1. Dr. David Gillanders University of Edinburgh / NHS Lothian Chronic Pain Service Acceptance & Commitment Therapy: Empirical Status University of Edinburgh / NHS Scotland Training Programme in Clinical Psychology

2. The Empirical Base for ACT This is very brief and selective There are references on the reading list to pursue to see more of the evidence base In particular Hayes et. al., 2006 in BRAT and Ost (2008)

3. Experimental & Theoretical Work: Experimental work in experimental pain tolerance, panic induction, distressing thoughts, 7 published component and experimental psychopathology studies (N = 199) Several more are done and on the way and so far the results are quite supportive of the act model Evidence base for ACT

4. Experimental & Theoretical Work: Questionnaire studies using the Acceptance & Action Questionnaire: There are now 27 studies using the AAQ, involving 5,616 participants Evidence base for ACT

5. 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

6. Outcome Studies Across diverse clinical areas: depression, anxiety, OCD, psychosis, chronic pain, smoking, substance abuse, diabetes, cancer, epilepsy 20 randomized controlled trials are now done containing 24 planned between group comparisons. 23 of the 24 favor ACT (not all significantly, just in terms of effect sizes). Several controlled time series designs Control conditions include minimal comparisons (placebo; TAU; wait list) as well as structured active treatment comparisons Evidence base for ACT

7. The first RCT: Depression Zettle and Hayes, 1987 Done at the Centre for Cognitive Therapy in Philadelphia with Aaron T. Beck Surprisingly… Evidence base for ACT

8. Significantly Better Outcomes PrePost2 mo Follow up 0 5 10 15 20 CT ACT Hamilton Rating Scale (BDI was similar) Cohen’s d at F-up =.92

9. Not only that, but process too! 0 % 10 % 20 % 30 % 40 % 50 % 60 % ACT CT Pre to Post Pre to Follow up Pre-Post Reductions in the Believability of Depressive Thoughts

10. ACT For Psychosis Bach & Hayes, 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

11. Impact on Rehospitalization ACT.6.7.8.9 1.0 4080120 Days After Initial Release Treatment as Usual Proportion Not Hospitalized

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

13. Processes of Change: Believability PreF-up 80 60 Control ACT 40 Literal Believability of Psychotic Symptoms (0-100) Phase

14. Chronic Pain Chronic Pain McCracken, Vowles, & Eccleston, BRAT, 2005 108 chronic pain patients Average of 132 months of Chronic pain 6.3 treatment programs Multidisciplinary in-patient program Within subject analysis: Preassessment; 3.9 months later (on average) pretreatment assessment; 3-4 week residential program; 3 month follow-up

15. Chronic Pain Chronic Pain McCracken, Vowles, & Eccleston, BRAT, 2005

17. Refractory Epilepsy Refractory Epilepsy Lundgren, Dahl, Melin & Kies (2006) Epilepsia Small RCT: n = 27; 14 in ACT, 13 supportive therapy ACT intervention: values, reasons, acceptance of seizure, defusing ‘self as stigmatised,’ contact with self, plus standard behavioural procedures Supportive Therapy: Talking about epilepsy and its impact on living, what it means to have epilepsy etc.

18. Refractory Epilepsy Refractory Epilepsy Lundgren, Dahl, Melin & Kies (2006) Epilepsia Limitations: non blinded outcome measurers, small numbers. Main outcome measure: nursing records of daily seizures frequency and length – multiplied to give seizure index. Here’s the data:

19. Refractory Epilepsy Refractory Epilepsy Lundgren, Dahl, Melin & Kies (2006) Epilepsia Interestingly the seizures reduce before the delivery of the behavioural technologies.

20. Evidence base for ACT: Overall effect sizes across all RCT’s Vs.# Post dN F-Up dN F-Up weeks No Rx/ TAU9.99248.7217621 Active Rx15.56793.8272736 CT / CBT6.55205.5512044 All24.661041.890333

21. “Overall ACT seems to be producing consistently positive gains, sometimes quickly, across an unusually broad range of problems including notably severe ones, and at times better than existing empirically supported procedures It seems to work through at least some of its theoretically specified processes and components, not just through general processes of change” Steven Hayes, 2005 Evidence base for ACT

22. First external meta analysis of ACT versus CBT Effect Sizes: Overall0.68 (15 studies) WL Control0.96 (2 studies) TAU0.79 (5 studies) Active Treatment0.53 (8 studies) Lars Goran Ost (BRAT 2008) Evidence base for ACT

23. Also: Background variables ACTCBTp value Numbers starting52.176.5NS Attrition (% starters)15.416.1NS No of weeks8.217.2<0.01 No of hours10.722NS Months follow up4.29.6NS Lars Goran Ost (BRAT 2008) Evidence base for ACT

24. However: Using a scale to rate methodological rigour ACT studies on average are significantly poorer quality than recent CBT studies: Total quality score (max 44) ACT = 18.1 (SD = 5.0)CBT = 27.8 (SD = 4.2) p <0.0001 Lars Goran Ost (BRAT 2008) Evidence base for ACT

25. ACT studies are poorer on criteria such as; Representativeness of the sample, reliability of diagnosis, reliability and validity of outcome measures, assignment to treatment, number of therapists, therapist training and experience, treatment adherence checks, control of other treatments. Lars Goran Ost (BRAT 2008) Evidence base for ACT

26. ACT studies are equivalent on other criteria: clarity of sample description, severity / chronicity of disorder, specificity of measures, use of blind assessors, assessor training, design, power analysis, assessment points, manualised specific treatments, checks for therapist competence, handling of attrition, statistical analyses and presentation of results, clinical significance of results. Lars Goran Ost (BRAT 2008) Evidence base for ACT

27. In conclusion; The ACT literature is promising, shows moderate to large effect sizes across a range of conditions in a notably briefer time scale than existing therapies. The literature is not yet as mature as existing psychotherapies literature and is not as methodologically rigorous in some areas. Future studies should benefit from Ost’s review as he gives specific guidance as to how RCT’s involving ACT could improve. Evidence base for ACT