1. Delivering acceptance and commitment therapy online
Michael E. Levin
Utah State University

2. What I want to talk about
Things that get me excited about this work
Challenges and opportunities I see in scaling up mental health services with technology
The importance of theory-focused treatment research that goes beyond just testing efficacy
How to make things better, not just prove it works

3. Challenges addressing mental health
We have effective treatments but…
Effect sizes are not improving much
A sizeable portion of people don’t improve
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

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

5. The benefits of focusing on theory
We have effective treatments but
Effect sizes are not improving much
A sizeable portion don’t improve
Supply side challenges with providers
Barriers to training/adoption
Focus on key mechanisms and components
Tailored to the individual
Train practitioners in broadly applicable evidence-based principles

6. Using Theory as a Guide
Refine a transdiagnostic model of psychopathology
That highlights key components and mechanisms of change
That lead to effective outcomes for a wide range of problems

7. Refine a transdiagnostic model of psychopathology
Using Theory as a Guide
Refine a transdiagnostic model of psychopathology
That highlights key components and mechanisms of change
That lead to effective outcomes for a wide range of problems

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

9. 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

10. That highlights key components and mechanisms of change
Using Theory as a Guide
Refine a transdiagnostic model of psychopathology
That highlights key components and mechanisms of change
That lead to effective outcomes for a wide range of problems

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

12. That lead to effective outcomes for a wide range of problems
Using Theory as a Guide
Refine a transdiagnostic model of psychopathology
That highlights key components and mechanisms of change
That lead to effective outcomes for a wide range of problems

13. Cumulative # of Published RCTs

14. Evidence for ACT Mental health problems Behavioral health problems
Depression
Anxiety
OCD & spectrum disorders
Eating disorders
Addictions
Psychosis
Self-harm
Behavioral health problems
Chronic pain
Weight loss & exercise
Smoking cessation
Diabetes management
Coping with epilepsy & cancer
Psychosocial functioning
Developmental disabilities
Work and school performance
Burnout/stress
Athletic performance
Stigma/prejudice

15. Developing Web/Mobile Apps Based on the ACT Model

16. Technology helps address many barriers
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 intervention
Tools to support practitioners
Low implementation cost
Ease/anonymity of access

17. Using web-based ACT to prevent mental health problems in college
Co-PIs: Michael Levin, Jacqueline Pistorello & Steven Hayes
NIMH R43MH085336

18. Mental health needs among students
Psychological problems are highly prevalent in college
Campuses are struggling to keep up with increases in demand for psychological services
Need to reduce onset of the wide range of problems students are at risk for
Pistorello, Hayes & Levin, 2012

19. 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

22. Pilot Waitlist RCT Pilot RCT with 76 first-year college students
Randomized to ACT-CL or Waitlist
Assessed at baseline and post (3 weeks later)
High ratings of usability/acceptability
ACT-CL produced greater gains than waitlist on
Education values
Depression and anxiety symptoms
Levin, Pistorello, Hayes & Seeley, 2014

23. Psychoeducation RCT Results
RCT with 228 college students
Comparing ACT-CL to a psychoeducation website
Only 55% completed ACT-CL versus 86% completing control
No between condition differences on outcome or process measures
Engagement in ACT-CL predicted improvements in psychological inflexibility
And improvements in psychological inflexibility predicted improvements in outcomes
Levin, Hayes, Pistorello & Seeley, 2016

24. Looking back at failed findings
Challenges with universal prevention
Engaging students who aren’t looking for help
Challenges with program development
A $50,000 prototype had equal satisfaction ratings to a two session qualtrics-based program
Adherence was higher with the qualtrics program

25. Using web-based ACT for distressed students
PI: Michael Levin
Alan E. Hall Innovation for Undergraduate Student Success Award

26. Developing with Existing Platforms
Creating custom programs from the ground up is expensive and time consuming
May not be needed for earlier stage or more experimental research
Another approach – using existing content management systems (CMS)
Leverages an existing system with good stability and usability
Increase speed and efficiency of development while reducing cost

29. 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 & Twohig, In preparation

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

31. 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

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

33. “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.”

34. Summary of Findings
A transdiagnostic approach reduced mental health concerns
But emphasizing different treatment components did not affect results
Developing self-help programs through a survey CMS can lead to adequate acceptability, usability and efficacy
Stand alone interventions provide broad reach
But effect sizes tend to be smaller than more integrated approaches

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

36. Integrating ACT technology 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 homework between sessions
Supporting therapists in learning a new treatment

37. 30 Counselors across 4 centers 82 clients recruited by counselors
Range of problems, but clinically stable
Online baseline survey
Online baseline survey
10 Week Program Period
Training
4 Week Program Period
Certification test (> 80%)
80% of counselors passed
Post Assessment
Completed by 44%
Recruit students
Post Assessment
Completed by 67%
Levin et al., 2015

38. Levin et al., 2015

39. 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 all process and outcome measures
ANCOVA partial η2 ranging between .05 and .22
Except acting with awareness, values, and life satisfaction
Levin et al., 2015

40. Summary of Findings
ACT-CL appears to be feasible and acceptable with both counselors and their clients
Significant improvements in outcomes and processes
Need to test the additive effects of ACT-CL to counseling
Developing the full program to test in a multisite RCT this August

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

42. 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

43. ACT Daily

44. Overview of ACT Daily Studies
Pilot open trials found ACT Daily improves symptoms and inflexibility over 2 weeks
With clients waiting to start counseling
With clients receiving ACT from a therapist
Are effects due to tailoring skill coaching specifically?
Control for check-in assessments and non-tailored skill coaching in a RCT
Levin et al., 2017;
Haeger & Levin, In Preparation

45. 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)
Post Assessment
Completed by 78%
Post Assessment
Completed by 86%
Post Assessment
Completed by 92%
Levin, Haeger & Cruz, Under Review

46. Improvements over 4 weeks

47. Summary of findings with ACT Daily
ACT can be delivered in a high frequency, low intensity format to improve mental health
Tailoring what skill is provided in the moment improves outcomes
Future research needed to enhance tailoring
What skills are delivered for what person under what conditions

48. Summarizing Lessons Learned and Future Directions

49. The Potential of Online Interventions
Treatments like ACT can be delivered through websites and apps
Increase access to mental health services
Enhance the efficiency, reach, and impact of in- person services

50. But There Are Major Challenges
Engaging users can be challenging
“If you build it, they might not come”
Developing programs and refining based on research can be challenging
Typical method is slow, limited by funding, and inflexible
Pull for a focus on product development and validation rather than producing generalizable knowledge

51. What is the Goal?
Confirmatory efficacy research determining if programs are efficacious
But are we just trying to prove our idea/program works?
Develop generalizable knowledge about what works and how to make treatment better
What components and mechanisms are effective
For which clients and contexts
And how to effectively implement and integrate technology as part of mental health services

52. Thank you! Questions?