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1 Understanding the Clinical Processes in ACT Yvonne Barnes-Holmes & Dermot Barnes-Holmes.

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Presentation on theme: "1 Understanding the Clinical Processes in ACT Yvonne Barnes-Holmes & Dermot Barnes-Holmes."— Presentation transcript:

1 1 Understanding the Clinical Processes in ACT Yvonne Barnes-Holmes & Dermot Barnes-Holmes

2 2 Co-Authors Ian Stewart Louise McHugh Kelly Wilson Barbara Johnson Brandy Fink Andy Cochrane Anne Kehoe Hilary-Anne Healy Claire Keogh Jenny McMullen Carmen Luciano Francisco J. Molina Cobos Olga Gutiérrez Sonsoles Valdivia Marisa Páez Miguel Rodríguez Francisco Cabello Carmelo Visdómine José Ortega Francisco Montesinos Mónica Hernández Laura Sánchez

3 3 Introduction There is no theory behind therapy, the former is a coherent set of theoretical constructs that hang together and make predictions, the latter is a coherent set of techniques that make a different set of predictions Almost never in the history of psychology have they come together in a manner that was both theoretically consistent and technologically effective ACT is no different, but as the field develops, there is growing reason to believe that there is considerable overlap between Relational Frame Theory (RFT) and ACT and that the former can make sound predictions about why the latter works, and to some extent about what the latter should look like

4 4 Overview The current talk will review some of the predictions and empirical evidence that support processes and techniques identified in ACT For the sake of simplicity, and in order to be consistent with the evidence, we will divide ACT into the following: Acceptance vs. Avoidance Acceptance vs. Cognitive Control Values Defusion

5 5 Acceptance vs. Avoidance

6 6 Our first place to start looking at ACT (Study 1) was to analyse the distinction between acceptance and avoidance – if this was not clear-cut, then the basic terminology might need to be reconsidered ACTs emphasis on the dichotomy between acceptance and avoidance and the development of the AAQ suggested that we might be able to functionally differentiate individuals in terms of their propensity towards acceptance or avoidance We took 15 undergraduates who were low in acceptance (at least 1 SD below the mean on the AAQ) and 14 high in acceptance (at least 1 SD above the mean) Acceptance vs. Avoidance

7 7 Participants were exposed to a simple automated task that required them to match nonsense syllables During the task, however, matching on some trials resulted in the presentation of a horrible aversive image (e.g. mutilated bodies) for 6 seconds Participants were required to rate each aversive picture But, primarily we wanted to determine how long it took them to do the task when they had discriminated which type of picture would come next Our prediction was that low accepters/high avoiders would take longer to complete tasks, which they had learned would be followed by an aversive picture This, for us, was a type of avoidance Acceptance vs. Avoidance

8 8 During the task, High Acceptance produced similar reaction times whether they expected to see either an aversive or a neutral image next, so anticipation or avoidance was limited But, Low Acceptance exhibited significantly longer reaction times when they expected to see an aversive image (p = 0.015) HighLow Median Reaction Times A N But could this be simply because the Low Acceptance Group perceived the neutral pictures to be more unpleasant and thus legitimtely more avoidable than the High Acceptance group?

9 9 No, because High Acceptance rated the aversive images as more unpleasant and more emotionally intense than Low Acceptance But yet, Low Acceptance were less willing to look at either images than High Acceptance Pleasant Unpleasant Mild Intense Willing Unwilling Self-Report Ratings

10 10 Discussion So, the outcomes were consistent with ACT predictions regarding acceptance and avoidance and their dichotomy Individuals low in acceptance/high in avoidance showed greater anticipatory avoidance of the negative pictures than those high in acceptance/low in avoidance This avoidance was consistent with their own ratings of willingness to look at the pictures Furthermore, this avoidance occurred even though these individuals rated the pictures as less unpleasant and less intense than the other group The high acceptance groups, therefore, showed less avoidance and greater experiential willingness in the face of adversity – outcomes that are consistent with ACT predictions

11 11 Study 2 replicated Study 1, but incorporated Event Related Potentials (ERPs) during the task with: 6 High Acceptance 6 Low Acceptance 6 Mid-Range Acceptance Once again, we predicted that level of avoidance would differentiate and we hoped it would be detected by the ERPs ERPs and Avoidance

12 12 Identical to Study 1, High and Mid Acceptance produced similar reaction times for both aversive and neutral images, showing no anticipation or avoidance But, Low Acceptance again emitted longer reaction times when they expected to see an aversive, rather than a neutral, image (p = ) HighMid Low Median Reaction Times A N A N A N

13 13 Again, this was not because the pictures were less unpleasant, because the High and Mid Acceptance rated the aversive images as more unpleasant and emotionally intense than Low Acceptance But, Low and Mid Acceptance were less willing to look at the images Pleasant Unpleasant High Low Mid Mild Intense Willing Unwilling Self-Report Ratings

14 14 ERPs Recordings As expected, the ERPs recordings discriminated between the two types of pictures, with the unpleasant pictures producing significantly more positive wave forms than the neutral pictures for all groups And an interesting finding emerged with regard to the scalp locations...

15 15 Low Acceptance High Acceptance Area Dimensions ( V ms)

16 16 The fact that the Low Acceptance group showed greater negative activation for left hemisphere electrodes could suggest greater verbal activity for this group, which might indicate the use of verbal avoidance strategies (e.g. This is not real, think of something else, etc.) ERPs Recordings

17 17 So again, the avoidance groups could be distinguished from one another on several predictable counts -- Low Acceptance showed greater anticipation of the aversive images than the others and were less willing to look at them - - and yet, they rated the pictures as less unpleasant Some willingness distinctions even emerged between mid and high range accepters The unwillingness and tolerance avoidance for Low Acceptance was associated with greater negative activation for left hemisphere electrodes, suggesting the activation of verbal areas Again, the former outcomes are consistent with ACTs emphasis on acceptance, avoidance and willingness and the ERPs data were consistent with RFTs emphasis on verbal behaviour Discussion

18 18 Acceptance vs. Cognitive Control

19 19 Acceptance Up until the mid-90s, CBT was still insistent that explicit attempts to control cognitive events directly would reduce their frequency and impact, and thus be associated with positive clinical outcomes ACT has always offered a counter-approach because of its contextualistic underpinnings that argues that the only way to change verbal events is to change the context in which they occur and acceptance is the term we use to describe this broader target In this regard, though not intentionally, ACT is more in line with Eastern traditions that emphasise acceptance/mindfulness But Eastern traditions are not sciences and thus cannot be relied upon to provide scientific argument or evidence

20 20 Acceptance Although in Eastern traditions and in ACT, we had reason to believe that acceptance was an active ingredient in positive clinical outcomes and psychological well-being generally, there was almost no empirical evidence to attest to this Furthermore, positive empirical evidence for the impact of acceptance would to some extent undermine positivity for the main existing alternative that was cognitive control – which functionally may be seen as the opposite of acceptance It should also be added that empirical evidence for cognitive control as an active ingredient in CBT is relatively scarce, in spite of its wide usage

21 21 So, thus far, we had some comfort in the terminology that suggested a dichotomy between acceptance and avoidance But, acceptance as a clinical tool was something else In our first empirical analysis of acceptance as a mechanism of change, we set out with a very simple aim -- to see if we could construct a short, but potent, acceptance intervention that would be functionally similar to what is presented in therapy, but which might just work in an experimental context This was demonstration research of the simplest kind Acceptance

22 22 During Study 3, normal participants were simply presented with a computerised task in which they were asked to match a lot of neutral pictures and a small number of horrible aversive pictures (e.g. mutilated bodies) The former pictures simply represented an experimental control, while the latter represented our core effort to provide participants with a clinical strategy they could use to deal with unpleasant psychological/visual content Study 3

23 23 Because the matching was too simple to function as a dependent variable, we targeted participants willingness to look at the aversive pictures by: (1) giving them the option to avoid the pictures altogether before the trial and counting how many they looked at and (2) observing how long they would endure them on screen Avoiding Negative Images

24 24 Participants were exposed to the baseline matching task, the intervention, and then the task again Both interventions involved the presentation of a vignette in which participants were asked to -- imagine that they had witnessed a horrific car accident in which they had to rescue the badly injured and bloodied victims from the car and to imagine that they found the sight of blood extremely aversive They were then given a coping strategy/intervention to help them deal with the vignette (and to influence their subsequent performances on the negative pictures) Acceptance or Control

25 25 Participants in Cognitive Control were instructed to try to control their emotional reactions and to avoid feelings of discomfort (e.g. by imaging that the blood was just like tomato ketchup) Participants in Acceptance were instructed to fully embrace their feelings of discomfort (i.e. to fully accept that trying to save the bloodied and mutilated victims would be the most horrific experience of their lives) Acceptance vs. Control

26 26 Experimenter influence were also manipulated by altering the instructions and the extent to which the experimenter monitored the matching performances During the No Instruction/No Monitoring conditions, participants were informed that it did not matter whether they looked at the negative pictures (i.e. no instruction) and the experimenter sat approximately 30 feet away and pretended to read a book (no monitoring) During the Instruction/Monitoring conditions, participants were told that it was very important to look at the negative pictures (instruction) and the experimenter walked around actively monitoring performances (monitoring) Experimenter Influence

27 27 The results of the study failed to differentiate between the two groups on the number of aversives observed However, they did differ in their mean response latencies while the aversives were on the screen (i.e. aversive tolerance time) Results

28 28 Mean Response Times: Neutral Pictures On the neutral pictures, there were no changes at all between Baseline and Post-intervention, as expected Baseline Post-Intervention Tolerance Time in ms.

29 29 Mean Response Times: Aversive Pictures But, on the aversive pictures, Acceptance and Control differed significantly when combined with Instruction/Monitoring (p = 0.002) Strategy and Experimenter Influence interacted significantly Accept/Instruct Accept/No Instruct Control/No Instruct Control/Instruct BaselinePost-Intervention

30 30 Discussion The Acceptance strategy increased participants tolerance time in the presence of the aversive pictures (when combined with active experimenter influence) Control did not and decreased tolerance in both cases While both strategy outcomes appeared to be influenced by the social context, further analyses indicated that this primarily affected the extent to which participants applied the strategies, rather than affecting the strategies directly (i.e. the strategies were applied more when the experimenter attended) This was our first empirical evidence that acceptance could be delivered as a brief therapeutic intervention in an experimental context and was associated with positive outcomes Cognitive control was in fact counter-productive in terms of altering aversive tolerance when the images were present

31 31 In Study 4, we were concerned that the data so far would not generalise to physical pain and the psychological content associated with that – perhaps different outcomes would emerge relative to coping with aversive visual imagery So, we exposed participants to systematic electric shocks This was based on a previous study by Gutierrez, Luciano, Rodriguez, and Fink who compared acceptance and control as coping interventions with electric shock with 40 undergraduates They reported that Acceptance not only increased shock tolerance, but also reduced participants believability of their own subjective pain ratings Acceptance vs. Control with Pain

32 32 Although the original study was entirely consistent with our own findings thus far, there was increasing concern within the community about experimental precision – but this was hard to offset against external validity So in Study 4, we tried to come up with a format that was fully automated (hence experimentally clean), but that would still allow the interventions to be impactful We did some refinement of the Acceptance and Control exercises and metaphors to remove possible confounds And we began to look at values as an active addition to acceptance Our Study

33 33 40 normal participants were assigned to four conditions Design InterventionValues Context Pre- Intervention Post- Intervention AcceptanceHigh Low ControlHigh Low

34 34 Play Video 1Play Video 2Play Video 3Play Video 4Play Video 5Play Video 6Play Video 7Play Video 8 Delivery The entire procedure was automated through a program containing a series of video clips Participants progressed through the clips at their own pace, individually and alone Clips were rated first by independent observers, for consistency, adherence and empathy and were found to not differ in any capacity

35 35 Delivery

36 36 A Participants were provided with metaphors and experiential exercises indicating that the best way to deal with pain related thoughts and feelings was to accept them in the context of whatever action is being taken HV Participants were asked to imagine that they suffered from chronic pain and that the task involving shock was one which they must do in order to support their family LV Participants were told that the aim of the experiment was to contribute to research on the relation between voltage level and perception of shock

37 37 C Participants were given metaphors and experiential exercises designed to teach them that the best way to deal with pain related thoughts and feelings was to distract themselves by imagining pleasant images HV Participants were asked to imagine that they suffer from chronic pain and that the task involving shock was one which they must do in order to support their family LV Participants were told that the aim of the experiment was to contribute to research on the relation between voltage level and perception of shock

38 38 Shock Tolerance Data The Acceptance participants significantly increased their shock tolerance from pre- to post-intervention Control produced no change Pre-Intervention Post-Intervention Control Acceptance No. of Shocks Taken

39 39 Self-Report Data There was an interesting effect for values – although there was no significant main effect, High Values participants rated the pain as greater across time, whereas Low Values rated it as less Pre-InterventionPost-Intervention Low Value High Value High Pain Low Pain

40 40 Tolerating High Pain We wanted to check whether some of the effects were driven by people who had different perceptions of how much pain they were in -- so we examined only those reporting great pain more closely 100% of participants in Acceptance who reported greater experienced pain Post-Intervention showed an increase in tolerance levels, compared to only 50% of the same sub-set of Control (significant: p = ) We also analysed the number of trials for which participants continued in the Post-Intervention task after reporting high levels of pain (>= 80) and found that the median number of trials for Acceptance was 4, compared to 2 for Control (significant: p = )

41 41 So as an intervention, Acceptance worked better than Control in the context of experimentally physical pain in the form of electric shock Changes in tolerance were particularly strong for participants experiencing a lot of pain and using Acceptance The effects were the same as those reported by other researchers even in a highly structured automated experimental environment While the Values manipulation did not have a significant effect on shock tolerance, it did affect self-reports of pain, in that participants in High Values reported more pain subsequent to the intervention (perhaps the values component oriented them more towards their pain, but not in an avoidant way) Discussion

42 42 One issue that had been emerging across experiments was the possibility that participants were not really engaging with the various features of the interventions (i.e. the exercises and metaphors), but that they were simply generating or following simple rules So, in Study 5, we compared the full Acceptance and Control interventions used before, but added two new interventions that simply comprised of an Acceptance Rule and a Control Rule -- a brief and simple rule for accepting or distracting In this study, we also employed a Placebo Condition Study 5: Simple Rules

43 43 Acceptance Rule Acceptance Rule, Metaphor & Exercise Control Rule Control Rule, Metaphor & Exercise Placebo Experimental Conditions

44 44 Only Full Acceptance increased tolerance significantly from Pre- to Post-Intervention, but none of the other four Distraction-Rule actually decreased tolerance significantly Tolerance Data Pre-InterventionPost-Intervention Rule Distraction Rule Acceptance Placebo Distraction Acceptance Self-Delivered Shocks (p <.002) (p <.03)

45 45 Again, we looked at those participants who reported more pain and still took more shocks and found that these were mostly in the Acceptance Conditions Percentage of Participants More Pain & More Shocks

46 46 So, the positive acceptance outcomes thus far could not be explained in terms of simple rule following – the metaphors and exercises were essential When these were absent, the moderate improvement in pain tolerance for an acceptance rule was non-significant Although Distraction effects are again negligible Distraction actually makes you worse when it comes in the form of a simple rule Discussion

47 47 The next study (Study 6) was also concerned acceptance, but attempted to broaden the generality of the work by employing a new type of pain induction, that might circumvent criticisms that electric shock is not a good analogue of clinical pain So, three groups of participants were assigned to: Acceptance Control Placebo And were exposed to the radiant heat pad in a fully automated procedure Different Pain Same Outcome

48 48 Heat Apparatus

49 49 Results At baseline, the groups did not differ on a series of psychological measures And the amount of heat tolerance was tightly controlled

50 50 Tolerance Data Baseline Post-Intervention Reminder Heat Time Tolerance (Seconds) P =.005 Placebo Control Acceptance Both Acceptance and Control increased pain tolerance, but only Acceptance was significant

51 51 So, positive outcomes again for acceptance – now a total of six experiments Acceptance is always significantly better than Control, which had negligible effects Outcomes so far have included tightly controlled experimental environments, a range of populations and numerous experimental methodologies and types of pain The data overall are highly consistent with ACTs centrality for acceptance and its predictions on avoidance The ERPs data were consistent with both ACT and RFT and added legitimacy to the outcomes and methodologies Discussion

52 52 But one thing troubled us and we had seen it in research by other labs In some studies, there had been positive (albeit limited and never significant) outcomes for Cognitive Control So, in the radiant heat research, we began to look more closely at our interventions and those used in other studies In the heat study, in particular, we noticed that part of the Control intervention involved saying a pain-related thought aloud before participants tried to distract themselves from it One Query?

53 53 So, we thought that it might just be possible that this feature offered a type of defusion, or at least cognitive distancing, that may have attributed to the outcomes And we set about modifying the Control intervention so as to eliminate this potential confound (Study 7) Our new condition was called Control Revised And we were amazed at what we found... Revisions

54 54 Tolerance Data The effects for Acceptance were exactly the same But, Control had no effect at all, and in fact increased pain tolerance was decreasing Baseline Post-Intervention Reminder Heat Time Tolerance (Seconds) P =.005 Control Revised Acceptance

55 55 So, even the small improvements that had been previously recorded for Cognitive Control may not have functioned in the way that was intended Some of the experimental interventions had spurious features that enabled aspects of defusion to creep into the Control protocols In our latter heat experiment in which this feature was addressed directly, the effects for Control could not be differentiated from Placebo Discussion

56 56 Values

57 57 But, of course, there is more to ACT than acceptance and much of what we do in the therapy depends upon the combination of active ingredients rather than simply a series of incoherent or unintegrated steps However, as much as possible, we try to isolate the components individually for experimental purposes to get a better understanding of outcomes and processes So, we turned our attention next to Values But note, that where we had looked at values before, the outcomes were mixed and it would be very difficult to deliver values as a solitary intervention Investigating Values

58 58 We have done only one study (Study 8) to date looking specifically at values This study was conducted in Spain and attempted primarily to assess the influence of a values clarification exercise Although two types of exposure to painful private events were also compared (writing down versus experiential exercise) across three conditions Values Values Clarification + Writing Values Clarification + Experiential Exercise

59 59 10 participants were assessed on personal barriers, valuable actions and areas of valued living affected by problems and barriers Values Subject REPORT VALUES CLARIF F/U Values Clarification Barriers Valued Living Values Clarification alone quickly and steadily reduced barriers and improved reports of valued living and effect enhanced across time

60 60 S.8 VC EXERCISE F/U REPORT VC WRITING F/U S.7 Barriers Valued Living Values Clarification + Writing Values Clarification + Exercise Values Clarification + Writing alone showed a similar outcome, but the decrease in barriers was less Values Clarification + Exercise alone was similar Overall, the type of exposure to private events did not matter greatly, and these even softened the effects relative to Values Clarification alone

61 61 So, some positive effects for values clarification No matter, how you do it, a simple values clarification exercise helps to increase the extent of actual valued living and decrease barriers to same There were some minor differences in terms of how this can be done, but these were minimal The data also identified what appeared to be a functional relationship between decreases in barriers and improvements in valued living These are entirely consistent with ACT predictions regarding how private events can function as barriers and how these can be altered with values Discussion

62 62 Defusion

63 63 But, no-one would think for a second that ACT would be ACT without defusion In fact, defusion, it seems is the gel that glues the active ingredients together In fact, acceptance is often difficult when defusion is not in place Also, for RFT the deliteralisation effects that underpin defusion techniques are central to ACTs outcomes, so in ways studying defusion is perhaps the best test of the relationship between the theory and the therapy Defusion

64 64 When we started looking at defusion, we had only one previous study by Masuda et al. (2004) to work from They attempted to assess the impact of word repetition on believability and discomfort levels associated with negative self-relevant words (e.g. anxious, anxious, anxious etc.) Their findings indicated that the use of a defusion rationale produced greater reductions in discomfort and believability about the words when compared to a thought suppression rationale or a distraction task Defusion

65 65 In this study (Study 9), we automated the presentation of 20 positive and 20 negative self-statements This generated a total of 60 statements because there were three exposures to each statement After the appearance in screen of each statement, participants were asked to provide ratings regarding their reactions to the statements in terms of: Comfort Believability Willingness Defusion

66 66 We manipulated defusion in two ways (1) Defusion Instructions The 80 undergraduates were randomly assigned to: Defusion Condition (pro-defusion instructions) Anti-Defusion Condition (anti-defusion instructions) Neutral Condition (neutral-defusion instructions) Defusion

67 67 In the current experiment, we are interested in the emotional impact of unusual self-statements. The scientific literature in this area shows that if you rephrase a self-statement like I am an awful person into I am having the thought that I am an awful person, then the emotional impact of the statement is reduced In other words, thinking or saying words like I am having the thought that I am an awful person is easier to deal with than simply thinking or saying I am an awful person Defusion Instructions

68 68 (2) Defusion in Visual Format We wanted to see the extent to which defusion within the visual presentation of the self-statements would give rise to defusion-predictable outcomes To manipulate this, we employed three types of presentation format for each statement: Normal Defusion Abnormal Defusion

69 69 Normal Negative Self-Statement Deep down there is something wrong with me

70 70 Defusion Negative Self-Statement I am having the thought that deep down there is something wrong with me

71 71 Abnormal Negative Self-Statement I have a wooden chair and deep down there is something wrong with me

72 72 Results: Comfort NormalAbnormalDefusion Anti-Defusion Instruction Defusion Instruction Neutral Instruction Uncomfortable Comfortable The (pro) defusion instructions were correlated with less discomfort than the other two types of instruction As was the defusion presentation format

73 73 Results: Willingness NormalAbnormalDefusion Anti-Defusion Instruction Defusion Instruction Neutral Instruction Unwilling Willing The (pro) defusion instructions were correlated with more willingness than the other two types of instruction As was the defusion presentation format – very similar results to comfort ratings

74 74 Results: Believability NormalAbnormalDefusion Anti-Defusion Instruction Defusion Instruction Neutral Instruction Unbelievable Believable Contrary to predictions, the (pro) defusion instructions were correlated with more believability than the other two types of instruction As was the defusion presentation format – very similar results to comfort and willingness ratings

75 75 Discussion Although they looked impactful in the ratings, the defusion instructions did not have a significant influence However, the Defused presentation format significantly decreased discomfort, increased willingness, but unexpectedly increased believability However, on closer inspection of the data and other information gathered from participants it may be the case that they were rating the believability of whole statements – I am having the thought that.. rather than the content itself – this is not unlike defusion

76 76 Discussion So, increases in willingness to having negative self- referential content were consistent with ACTs predictions regarding defusion Believability ratings, upon closer inspection, suggested that the defused format decreased participants believability of the content directly Decreases in discomfort were not directly predicted by ACT, but such outcomes are positive although they would not be targeted directly

77 77 Defusion Interventions In the previous study, we had assessed simple impacts for defusion and found that it generated positive and largely ACT consistent outcomes even when defusion occurred within the visual presentation of the content But, if we employed defusion as an intervention, as had been the case for Masuda et al., would we find similar outcomes? Study 10 attempted to address this question

78 78 Study 10 Participants generated a personalised negative self-relevant thought that represented a summary of several related personal statements They were then given a written protocol that contained an instruction followed by an exercise The three protocols were: Defusion Thought Control Placebo

79 79 RationaleExercise Defusion Thought Control DefusionThought Control Defusion Placebo Thought ControlPlacebo Defusion PlaceboThought Control Placebo Experimental Conditions

80 80 Once again, the emotional impact of the negative self-referential statements was measured in terms of: Discomfort Believability Willingness Method

81 81 Results: Comfort All interventions with a defusion component generated decreases in discomfort But, the largest effects were DD and PD, suggesting activity in the defusion exercise Condition Uncomfortable Pre-Intervention Post-Intervention DDTC/ TC D/ TC TC/ D D/PTC/ P P/DP/ TC P/P Comfortable

82 82 Results: Comfort Interestingly, the only significant differences pre- and post- intervention emerged for the following conditions: Placebo-Defusion Defusion-Placebo Defusion-Defusion Thought Control-Thought Control

83 83 Results: Believability All effects were in the right direction of decreasing believability But, D-D and TC-D showed largest decreases in believability Believable Condition Pre-Intervention Post-Intervention Unbelievable DDTC/ TC D/ TC TC/ D D/P TC/ P P/D P/ TC P/P

84 84 Results: Believability The only significant differences pre- and post-intervention emerged for the following conditions: Placebo-Defusion Placebo-Thought Control Defusion-Placebo Defusion-Defusion Defusion-Thought Control Thought Control-Defusion Thought Control-Thought Control So, a very mixed bag overall

85 85 Results: Willingness All effects were in the right direction of decreasing unwillingess But, D-TC was the only significant outcome Unwilling Condition Pre-Intervention Post-Intervention Willing DDTC/ TC D/ TC TC/ D D/P TC/ P P/DP/ TC P/P

86 86 Discussion Quite a mixed bag overall But, generally most positive effects in predicted directions for packages containing defusion features Defusion exercise appeared to be somewhat more effective than a simple rationale

87 87 Concluding Comments

88 88 There are many more analogue studies completed and underway than those reported here The effects for ACT components across the board are predominantly as predicted and compare favourably with substantively weaker outcomes generated by target comparisons The range of issues generated by the studies shows the complexity of the effects and the difficulty in conducting high quality research in this modality As studies progress, the standard of experimental rigour is exceptional Concluding Comments

89 89 Automated interventions Balancing for gender Balancing for heat tolerance, acceptance etc. Pre-screening with relevant psychological assessments Including self-report measures Blind experimenter Use of different types of physical and psychological stressors Use of non-clinical populations Very substantive N in some cases Interventions are very closely matched, topographically and functionally Range of ACT components tested Concluding Comments

90 90 We are now in a place where these types of analyses can be done effectively and with high levels of precision The evidence is overwhelmingly positive... Concluding Comments

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