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Acceptance & Commitment Therapy (ACT): Empirical Investigations Ian Stewart.

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1 Acceptance & Commitment Therapy (ACT): Empirical Investigations Ian Stewart

2  Q. What is Acceptance Commitment Therapy?  A. A form of psychotherapy that claims that experiential avoidance is a centrally important feature of many forms of psychopathology INTRODUCTION

3  ACT derives from the philosophy of functional contextualism…and contemporary behavior analysis (Hayes & Wilson, 1993). ACT argues that humans are unique to the degree they substitute cognitions for direct experience (cognitive fusion) and work to avoid negatively evaluated private experiences despite significant costs of doing so (experiential avoidance). From an ACT perspective, many forms of psychopathology can be conceptualized as (a) unhealthy attempts to control emotions, thoughts, memories and other private experiences…(b) unhealthy examples of the domination of cognitively based functions over those based in actual experience and (c) a lack of clarity about core values and the ability to behave in accordance with them. The general goal of ACT is to diminish the role of literal thought (cognitive defusion), and to encourage a client to contact psychological experience - directly, fully and without needless defense (psychological acceptance) - while at the same time behaving consistently with one’s chosen values. Hayes, Masuda, Bissett, Luoma, Guerrero (2004)

4  Many traditional forms of psychotherapy employ strategies that focus on controlling negative thoughts and feelings, but ACT based researchers and others have argued against this generic approach (Friman, Hayes, & Wilson, 1998)  Results from a number of studies now suggest that these methods of cognitive and/or emotional control may often be ineffective or even counterproductive (e.g., Hayes, Bissett, Korn, Zettle, Rosenfarb, Cooper, & Grundt, 1999)

5 Gutierrez, Luciano, Rodriguez & Fink (In press)  This study compared an acceptance based intervention with a cognitive-control-based intervention for coping with experimentally induced pain  40 participants were randomly assigned to an acceptance based protocol (ACT), the goal of which was to disconnect pain-related thoughts and feelings from literal actions, or to a control-based protocol (CONT) that focused on changing or controlling pain-related thoughts and feelings  Ps took part in a nonsense-syllables-matching task that involved successive exposures to increasingly painful shocks

6 Gutierrez, Luciano, Rodriguez & Fink (In press)  In both conditions, the task involved an overall value-oriented context that encouraged participants to continue with the task despite pain  At times throughout the task, participants were asked to continue with the task and be shocked or stop and avoid shock; each choice had specific costs and benefits  Participants performed the task twice, both before and after receiving the assigned experimental protocol

7 Gutierrez, Luciano, Rodriguez & Fink (In press)  Two measures were obtained at pre- and post-intervention  Tolerance of shocks  Self-reports of pain  ACT ps. showed significantly higher tolerance to pain and lower believability of experienced pain compared to the CONT condition

8 Johnson et al. (under submission)  Aimed to replicate and extend the Gutierrez et al research  Automated delivery of ACT and CONT intervention  Direct manipulation of the values-oriented context  Refining of the ACT and CONT exercises and metaphors to remove possible confounds

9 Method  40 ps. balanced for gender across 4 conditions  The design was a 2X2X2 mixed factorial design ACT PRE - INTERVENTION CONT HI V LO V POST - INTERVENTION HI V LO V

10 Schematic of Experiment Pre-Experimental Stage Calibrate Pain Threshold Pre-Intervention Task Intervention Post-Intervention Task Adherence Measures Debriefing

11 Pre-Experimental Stage  Before the start of the experiment, participants were provided with general instructions  They were then required to  (1) Sign a consent form  (2) Complete a medical screening form  (3) Complete 2 self-report questionnaires:  Acceptance and Action Questionnaire [AAQ] (Feldner, Zvolensky, Eifert, & Spira, 2002)  Valued Living Questionnaire [VLQ] (Wilson, 2002)

12 100 (Pain as bad As it could be) 1 (No pain) Click here when you have entered your pain rating Click here to continue Click here to end experiment Click here to continue Pain Calibration

13 1 (No pain) 100 (Pain as bad As it could be) Click here when you have entered your pain rating Click here to continue Click here to end Click here to receive a shock and continue Score 1

14 Score 1 Click here to end Click here to receive a shock and continue

15 Click here to end Click here to receive a shock and continue

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

17 Play Video 1Play Video 2Play Video 3Play Video 4Play Video 5Play Video 6Play Video 7Play Video 8 A Ps. are given metaphors and experiential exercises designed to teach them that the best way to deal with pain related thoughts and feelings is to accept them in the context of whatever action is being taken HV Ps. are asked to imagine that they suffer from chronic pain and that the task involving shock is one which they must do in order to support their family

18 Play Video 1Play Video 2Play Video 3Play Video 4Play Video 5Play Video 6Play Video 7Play Video 8 A Ps. are given metaphors and experiential exercises designed to teach them that the best way to deal with pain related thoughts and feelings is to accept them in the context of whatever action is being taken LV Ps. are told that the aim of the experiment is to contribute to research on the relation between voltage level and perception of shock

19 Play Video 1Play Video 2Play Video 3Play Video 4Play Video 5Play Video 6Play Video 7Play Video 8 C Ps. are given metaphors and experiential exercises designed to teach them that the best way to deal with pain related thoughts and feelings is to distract themselves from them by imagining pleasant images HV Ps. are asked to imagine that they suffer from chronic pain and that the task involving shock is one which they must do in order to support their family

20 Play Video 1Play Video 2Play Video 3Play Video 4Play Video 5Play Video 6Play Video 7Play Video 8 C Ps. are given metaphors and experiential exercises designed to teach them that the best way to deal with pain related thoughts and feelings is to distract themselves from them by imagining pleasant images LV Ps. are told that the aim of the experiment is to contribute to research on the relation between voltage level and perception of shock

21 Adherence Measures  Measures of whether the participant adhered to the particular intervention delivered included the following  During the video intervention stage, subjects were required, after the playing of each video, to describe briefly and in their own words what it was they had been told and what they were required to do  After the pain tasks were over, ps. were asked to describe what they thought they had had been required to do during the post-intervention task, what they had done in order to do it, and whether they thought it had been successful

22 Debriefing  When the experiment finished, participants were provided with a debriefing sheet which thoroughly described the nature of the experiment in general as well as the purpose of each of the experimental manipulations

23 RESULTS: Outline  Pre-check  Analyses  Shock Tolerance  Self-Reports  Pain Believability

24 RESULTS: Pre-check  ANOVAs revealed that the conditions did not differ significantly in terms of  Age  Pre-Intervention shock tolerance  Pre-Intervention self reports of pain  AAQ scores  VLQ scores  All variables on which ANOVAs were conducted met the assumption of homescedasticity (as per the Levene test)

25 RESULTS: Shock Tolerance Increase No Change Decrease ACT / Hi V ACT / Lo V CONT / Hi V CONT / Lo V Increase No Change Decrease ACT / Hi V ACT / Lo V CONT / Hi V CONT / Lo V 4 2 4

26 RESULTS: Shock Tolerance  A 3-way mixed ANOVA with (i) ACT/CONT and (ii) Hi/Lo Values as Between-Ss variables, and (iii) Pre-/Post Intervention as the Within-Ss variable revealed  A significant main effect for Pre-/Post- Intervention (F(1, 36) = , p = )  A significant interaction effect between Pre- /Post-Intervention and ACT/CONT (F(1, 36) = , p = )

27 RESULTS: Shock Tolerance  To investigate the interaction between Pre-/Post Intervention and ACT/CONT, we grouped the two Acceptance conditions together and the two Control conditions together and conducted a paired t-test  This revealed a highly significant difference (t(19) = , p = ) for the Acceptance condition with no difference for the Control condition (t(19) = -.374, p =0.7125)

28 RESULTS: Shock Tolerance

29 RESULTS: Self-Reports

30  A 3-way mixed ANOVA with (i) ACT/CONT and (ii) Hi/Lo Values as Between-Ss variables and (iii) Pre-/Post Intervention as the Within-Ss variable revealed  A significant interaction effect between Pre- /Post Intervention and Hi/Lo Values (F(1, 33) = 9.621, p = ) RESULTS: Self-Reports

31  To investigate the interaction between Pre- /Post Intervention and Hi/Lo Values, we grouped the two Hi Value conditions together and the two Low Value conditions together and conducted a paired t-test  This revealed a significant difference (t(18) = , p = ) for the Hi Value condition with no difference for the Lo Value condition (t(17) = 1.822, p =0.0861) RESULTS: Self-Reports

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33 RESULTS: Pain Believability  Two analyses were conducted to explore the relationship between both measures of pain (shock tolerance and self-reports), which was used as a behavioural measure of the believability of pain, or in other words, the degree to which ps. considered experienced pain to be a barrier to continuing the pain task

34  Analysis 1: Change in tolerance levels of ps. who reported an increase in experienced pain during the Post-Intervention task  In the Acceptance conditions, 100% of such ps. showed an increase in tolerance levels  In the Control conditions, only 50% of such ps. showed an increase in tolerance levels  A Chi-Square analysis showed this difference between Acceptance and Control to be significant (  2 (1, N=12) = 4, p = ) RESULTS: Pain Believability

35  Analysis 2: Number of trials for which ps. continued the Post-Intervention task after reporting high levels of pain (>= 80)  Across the two Acceptance conditions, the median number of trials was 4, while across the two Control conditions, the median was 2  A Mann Whitney U-test showed the difference between conditions to be significant (U=16, df = 20, p = ) RESULTS: Pain Believability

36 DISCUSSION  The current findings suggest that the acceptance but not the control strategy increased the participants’ tolerance for pain  This finding supports previous work using a highly controlled and precise experimental procedure in which experimenter cuing and other artifacts could not play a significant role  The values manipulation did not have a significant effect on shock tolerance, though it did have on self-reports of pain; those in the ‘Hi- Value’ conditions reported more pain subsequent to the intervention

37 DISCUSSION  This result may be a function of valuing something highly; the more one values something the greater the associated emotional affect and perhaps greater affect increases perception of pain  An alternative explanation might be that the Hi- Values manipulation was perceived by participants as being somewhat coercive or manipulative, which produced negative affect (e.g., Pretty & Seligman, 1984), thus again increasing perception of pain  In any case, further research is needed to explicate more fully the relationship between acceptance and values in coping with pain

38 Cochrane, Barnes-Holmes, Barnes-Holmes, Stewart, Luciano & Wilson (under submission)  This study examined acceptance and avoidance of negative and neutral imagery using a variety of empirical measures including reaction times, accuracy and events related potentials

39  A short version of the Acceptance and Action Questionnaire (AAQ-2, Hayes et al., 2002) was administered to 144 undergraduate students to identify those predisposed to acceptance or avoidance  15 participants low in acceptance (scoring at least 1 SD below the mean on the AAQ) and 14 that were high in acceptance (at least 1 SD above the mean) were exposed to a match-to-sample procedure in which arbitrary stimuli were paired with either aversive (e.g., mutilations, violence etc.) or neutral (e.g., neutral faces, household objects etc.) visual images from the International Affective Picture System (IAPs) Method

40 A1 B1B2 CORRECT Aversive Image Presented for 6 secs WRONG Aversive Image Presented for 6 secs 1 Pleasant 100 Unpleasant Plus Two Other Sliding Scales: 2. Emotional Intensity 3. Willingness to Look The Task (1)

41 A1 B1B2 CORRECT Neutral Image Presented for 6 secs WRONG Neutral Image Presented for 6 secs 1 Pleasant 100 Unpleasant Plus Two Other Sliding Scales: 2. Emotional Intensity 3. Willingness to Look The Task (2)

42  Both groups demonstrated similar correct response rates in the match to sample task  However, whereas the high acceptance group produced similar reaction times whether they expected to see either an aversive or a neutral image, the low acceptance group exhibited significantly longer reaction times when they expected to see an aversive rather than a neutral image (z = , p = 0.015) Median Reaction Times Taken by Both Groups to select Aversive and Neutral Images Experiment 1: Results

43  The participants rated the images viewed using 3 bi-polar scales for: (a) pleasantness (b) emotional intensity (c) willingness to look  The high acceptance group rated the aversive images as more unpleasant and emotionally intense than the low acceptance Group. But the low group were less willing to look at either the aversive or neutral images than the participants in the high acceptance group Mean Ratings for Aversive Images on the 3 Scales Pleasant Unpleasant Mild Intense Willing Unwilling Experiment 1:Results

44  Replicated Experiment 1 with an additional measure to assess psycho-physiological response to the visual stimuli  Although event related potentials (ERPs) have not traditionally been used to examine emotion, Cuthbert et al. (2000) demonstrated that ERPs could reliably discriminate responses to aversive versus neutral stimuli  Event related potentials (ERPS) recorded during the task (n = 18):  6 High Acceptance  6 Low Acceptance  6 Mid-Range Experiment 2

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46 Findings of Experiment 1 replicated Similar correct response rates in the match to sample task Both the high and mid acceptance group produced similar reaction times for both aversive or neutral images Only the low acceptance group exhibited significantly longer reaction times when they expected to see an aversive rather than a neutral image (z = , p = ) Median Response Times Taken by Each Group to Select Aversive and Neutral Images Experiment 2: Results

47 Both the high and mid acceptance groups rated the aversive images as more unpleasant and emotionally intense than the low acceptance group Whereas the low and mid groups were less willing to look at either the aversive or neutral images than the participants in the high acceptance group Mean Ratings for Aversive Images on the 3 Scales Pleasant Unpleasant High Low Mid Mild Intense Willing Unwilling Experiment 2: Results

48 Aversive ImagesNeutral Images Experiment 2: Results

49 Aversive ImagesNeutral Images

50  Area dimensions (  V ms) were analysed with a 4- way 2x2x3x3 Mixed ANOVA:  Between (AAQ Level: High/Mid versus Low Acceptance)  Within (Picture Content: Aversive versus Neutral Pictures)  Within (Laterality: Left, Middle, Right).  Within (Position: Frontal, Central, Parietal)  Main effects for  Picture Content (F(1, 7) = , p =.0002, partial eta squared = 0.9)  Laterality (F(2, 14) = 8.247, p =.0043, partial eta squared = 0.54)  A 3-way interaction was identified for  AAQ * Content * Position (F(4, 28) = 3.950, p =.0115, partial eta squared = 0.36)  Thus two separate repeated measures ANOVAs were conducted for each AAQ group Experiment 2: Results

51  Low Acceptance Group ANOVA:  A main effect for Laterality (F(2, 6) = , p =.0102, partial eta squared = 0.78)  High Acceptance Group ANOVA:  No main effect for Laterality (F(2, 8) = 1.850, p =.216) Experiment 2: Results

52 Low Acceptance Group High Acceptance Group Area Dimensions (  V ms)

53  Experiment 2 replicated the response-time and rating measures of Experiment 1  The neurophysiological measure discriminated between aversive and neutral visual stimuli for both groups  Slow positive potentials thought to index the increased attentive processing allocated to emotionally arousing stimuli (Cuthbert et al., 2000)  The Low Acceptance group showed greater negative activation for left hemisphere electrodes  This could suggest greater verbal activity for the former group, which might indicate the use of verbal avoidance strategies (e.g., “This is not real, think of something else,” etc.)  However, replication with a larger sample is required Discussion (Experiment 2)

54 The automated experimental procedures used in this research appear to discriminate between high and low acceptance in a non-clinical sample, as demonstrated by the response times, self-report measures, and ERPs This provides support for the short-version AAQ The procedure could be used in future studies to help determine if individuals who are predisposed towards high or low acceptance react differently to acceptance- versus control-based interventions Discussion

55 Acceptance & Commitment Therapy (ACT): Empirical Investigations Ian Stewart


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