1. DOING ACT RESEARCH: AN INTERACTIVE PRIMER FOR BEGINNERS Jason Lillis, Ph.D. University of Nevada, Reno

2. My background  ACT trainer  UNR Hayes lab graduate  RCT on ACT for weight stigma/ weight control  Project Coordinator on R01 ACT for suicidality  Developed and tested ACT for prejudice (quasi)  Co-author/ therapist on ACT for MH stigma  Co-author on micro-component study for defusion  Co-author ACT meta-analysis

3. Goals  Learn the ACT model of psychopathology  Understand the ACT research literature and its implications for designing research studies  Design an ACT empirical research study  Collaboration: Lab feel  Ultimately this can be whatever you want

4. A few questions  Why are you at this conference? What matters?  With that in mind, what is of interest to you from a research perspective?  One thing you might want to get out of this workshop

5. Creating an Agenda

6. Background  ACT is form the BT and CBT tradition  BT built on well-developed theory  Reinforcement and punishment  Contingency management and Exposure  BT could not adequately deal with cognition  CBT was born, explicit focus on thoughts  Lead to improvements in outcomes, but also marked a shift in the scientific approach to clinical psyc

7. FDA Science Model  As a result, also a new way of doing science  Treatment development based on empirical support as opposed to theory testing and basic science  Good science = empirical support  ABCT mission statement  Manualized Tx, well-defined disorders, outcomes, tightly controlled studies

8. Problems with FDA Model  Assumes topographically defined “disorders” will lead to coherent, theoretically sensible entities  i.e. psychiatric symptoms lead to true diseases  DSM-V planning committee quotes  Focus on validated techniques leaves no basis for using knowledge to apply for a new problem or situation, no means to develop new techniques  Disorganization and incoherence, mass validation  Difficult to assimilate mountain of knowledge  Difficult to extrapolate and predict based on findings  Example

9. Contextual Behavioral Science (CBS)  An alternative, the approach followed by ACT  Hey, the name of the conference!  “A principle-focused, inductive strategy of psychological system building, which emphasizes developing interventions based on theoretical models tightly linked to basic principles that are themselves constantly upgraded and evaluated.”  Hayes et al, 2008  Look at key aspects of CBS

10. Explicate Philosophical Assumptions  CBS built on Functional Contextualism  Goals: prediction & influence with precision & scope  Explains a lot, applies to a lot, as simple as is useful  Pragmatic truth  What works given one’s goals (no objective truth)  Science is languaging, useful or not  Focus on manipulable events  Contextual variables- e.g. not thoughts and emotions

11. Develop Basic and Applied Theory  Basic Science: Identify manipulable factors  Develop Principles  Applied Science: Test precision and scope  Feedback between both  RFT is the basic account of language and cognition that underlies ACT theory and methods  Examples

12. Develop a Model  Model of pathology and intervention tied to basic principles and theories  Use of middle level terms (the ones you know)  Allows for ease of understanding and use without full knowledge of the basic science  The Operating System  Established already, though revision based on data is always possible  ACT Model in figures

13. The Primary ACT Model of Psychopathology

14. Psychological Flexibility The Primary ACT Model of Treatment

15. Techniques and Components  Model is the foundation on which to build techniques- grouped by process/ component  Can be created, or borrowed  Allows for analogue and component studies (small, lab-based)  Easy, feasible, contribute growing base of evidence  Enables early detection of inactivity, revisions, targeting specific theoretical questions

16. Measuring Theoretical Processes  Process of change = VERY important  The link between theory, principles, and techniques  Measures that link a theoretical construct with the phenomena or condition (e.g. psychological flex)  Important area of research  Without, can’t theory test  CBS/ ACT frequently uses idiographic measures, and values adapted, specific, theoretically- consistent assessment over traditional validation

17. Emphasis on Mediation  Outcome studies fit here, but…  Heavy emphasis on mediation  ACT is a model, not a set of techniques  Moving processes is the primary goal  Tests coherence and utility of model  Failure or success in outcomes is meaningless without

18. Effectiveness, dissemination, training  Early and often  “What works” needs to also work in real settings  “What works” for training others?  “What works” in terms of acceptability?  “What works” in terms of cost-effectiveness?  Questions to ask now as opposed to later

19. Broad Range Testing  Generalizabilty is important- search for limits  Targeting experiential avoidance should be helpful  Individual, groups, phone, internet, books, etc…  Anxiety, depression, substance use…  But maybe also health behavior change, or prejudice  And also for the individual, organization, and biology  This is the “scope” part  It is explicitly anti-syndromal thinking

20. Highlight Differences  Components  Mediation emphasis  Scope  Creation/ use of measures  Early effectiveness/ training

21. Components  Small scale, focused  Few resources needed, lab-based  Allows isolation of process  Test whether techniques or components are “active”  Test parameters

22. Defusion Masuda, Hayes, Twohig, Guerrero, & Sackett, BRAT, 2004 Generate two highly disturbing thoughts Randomly assign them either to defusion (“milk, milk, milk”) or thought control (positive self-talk, positive thinking) Apply in an alternating treatments format

23. Defusion Reduces Distress and Believability Cohen’s d = 1.98 (distract) and 2.63 (control)

24. Follow-up Study Masuda, Hayes, Twohig, Cardinal, & Lillis (2009) BMod

25. Acceptance Levitt, Brown, Orsillo, & Barlow, Behavior Therapy, 2004  60 individuals with a primary diagnosis of panic disorder with or without agoraphobia randomly assigned to one of three groups (10 min audiotape): Acceptance, Suppression, Control (irrelevant distraction)  15-minute 5.5% CO 2 challenge (panic provocation)

26. Anxiety During the Challenge AcceptSuppressControl 0 1 2 3 4 Cohen’s d at post =.5 (suppress) and.45 (control)

27. Willingness to do it Again AcceptSuppressControl 0 1 2 3 4 Cohen’s d at post =.67 (suppress) and.81 (control)

28. Mediation  “Why” the treatment worked  “Why” the treatment didn’t work  Without process/ mediation, you can’t be sure what you did, what you targeted, whether its relevant  Changes the focus from outcomes to process- allows for treatment to focus on common core processes  Broadly targeting robust processes that relate to outcomes = predict & influence w/ precision & scope

29. Mediation Analysis Treatment Conditions OutcomeMediator

30. Mediation Analysis ACT Intervention DepressionAcceptance

31. Mediation Analysis ACT Treatment Depression Acceptance a b c c’

32. ACT for Weight, Stigma, QOL Lillis, Hayes, Bunting, Masuda, 2009, Annals of BMed  Randomized controlled pilot study (N=84)  1-day ACT workshop  Targeted adults trying to lose weight and maintain weight loss  ACT group vs. Wait-list Control (TAU)

33. Weight Status at Follow-up % gaining 5+ lbs% losing 5+ lbs 35 25 15 10 5 0 x² = 8.8, p<.003 d = 1.21 30 20 ACT Control

34. Stigma (WSQ) Baseline3 Month FU 60 40 50 ACT Control F = 24.3, p<.001 η 2 =.23

35. Quality of Life (ORWELL) Baseline3 Month FU 60 30 45 ACT Control F = 27.4, p<.001 η 2 =.25

36. Mediation Analysis: Weight Control Treatment Conditions BMI change Experiential Avoidance r =.34 p =.002 r =.54 p =.0001 r =.44 p =.0027 r =.11 p =.242 c c’ a b

37. What does this tell us?  The treatment targeted experiential avoidance  Changes in experiential avoidance accounted for changes in weight, stigma, QOL.  Treatment packages targeting EA could impact relevant outcomes in other studies  Provides support for EA as a common core process  Targeting EA is relevant in area of stigma and health behavior change, should be helpful elsewhere

38. Areas with mediation evidence  Treatment Outcome Studies  Depression, OCD, Worksite Stress  Rehospitalization (SMI) x2  Weight Loss, Smoking Cessation, Diabetes Management, Epilepsy, Chronic Pain?

39. Scope  Goals: prediction & influence with precision & scope  Create a science more adequate to the challenge of human suffering  Should have something to say about anything that relates to behavior (i.e. almost everything)  % of people who contact mental health? 5%?

40. Relevant to Stigma and Prejudice?  RFT tells us that relational networks work by addition, not literal subtraction  Suppression and avoidance of cognitive content generally increases its impact, especially over time  Can ACT help?

41. Stigma Treatment Hayes, Bisset et al, 2004, Behavior Therapy  90 drug counselors randomly assigned to day long workshop on  ACT  Multicultural training  Class on biological models of SA  Stigma towards clients  Provider Burnout  3 Month Follow-up

42. Effects on Stigma ACT Multicultural Control

43. Change in Burnout ACT Pre- Post Pre- F-up Multicultural Education 4 0 -4 Pre- Post Pre- F-up Pre- Post Pre- F-up

44. Racial Prejudice Lillis and Hayes, 2007, BMod  Replicated with racial bias in a college student population  Within subject test comparing racial bias education and ACT  Alternating design  32 participants across 2 classes  90 minute class period  1 week follow up

45. Results

47. Other areas: Limit testing  Psychosis, Epilepsy, Adjustment to College

48. Effectiveness

49. The Effectiveness Project Strosahl et al, Behavior Therapy, 1998  8 HMO therapists trained 1 yr in ACT; 10 not. The two group were self-selected, not randomized  Before training for a month all assigned clients (N=59) assessed at initial visit and 5 months later  All assigned clients (N=67) similarly assessed after 1 yr of training  No difference in average number of sessions

50. 9/2/2015 Treatment was Faster

51. Treatment was Cheaper No Training

52. Treatment was Better

53. Other Important Issues  ACT targets  Counterintuitive findings  Incubation effects  ACT measures  Single case

54. ACT Outcome Targets  ACT model suggests that mindfulness, acceptance, defusion, self, values, and behavioral commitment is psychological flexibility = positive life functioning  Nowhere in the model is symptom reduction  Nowhere in the model is syndrome amelioration  This has lead to problems with acceptability and validation in the main stream  What is more convincing to you?  Ultimately, me must play both games

55. ACT Targets  Functional improvement  Sick days (chronic pain), job performance, diabetic control, use of ESTs, health care utilization  Quality of Life  Successful, vital living- consistent with values  Not “happy”, but targeting ACT processes does improve traditional targets as well  Depression (BDI, Hamilton), OCD, GHQ (Psyc distress)

56. Exercise  Start shaping your own idea  Pairs/ Groups  Pick an interesting question  Goals of your study (to learn?)  Identify a population  Pick a setting  Design a methodology  Issues of practicality  Consultation

57. Counterintuitive Findings  Related to issue of targets  ACT not targeting symptoms, in fact targeting more mindful awareness of thoughts and feelings, flexibility in relating to thoughts and feelings, and behavior tied to values  Sometimes leads to model consistent, but a-typical findings

58. Adopting ESTs Varra, Hayes, Roget, & Fisher, 2008, JCCP  59 drug and alcohol counselors randomly assigned to  One day ACT workshop focused on defusing from the psychological barriers to learning new treatment approaches, and acceptance of the emotions they bring up  Control condition: One day workshop on matters not linked to empirically supported treatments (EAP policies; etc)  Both groups then do a one day educational workshop (the following day) on empirically supported treatments in the drug and alcohol area focusing particularly on the use of agonists and antagonists

59. Frequency of Perceived Barriers to Using Empirically Supported Treatments PrePost 75 Mean Score Phase 70 ACT plus Education Control plus Education 65 ACT group acknowledges the presence of significantly more barriers to using these treatments p <.05

60. Believability of Perceived Barriers to Using Empirically Supported Treatments PrePost 70 Mean Score Phase 65 ACT plus Education Control plus Education 60 ACT group is significantly less likely to believe that these barriers are real p <.05

61. Willingness to Use Pharmacotherapy PrePost 3.5 3.25 2.25 Mean Score on 1-5 Scale Phase 3 2.75 2.5 ACT plus Education Control plus Education 2 ACT group reports being significantly more willing actually to use empirically supported treatments (pharmacotherapy score is shown) p <.01

62. Subsequent Use of Pharmacotherapy Three months later ACT group reports a large increase in actually using pharmacotherapy more frequently. p <.001 Pre3 month Follow - up 3.5 3.25 2.25 Phase 3 2.75 2.5 ACT plus Education Control plus Education 2

63. Coping with Psychotic Symptoms Bach & Hayes, JCCP, 2002  80 S’s hospitalized with hallucinations and/or delusions randomized to either ACT or TAU  3 hours of ACT; all but one session in-patient  ACT intervention focused on acceptance and defusion from hallucinations / delusions

64. Impact on RehospitalizationACT.6.7.8.9 1.0 4080120 Days After Initial Release Treatment as Usual Proportion Not Hospitalized

65. Processes of Change: Symptoms PreF-up 100 75 25 Control ACT 50 Percentage Reporting Symptoms Phase

66. Processes of Change: Symptom Reporting and Acceptance 50% 40% 30% 20% 10% Rehospitalization Rate ACTTAU Admit Deny Admit Deny

67. Findings Summary  ACT is targeting changing one’s relationship to thoughts and feelings, in particular the willingness to experience them in the service of valued ends  Thus, participants may acknowledge more symptoms, or more barriers, but the impact on behavior is much less  This kind of finding is very cool as it is consistent with the ACT model  But keep in mind what would be predicted by the model when designing study and analyzing data

68. Incubation  Sometimes ACT effects are not seen at post

69. Severe Substance Abuse Hayes, Wilson, et al, 2004  124 polysubstance abusers  3 conditions  ACT + Methadone  ITSF + Methadone  Methadone only  ACT + ITSF  16 weeks/ 3 sessions per week  Methadone + counseling

70. Post 6 Mo Follow Up Percentage Negative QAs Phase 45 55 35 25 ACT MM ITSF 55 Objectively Assessed Opiates Pre

71. Post6 Mo Follow Up Percentage Negative QAs Phase 45 55 35 25 ACT MM ITSF Pre Total Drug 15

72. Smoking Cessation Gifford et al, 2004, BT  Nicotine Replacement Therapy  Initial education meeting  Weekly contact for assessment  Acceptance and Commitment Therapy  Weekly and group meeting  10 Weeks

73. Outcomes Post1Yr Follow Up 55 45 5 Percentage Not Smoking Phase 35 25 15ACTCompleters All NRT All Completers

74. Incubation Summary  What seems to happen: ACT lays seeds of acceptance, defusion, willingness, values and over time natural contingencies take over and patterns of behavior become larger  Post treatment is a muddy picture for outcomes  Process data is key

75. ACT Measures  Acceptance and Action Questionnaire (AAQ)  Most widely used  Experiential avoidance/ psychological flexibility

76. Origin of the AAQ  Although the AAQ is often said to be a measure of experiential avoidance, the original item pool focused on all major ACT processes  These 9-16 items (depending on the version) cover a wide range of issues, including acceptance, defusion, and action  There are now 30+ studies using the AAQ, involving 6000+ participants

77. 9/2/2015 AAQ Scores Are Associated With ….  Higher anxiety  More depression  More overall pathology  Poorer work performance  Inability to learn  Substance abuse  Lower quality of life  Trichotillomania  History of sexual abuse  High risk sexual behavior  BPD symptomatology and depression  Thought suppression  Alexithymia  Anxiety sensitivity  Long term disability  Worry ALMOST EVERYTHING

78. Quantitative Summary  All reported correlations are positive for the model  BDI (8 studies).50  SCL 90 (3 studies).53  BAI or STAI (3 studies):.49  GHQ (3 studies):.40  Overall effect size.42  (CI: 0.40– 0.44)  Hasn’t been updated in a few years

79. AAQ-II

80. ACT Measures- Specific AAQs  Specific Measures adapted and used successfully  AAQD- Diabetes  AAQW- Weight  AAEpQ- Epilepsy  BI-AAQ- Body Image  CPAQ- Chronic Pain  AIS- Smoking  TAQ- Tinnitus  VAAS- Auditory Hallucinations

81. AAQD- Diabetes

82. Other ACT Process Measures  Bulls Eye (Values)  PVQ (Personal Values Questionnaire)  ATQ-B (Automatic Thoughts-Believability: Fusion)  CFQ (Cognitive Fusion Questionnaire)  FFMQ (Five Facets Mindfulness)  PMS (Philadelphia Mindfulness)  AAQ measures covers acceptance, or acceptance and defusion, or psyc flexibility

83. ATQ-B

84. Bull’s Eye Far from In the vicinity Close Bullseye Very close

85. Other ACT Process Measures  Also child measures  Thought suppression  Internalized shame  Coping measures  http://contextualpsychology.org/act-specific_measures

86. Brief Idiographic Measures  E.g. Masuda study on defusion  Distressing thought- turned into one word  Distress and Believability scales  100 millimeters, mark from low to high  |------------------------------------------------|

87. Single Case

88.  4 OCD patients  8 sessions of ACT w/o exposure Obsessive Compulsive Disorder Twohig, Masuda, & Hayes, Behavior Therapy, 2006

89. Days P 2 - Hoarding P 1 - Checking Compulsions per day P 3 - Cleaning P 4 - Checking 3 Mo FU

90. Summary  Pick something you care about  Know CBS principles  Start small, use resources (website!)  Kinds of studies:  Correlational  Component  Measures  Outcomes  Mediation  Effectiveness  Training  Single Case  Multiple baseline  Limit testers

91. Consultation  Ideas?  What can we help help with?  ACT specific or broad design issues

92. The End

93. Mediation  A good way to test the significance of the difference between c and c’ is the Sobel test  The Sobel test looks at the significance of the cross-product of the a and b regression coefficients  In general a*b = c – c’ so a significant Sobel = significant mediation

94. Mediation  A less sophisticated way is to infer mediation from causal steps, especially that  there is a significant treatment effect on outcome  treatment influences the mediator  The mediator is related to outcome controlling for treatment  and treatment does not impact outcome significantly if variability due to the indirect path is extracted

95. Racial Prejudice Lillis et al  Replicated with racial bias in a college student population  Within subject test (A/B/A/C/A) comparing racial bias education and ACT  16 participants in a racial differences class  90 minute class period  1 week follow up

96. Assessment Items  Bias Awareness  I feel that I am aware of my own biases  Bias Does Not Affect Me  I feel that my prejudicial thoughts are a significant barrier to me being culturally sensitive  My biases and prejudices affect how I interact with people from different racial and ethnic backgrounds.

97. Assessment Items  Acceptance  It is OK to have prejudiced thoughts or racial stereotypes  I try not to think negative thoughts I have about people from different racial or ethnic backgrounds.  Defusion and Action  When I evaluate someone negatively, I am able to recognize that this is just a reaction, not an objective fact.  It’s ok to have friends that I have prejudicial thoughts about from time to time.

98. Assessment Items  Positive Action  I would attend a social event where I was the only person of my race/ ethnic background.  I believe that I am able to transcend racial boundaries with my actions.  I plan to actively seek out experiences that could expose me to people who have a different cultural, racial, or ethnic background than me.  I am likely to join a campus organization or participate in a campus event that is focused on cultural diversity.

99. MODEL Correlation Longitudinal Component Studies Measure Development Outcomes & Mediation Effectiveness Training Dissemination Limit Testing Transdiagnostic