no idea what they value, or refuses to acknowledge valuesLikely intervention:Values clarification (see card sorting task)
79Restricted range of principles Utilizing the SLPRestricted range of principlesClients may endorse very few principles as important.They may endorse several as important, but state that they have not tried to put them into play.Finally, they may rate a number of value clusters as unimportantWhat are the barriers to putting the values into play?Likely interventions: acceptance, defusion, or overcoming practical barriers?
80Dominance of experiential control items Utilizing the SLPDominance of experiential control itemsHigh importance on experiential control dimensionNothing inherently wrong with experiential control, unless in conflicts with other important principlesLikely interventions: Creative hopelessness, acceptance
81Presence of strong pressure Utilizing the SLPPresence of strong pressureResearch suggests that pressured principles tend not to lead to vital living or well-being (Sheldon & Kasser, 1995) and tend to be associated with hostility and sadness (Stefanic & Ciarrochi, 2008).Danger of contercompliance: In reaction to pressure, the client refuses to act according to the principle, or acts contrary to the principle
82Presence of strong pressure: Interventions Utilizing the SLPPresence of strong pressure: InterventionsTherapist behaviours: acting with humility in session, undermining your own authority, encouraging clients to not believe anything you sayRemove source of pressure. E.g., imagine nobody knew you were living the principle. Would you still live it?Seek to identify past experience that was vital. E.g., sweet spot exercise. Connect their valued statements to this vital past
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