1. Michael E. Levin Department of Psychology
Using online Acceptance and Commitment Therapy to improve the reach of mental health services
Michael E. Levin
Department of Psychology

2. An Overview
The potential for online ACT to improve services: Research on the efficacy of online ACT and its treatment components
Ways to implement online ACT and barriers to address: Lessons learned with different implementation methods for online ACT
How to start using these tools in practice: Tips for how to begin using technology in your work

3. Technology helps address barriers to accessing effective treatment
Supply side challenges with providers
Barriers to training/adoption
Availability of practitioners vs. prevalence of disorders
Demand side challenges with people in need
Low rates of treatment seeking
Barriers to engaging in treatment (access, stigma, cost)
Self-guided interventions
Tools to support practitioners
Low implementation cost
Ease/anonymity of access

4. My program of research
Improve the efficacy, efficiency, and reach of mental health services
Self-help books, apps, and websites
Telehealth and adjunctive technologies
Driven by two integrated arms of research
Refining a theory of psychopathology and intervention
Developing intervention technologies based on this model

5. Psychological Inflexibility
Cognitive Fusion
Experiential Avoidance
Inaction, Impulsivity, Avoidance
Values Problems
Conceptualized Self
Attachment to
Poor Present Moment Awareness
Psychological Inflexibility

6. Psychological Inflexibility Treatment Dropout
General Well Being/Functioning
Depression
Psychosis
Burnout & Stress
Anxiety
Work
Performance
Psychological
Inflexibility
Chronic Pain
Parenting Behaviors
Eating Disorders
Stigma/
Prejudice
Borderline PD
Health Care Utilization
Addiction
Weight Management
Chronic Medical Problems

7. Psychological Flexibility
Be Aware
Cognitive Defusion
Acceptance
Committed Action
Values
Self-As-Context
Present Moment
Psychological Flexibility
Open Up
Do What Matters

8. ACT Psychological Inflexibility Treatment Dropout
General Well Being/Functioning
Depression
Psychosis
Burnout & Stress
Anxiety
ACT
Work
Performance
Psychological
Inflexibility
Chronic Pain
Parenting Behaviors
Eating Disorders
Stigma/
Prejudice
Borderline PD
Health Care Utilization
Addiction
Weight Management
Chronic Medical Problems

9. Completed Screener Fall 2016-2018
Ineligible or Do not sign up for a study referred to in-person/self-help resources (N = 390)
Eligible people triaged based on interests and eligibility (N = 347)
LifeToolbox Website for Distressed Students
(N = 181)
General Self-Help Website Study
(N = 53)
Self-Help Books for Social Anxiety
(N = 94)
ACT Daily Self-Help App
(N = 69)
App for Problem Pornography Use (N = 34)
Matrix Self-Help Website for Distressed Students
(N = 92)
Diet Trap Book for Weight Self-Stigma
(N = 50)
Matrix App for Health & Wellbeing
(N = 233)
Mobile App for Self-Criticism
(N = 87)

10. Using web-based ACT for distressed students
PI: Michael Levin
Alan E. Hall Innovation for Undergraduate Student Success Award
USU supported RA position

11. Pilot RCT Results 79 USU students randomized to ACT or waitlist
75% completed 3/6 sessions, 55% completed all 6
Greater improvements in ACT vs. waitlist for:
CCAPS depression, d = .52
CCAPS social anxiety, d = .75
CCAPS general anxiety, d = .46
CCAPS academic concern, d = .62
MHC Positive mental health, d = .53
But not hostility, alcohol, or eating concerns
Improvements in mindful acceptance and valued living mediated effects
Levin, Haeger, Pierce & Twohig, 2017

14. Online baseline survey
181 distressed students
Online baseline survey
Randomly assigned to
Full ACT
(n = 45)
Mindful-Only
(n = 45)
Values-Only
(n = 46)
Waitlist
(n = 45)
6 Week Post
(n = 40)
6 Week Post
(n = 40)
6 Week Post
(n = 38)
6 Week Post
(n = 40)
10 Week Follow Up (n = 36)
10 Week Follow Up (n = 38)
10 Week Follow Up (n = 32)
10 Week Follow Up (n = 38)
Levin, Krafft, Barrett & Twohig, In preparation

15. Psychological Distress
Time * Condition F = 4.91, p < .001
d =

16. Improvements in Targeted Problems
Similar improvements in all three ACT conditions vs. Waitlist for
Depression, F =3.42 , p < .01
Anxiety, F = 3.35, p < .01
Social anxiety, F = 3.54, p < .01
Academic distress , F = 3.13, p < .01
Eating problems , F = 2.63, p < .05
Hostility , F = 1.97, p = .07

17. Psychological Inflexibility
Time * Condition F = 3.33, p < .001
d =

18. “Most teenagers and college students are too afraid to ask for help for fear of judgment and will not go to see someone. This website allows them to get help without the fear of judgment.”

19. Lessons learned
Self-guided ACT can impact variety of mental health concerns
Stand alone programs have broad reach and are reasonably engaging
But effect sizes tend to be smaller than more integrated approaches
Engagement fairly low in an automated, self-guided format
75% completed 6/12 sessions, 44% completed all sessions
Unclear if emphasizing different components alters outcomes
Supports briefer, targeted component interventions
Indicates the need for ideographic and more refined analyses of when to use what components

20. Integrating web-based ACT into college counseling centers
Michael Levin, Jacqueline Pistorello, Steven Hayes, Crissa Levin & John Seeley
NCCIH R43AT006952
NCCIH R44 AT006952

21. Integrating ACT technologies into treatment settings
Increase engagement in online mental health
Credible recommendations from a therapist
Supportive accountability for using programs
Technology can enhance services by
Providing a support while on waitlist or at termination
Augmenting therapy as homework between sessions
Supporting therapists in learning a new treatment

22. ACT on College Life Program
Student self-help portal
8 online sessions
Additional resources and communication tools
Counselor portal
10 online training sessions
Invitation and monitoring tools
Communication tools

23. Pilot Results Recruited across 4 sites
30 counselors
82 clients
Assessments at baseline and 4-week follow up
Levin et al., 2015

24. Predictors of Client Improvements
Pre to post reductions on the AAQ-II related to post outcomes (controlling for baseline)
Depression, r = .39, p < .001
Anxiety, r = .29, p < .001
Stress, r = .30, p < .001
Clients whose counselors frequently discussed program (n = 35) vs. those who did not (n = 47)
Improved more on depression, anxiety, stress, and inflexibility
ANCOVA partial η2 ranging between .05 and .22
Levin et al., 2015

25. Lessons learned
An integrated, adjunctive ACT technology is feasible and acceptable with both counselors and clients
Targeted outcomes and processes of change improved
But need to test the additive effects of ACT-CL to counseling
Currently testing this in a RCT
Discussing the program with clients might improve outcomes
But counselors encounter challenges using these programs

26. Tailoring ACT skill coaching through mobile apps
PI: Michael Levin
Utah State University Research Catalyst Grant

27. Opportunities with mobile apps
Smartphones are
Very common (77% of adults own a smartphone)
Almost always available and used frequently
High frequency, low intensity interventions
Generalizing skills into day-to-day life
Opportunities to individually tailor the right skill at the right time

28. ACT Daily

29. Orientation to ACT Daily app
13 depressed/anxious clients recruited by ACT therapist (Levin et al., 2017)
11 depressed/anxious clients on counseling center waitlist (Haeger & Levin, In Prep)
Baseline survey
Orientation to ACT Daily app
Use ACT Daily for 2 weeks while in therapy (n = 13) or waiting to start therapy (n = 11)
Prompted 3x a day
85% and 82% used app at least once a day
Post Assessment 2 weeks later
100% Completion

31. 69 adults interested in self-help who completed online baseline
Randomly assigned to
Tailored app
(n = 23)
Random app
(n = 22)
EMA-only
(n = 24)
Use ACT Daily tailored app for 4 weeks (tailored based on check-in)
Use ACT Daily random app for 4 weeks (no tailoring based on check-in)
Use EMA check-in for 4 weeks (no skill coaching, just check-in assessments)
Post Assessment
Completed by 78%
Post Assessment
Completed by 86%
Post Assessment
Completed by 92%
Levin, Haeger & Cruz,
in press

32. Improvements over 4 weeks on DASS
Overall Time * Condition effect F = 3.48, p < .05
EMA pre-post d = -.21
Random vs. EMA d = .36
Tailored vs. EMA Post d = 1.21*
Random pre-post d = -.17
Tailored vs. Random Post d = .85*
Tailored pre-post d = .55*

33. In-the-moment pre-post changes* * *

34. Lessons learned
ACT can be delivered in a high frequency, low intensity app format to improve mental health
ACT apps can be integrated into mental health services at various points of contact
But there are challenges with implementation
Tailoring what skill is provided in the moment improves outcomes

35. A summary of this research
Online ACT is effective for a range of mental health problems
Including in self-guided formats or integrated into services
Engagement is a notable issue to address
Consider coaching and integrating into services
It is unclear if and when all components of ACT are needed online
Briefer interventions targeting key functions may be sufficient in some cases
But tailoring interventions to current needs could lead to stronger effects
Challenges with disseminating and accessing these tools
Gaps between development, research, and practice
Importance of researching websites, apps, and books that are readily available

36. Adopting and integrating technology in your work

37. A survey of ACBS members
356 Professionals and students interested in ACT (5% of 2016 members)
Most (65%) were not familiar with or using ACT apps
But almost all (90-95%) were interested and thought they would be helpful
What are the most common and helpful ways to use ACT apps?
Practicing mindfulness
Provide additional support for clients between sessions
Prompt use of ACT skills outside of session
Self-monitoring and self-reflection
More likely to use apps during/after therapy with skills taught in therapy
Lower ratings using apps as a stand-alone instead of or before face-to-face services
Lower ratings using apps to teach new concepts not yet covered in therapy

38. What are the most frequently endorsed barriers to app usage?
M (SD)
> 3 “moderately”
Not having enough guidance on which apps are credible and effective
4.20 (1.43)
73%
Ethical concerns if clients report being suicidal or homicidal over the app
3.58 (1.69)
60%
Concerns about commercial interest in the development of mobile apps
3.50 (1.59)
53%
Concerns about privacy of client data
3.40 (1.64)
50%
Low evidence base for ACT-related mobile apps
3.28 (1.33)
47%
Concerns about the credibility of developers of mobile apps
3.24 (1.41)
43%
Open responses
Availability of apps in other languages
Accessibility of apps to those with special needs
Concerns about apps being used as emotional control strategies

39. Overcoming Barriers Review lists of available resources
PsyberGuide:
ADAA:
USU CBS:
Get colleagues opinions on apps you are considering
Try out the app for yourself to see what it’s like
Identify and address any content issues with clients
Introduce and install the app with your clients in session

40. Supportive accountability
Empirically supported theory for improving adherence to self-help
Human support increases adherence
Clear accountability can further increase adherence
Principles and strategies
Motivation: Develop intrinsic motivators for engagement in program
Choice: Emphasize choice and minimize external pressures
Goal setting: Set adherence goals linked to larger values
Clarify expectations: program use, your role, etc…
Legitimacy: You (and the resource) are trustworthy, helpful, and have expertise
Social presence: Sense of a human being involved can improve adherence
Monitoring: Monitoring adherence is key
Address adherence level: Encourage meeting goals and address non-adherence

41. Introducing technologies
Go over the program and expectations
Link program to case conceptualization and client goals
Elicit and reinforce motivation: Desire, Ability, Reasons, Need
Identify barriers and problem solve
Elicit commitment to adhere to program and to process of coaching

42. Checking in on program usage
Typical check in steps
Assess program usage
Reinforce any usage (what did they learn?)
Collaboratively problem solve non-adherence
Elicit commitment
Address in session (review and discuss program in session)
Include monitoring and coaching outside of session
Consider or text message if clinically indicated and secure
Setup clear expectations and structure (if/when you will monitor and contact)
Use technologies that allow for secure monitoring and/or communication
Consider if data will be collected that could raise liability concerns.

43. Thank you! Questions?