The Turtle and the Hare Steven C. Hayes University of Nevada

A CBT Take on ACT From the point of view of some in the CBT mainstream ACT is a newcomer seemingly making bold new claims intended to threatening the dominant paradigm After all CT / CBT folks have long talked about [insert your ACT term here]

ACT and CBT From an ACT perspective, this response is off point in many ways ACT is not a newcomer, not anti-CBT, and not primarily a new set of terms or techniques While some of what is in ACT is in many clinical traditions, it is also relatively distinct What is distinct?

ACT and CBT ACT is a specific model, linked to a specific philosophy, theory, goal, and program of development It’s not just ACT, it is ACT, RFT, and Contextual Behavioral Science (post-Skinnerian behavior analysis) And to the extent that there is something new about ACT it is the entirety of it and most especially its developmental approach That will be my focus today … just a little data

ACT is Part of CBT Under the heading “ACT as a Contextual Cognitive-Behavior Therapy” we said [ACT] is a form of clinical behavior analysis or a behaviorally-rationalized therapy. But the content … is all about cognition and emotion, even though the model is not cognitive in an information processing sense. Thus, it is reasonable to call it a cognitive-behavior therapy.” Hayes, Strosahl, & Wilson, 1999)

ACT and CBT CBT can mean many things. It can mean an overarching term for a tradition. If it is that, ACT is part of it, and it makes no sense to compare a specific model to a loose and evolving tradition that ACT itself is part of and has helped over nearly 30 years to evolve It can mean a specific model and there you can make comparisons but you need to define terms and thus leave parts behind. For example Beck:

“cognitive therapy is best viewed as the application of the cognitive model of a particular disorder with the use of a variety of techniques designed to modify the dysfunctional beliefs and faulty information processing characteristics of that disorder” (Beck, 1993). That you can compare … but do know that if you do some people will say “that’s not CBT” and they will trot out their own favorites … often even brand new things. That is why I said in a recent article “you cannot compare a model to a scientific bowl of Jello”

Knowing the History Helps ACT has a unique history that is nearly 30 years old From the beginning we were very interested in cognition but wanted a theory that worked, against behavior analytic criteria In the mid-1980s we did a series of studies on what accounted for cognitive therapy effects - the results did not comport with a cognitive model And we did a component analysis of Beck’s cognitive approach - the results also did not comport with a cognitive model

History We developed an alternative approach based on our early behavior analytic thinking Compared it to Beck’s approach and found differences in outcomes and processes of change And committed firmly to our own developmental path, spending 15 years on it before bringing the results forward What is that path (white is common, yellow uncommon, red is very uncommon or unique)?

Developmental Characteristics of ACT: Clear Assumptive Base Be clear about your ultimate goals and constantly work toward them –a comprehensive psychology more adequate to the challenge of the human condition Be clear about philosophical assumptions and consciously link all work to them –functional contextualism / prediction and influence with precision, scope, and depth

Developmental Characteristics of ACT: Clear Theoretical Base Be clear about key processes that account for psychological problems Try to integrate these processes into a pragmatically useful overall model of psychological difficulties Be clear about key processes of psychological change Integrate these processes into a pragmatically useful overall model of psychological change

Psychological Flexibility Thus the Ubiquitous Hexagon Or Perhaps it is a Turtle

Developmental Characteristics of ACT: Basic Behavioral Principles Link all such processes to basic principles that describe the manipulable contextual and historical factors that account for them Develop additional basic principles of that kind if new ones are needed – and we came to believe that cognition required such additional principles Establish a basic research program on these principles that is independently of interest to experimental psychologists so as to expand that base Show that these basic principles can be used to model the phenomena supposedly originating from them

Developmental Characteristics of ACT: Process Focus Develop measures of these key problematic processes and processes of change – e.g., AAQ Show that they help explain psychopathology in naturalistic studies – approaching 10,000 Ss Document differences in processes of change and conduct formal mediational analyses early on, if these fail tweak the technology or model Do many component studies on the impact of targeted techniques

Meta-Analysis of ACT Mediation 12 ACT RCTs (out, in press, or submitted) have either formally tested ACT processes as mediators or we could get the data and do that using post mediators and follow up outcomes c c’ ab

The Resulting Study List StudyProblemComparison GroupOutcome MeasureMediation Measure Wicksell et al. (in press)Chronic painWait list controlSatisfaction with life scale PIPS Lillis et al. (under submission)Weight Maintenance Wait list controlBMIAAQ for weight Gifford et al. (under submission)SmokingBupropionOne year smoking statusAIS Lundgren et al. (in press)EpilepsySupportive treatmentSeizure frequency and duration AAQ-epilepsy, Varra et al. (in press)Resistance to use EBT EducationCurrent use of EBTSTA believability and AAQ Lazzarone et al. (2007)General DistressWait list controlGHQAAQ, KIMS Gregg et al. (2007)DiabetesEducationBlood glucose levelAAQ-D and self- management Lillis & Hayes, (2007)Ethnic prejudiceEducationPositive action intentionsAcceptance and Flexibility Lappalainen et al. (2007)Depression, anxiety CBTSCL-90AAQ Hayes et al. (2004)Stigma and Burnout Education ControlCASASAB Block et al. (2002)Social phobiaWait list controlSpeaking timeWillingness Zettle et al. (1986)DepressionCognitive TherapyBDIATQ-B

A Wide Variety of Problem Areas Mental Health: General psychological distress; Social phobia; Depression; Anxiety Health: Weight maintenance, Smoking cessation, Epileptic seizures, Diabetes management; Chronic pain Social and employment: Ethnic prejudice, Stigma and Burnout Learning and adoption: Resistance to using evidence-based treatments

And Comparison Conditions Traditional Behavior Therapy Traditional Cognitive Therapy Pharmacotherapy Psychoeducation Wait list control Supportive treatment

And ACT Process Measures 50% used a specific measure of experiential avoidance and psychological flexibility targeted toward the treatment domain 25% of the studies used defusion mediators 25% used the AAQ Others mediators used included mindfulness, willingness ratings, and values

Results All showed significant reduction of the direct effect due to the mediator (73% at p <.05; the rest at p <.1) A large portion of total effect of ACT at follow up is accounted for by mediators at post that are specified a priori by an ACT model (i.e., c’/c)A large portion of total effect of ACT at follow up is accounted for by mediators at post that are specified a priori by an ACT model (i.e., c’/c) That is not typicalThat is not typical c c’ ab

Developmental Characteristics of ACT: Process Focus Develop measures of these key problematic processes and processes of change – eg AAQ Show that they help explain psychopathology in naturalistic studies – approaching 10,000 Ss Document differences in processes of change and conduct formal mediational analyses early on, if these fail tweak the technology or model From the start, do component studies on the impact of targeted techniques

Component Studies We know of approximately 16 experimental component studies on defusion, values, acceptance, and self-as-context … and All have shown specific ACT techniques in these specific areas to be psychologically active and to work is a way that comports with an ACT model

Developmental Characteristics of ACT: Evaluation Strategy Do intensive, small N outcomes studies Yes, do randomized controlled trials Attack very difficult problems early on Use a wide variety of comparison conditions, including empirically supported treatments early on

Developmental Characteristics of ACT: Practicality and Breadth Conduct effectiveness studies from the beginning Begin prevention trials early Care about training methods and impact early on Early on examine automated interventions and bibliotherapy Challenge the model by wide extension to applicable domains –constantly extend the clinical breadth of application –examine non-clinical applications early

Controlled Studies Since 2000 on … Depression Smoking Anxiety Psychosis Substance abuse Diabetes Chronic pain Epilepsy Burnout Worksite stress Racial bias Self-stigma in substance abuse Weight loss PD Learning to use MI Learning to use pharmacotherapy Bias toward mental patients Social anxiety OCD ASD

The Hare When BT stumbled in the mid 70s, CBT jumped into clinical models of cognition, but to do so had to let go of the basic principles tradition of behavior therapy The CBT mainstream then made other jumps – it jumped into RCTs on packages, often without looking closely at: –how they worked –whether “ syndromes ” really made sense as a way to organize people into treatment responsive groups, or –what functional components they contained It has lead us to shocking outcomes like this …

Dimidjian et al, High Severity Group ADMCT Behavioral Activation Pre to Post Decreases in BDI 5

The Hare Seems to want to continue to jump. Into new clinical theories without a basic foundation of manipulable principles Or into new techniques often still hoping that a progressive science can be built around RCTs and empirically supported manuals linked to syndromes New Manuals!New Theories!New “Disorders”!It’s All CBT, CBT, CBT!!

The ACT Turtle Traditional CBT needs to get back to the lab … (and I think it will) but when it does it will find ACT / RFT turtle already there Walking its own path, with its slow focus on philosophy, theory, basic principles, processes, components, practicality, and breadth Assumptions … uhPrinciples … uhProcesses … uhOutcomes … uh

It is Not “ACT versus CBT” because The way of the turtle is not advanced one iota even if the hare collapses of manic exhaustion or internal contradictions We are not in a race against each other. We are in a race toward our own goals The hare ’ s goal have often seemed to the turtle to be different. This is different:

“cognitive therapy is best viewed as the application of the cognitive model of a particular disorder with the use of a variety of techniques designed to modify the dysfunctional beliefs and faulty information processing characteristics of that disorder” (Beck, 1993).

The Way of the Turtle is Different We are trying to build from the bottom up And when we fail (and we have and we will!) we will respond as we always have

The Way of the Turtle Did the process move? Did the process relate to the outcome? Do we understand the process? How can we move it or reformulate it?

The Turtle and Hare It is a difficult time for traditional CBT … as one CBT leader in Sweden recently said – ACT has given us a healthy kick in the teeth That is not what we came here to do: but it also does no good just to “ play nice ” The point is not politics but progress So let ’ s discuss things together … even as we follow the way of the turtle in the interests of those we serve