Contextual Methods and the Future of CBT

The Opportunity of Upheaval

Contextual Behavioral Science Strategy From a clear philosophy of science, and with a From a clear philosophy of science, and with a General-process account that addresses cognition, General-process account that addresses cognition, Construct transdiagnostic processes, and Construct transdiagnostic processes, and Organize them into a useful clinical model, with Organize them into a useful clinical model, with Components that derive from the model, and Components that derive from the model, and Substantial breadth of application, and Substantial breadth of application, and Successful mediators and moderators linked to those process; extended by a Successful mediators and moderators linked to those process; extended by a Dissemination and training strategy, and the Dissemination and training strategy, and the Construction of a development community Construction of a development community

Contextual Behavioral Science Philosophy: Functional contextualism Philosophy: Functional contextualism General process account: Behavioral principles and Relational Frame Theory nested within an overall evolutionary science perspective General process account: Behavioral principles and Relational Frame Theory nested within an overall evolutionary science perspective Transdiagnostic processes: Experiential avoidance, cognitive fusion, flexible attention to now, perspective taking sense of self, values, committed action Transdiagnostic processes: Experiential avoidance, cognitive fusion, flexible attention to now, perspective taking sense of self, values, committed action Clinical model: Psychological flexibility model Clinical model: Psychological flexibility model

Psychological Flexibility

Contextual Behavioral Science Functional Contextualism Functional Contextualism Behavioral principles and RFT within EvoS Behavioral principles and RFT within EvoS EA, fusion, now, self, values, action EA, fusion, now, self, values, action Psychological flexibility model Psychological flexibility model Components Components Breadth of application, Breadth of application, Mediators and moderators, Mediators and moderators, Dissemination and training strategy, Dissemination and training strategy, Construction of a development community Construction of a development community

Components AcceptanceDefusionContact with Present Self-as- Context Combinations of Four Mindfulness Components ValuesOther Combination Campbell-Sills et al., 2006 Marcks & Woods, 2005 Cioffi & Holloway, 1993 Williams, 2007 Arch & Craske, 2006Cohen et al., 2000Gutiérrez et al., 2004 Eifert & Heffner, 2003 Marcks & Woods, 2007 Kingston et al., 2007 Broderick, 2005Cohen et al., 2006McMullen et al., 2008 Levitt et al., 2004 Masuda et al., 2004 Leventhal et al., 1989 Burns, 2006Creswell et al., 2005 Paez-Blarrina et al., 2008 Low et al., 2008 Masuda et al., in press Logan et al., 1995 Feldner et al., 2003Crocker et al., 2008 Roche et al., 2007 Michael & Burns, 2004 Hayes et al., 1999Harris et al., 2005 Vowles et al., 2007 Haythornthwaite et al., 2001 Fein et al., 1997 Keogh et al., 2005; 2006 Paez-Blarrina et al., 2007 Masedo & Esteve, 2007 Spencer et al., 2001 Takahashi et al., 2002 Forman et al., 2007 Kehoe et al., 2007

Pain Tolerance McMullen et al., Acceptance and Defusion Distraction No Instructions Instructions, Metaphor, Exercise Instructions, Metaphor, Exercise Instructions Only Instructions Only Shocks to Continue Task

Hedges's g and 95% CI Favors ACTFavors Control Active Comparison (n=692) Persistence and Willingness Impact of ACT Components on Persistence and Willingness Inactive Comparison (n=440) Subjective Distress During Task Active Comparison (n=693) Inactive Comparison (n=564) Inactive Comparison (n=145) Subjective Distress While Recovering From Task g =.13 g =.69 g =.48 g =.37 g =.47 g =.38 Active Comparison (n=423)

Breadth of Application RCTs RCTs Depression3 Depression3 Stress4 Stress4 Psychosis2 Psychosis2 Anxiety1 Anxiety1 Pain4 Pain4 Burnout1 Burnout1 Trich1 Trich1 Substance 2 abuse Substance 2 abuse DD/DD1 DD/DD1 RCTs OCD1 Epilepsy2 Diabetes1 Weight 3 Prejudice2 Learning2 Cancer2 Smoking3 BPD2 Fitness1

StudyProblemComparisonMediator Tapper, 2009WeightDietPF/EA Woods, 2006TrichotillomaniaWait listPF/EA Gaudiano, 2009PsychosisEnhanced TAUDefusion Bond, 2000Work stressWait listPF/EA Wicksell, 2009PainMDT + medicationDefusion Wicksell, 2008PainTAUPF/EA Lazzaroni, 2009Work stressWait listPF/EA Zettle, 1986DepressionCTDefusion Hayes, 2004StigmaPsychoeducationDefusion Lappalainen, 2007Outpatient miscCBTPF/EA Lillis, 2009WeightWait listPF/EA Lillis, 2007Ethnic prejudiceEducationPF/EA Gifford, under reviewSmokingMedicationsPF/EA Lundgren, 2008EpilepsySupportive treatmentPF/EA Gregg, 2007DiabetesEducationPF/EA/Self-Manage Varra, 2008Resistance to ESTsPsychoeducationPF/EA/Defusion Zettle, in pressDepressionCTDefusion Gratz, 2006BPDTAUPF/EA Average Proportion Mediated:.53 (unweighted by n);.47 (weighted); Total n = 903 Follow up Change Outcomes; Post Mediators (3 studies no follow-up; 3 no post) Testing with bootstrapped cross product: All below p =.1 All but 3, p <.05 Large effect size Proportion Mediated

The CBT Future? My Guess Down: syndromes, brute force empiricism, EBP based only on packages. Down: syndromes, brute force empiricism, EBP based only on packages. Up: EB processes, EB procedures, functional analysis, transdiagnostic models. Why? More progressive and more functional. Up: EB processes, EB procedures, functional analysis, transdiagnostic models. Why? More progressive and more functional. I believe general functional contextual perspectives will compete with more structural, special process, or mentalistic accounts I believe general functional contextual perspectives will compete with more structural, special process, or mentalistic accounts … and I expect more of … … and I expect more of …

Contextual CBT (“Third Wave”) Is grounded in an empirical, principle-focused approach, that is particularly sensitive to the context and functions of psychological phenomena more so than their validity or form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones Is grounded in an empirical, principle-focused approach, that is particularly sensitive to the context and functions of psychological phenomena more so than their validity or form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones

Seeks the construction of broad, flexible and effective repertoires over an eliminative approach to syndromes, symptoms, or narrowly defined problems; Seeks the construction of broad, flexible and effective repertoires over an eliminative approach to syndromes, symptoms, or narrowly defined problems; Emphasizes the relevance of these issues for clinicians as well as clients; Emphasizes the relevance of these issues for clinicians as well as clients; Contextual CBT

Reformulates and synthesizes what is already known in behavioral and cognitive therapy, rather than rebelling against it; and Reformulates and synthesizes what is already known in behavioral and cognitive therapy, rather than rebelling against it; and Carries the behavioral and cognitive therapy tradition forward into deeper or more complex questions, issues, and domains that were previously addressed primarily by other, less empirical traditions. Carries the behavioral and cognitive therapy tradition forward into deeper or more complex questions, issues, and domains that were previously addressed primarily by other, less empirical traditions. Contextual CBT

Context Over Content “unlike CBT, there is little emphasis in MBCT on changing the content of thoughts; rather, the emphasis is on changing awareness of and relationship to thoughts.” (2004, p. 54). “unlike CBT, there is little emphasis in MBCT on changing the content of thoughts; rather, the emphasis is on changing awareness of and relationship to thoughts.” (2004, p. 54). Behavioral activation “interventions address the function of negative or ruminative thinking, in contrast to CT’s emphasis on thought content, [through] attention-to-experience interventions” (Dimidjian et al., 2006, p. 668). Behavioral activation “interventions address the function of negative or ruminative thinking, in contrast to CT’s emphasis on thought content, [through] attention-to-experience interventions” (Dimidjian et al., 2006, p. 668).

Context Over Content “MCT does not advocate challenging of negative automatic thoughts or traditional schemas.” (Wells, 2008, p. 651); while “CBT is concerned with testing the validity of thoughts (…) MCT is primarily concerned with modifying the way in which thoughts are experienced” (p. 652). “MCT does not advocate challenging of negative automatic thoughts or traditional schemas.” (Wells, 2008, p. 651); while “CBT is concerned with testing the validity of thoughts (…) MCT is primarily concerned with modifying the way in which thoughts are experienced” (p. 652).

A Content Focus is Not Buying Us Much ADMCTBehavioralActivation Pre to Post Decreases in BDI 5

Psychological Flexibility Open Aware Active Defusion Present Moment Perspective taking Values Acceptance Committed Action (modified from Harris, 2009 ) Simplified Psychological Flexibility Model

Psychological Flexibility Open Aware Active (modified from Harris, 2009 ) Is This Becoming a Consensus Contextual CBT Model?

The Triflex as a Consensus Contextual CBT Model?

Exposure with response prevention Beck’s Cognitive Therapy Dialectical Behavior Therapy Mindfulness Based Cognitive Therapy Rational Emotive Behavior Therapy Acceptance and Commitment Therapy Schema Therapy Barlow’s Unified Protocol Behavioral Activation Functional Analytic Psychotherapy Many others Appraisal work Mindfulness Based Stress Reduction C BT Motivational Interviewing Metacognitive Therapy The Big Tribal Umbrella

C BT EmotionCognition Sense of Self Overt Behavior With Shared Targets Social Functioning Spirituality

C BT Neo-BehavioralInformation Processing Behavior Analytic Social Learning But Varied Foundations Hypothetico-Deductive Inductive Contextual Behavioral Science Relational Frame Theory

C BT Functional Contextualism Elemental Realism Organicism Constructivism And Philosophies

A CT Functional Contextualism Behavior Analytic Inductive Contextual Behavioral Science Relational Frame Theory And Distinct Features, e.g.

CBT