1. A Review of Acceptance and Commitment Therapy (ACT) Empirical Evidence: Correlational, Experimental, Psychopathology, Component and Outcome Studies By Francisco J. Ruiz (2010)

2. ACT  A psychological intervention  Philosophically rooted in functional contextualism  Rooted in Relational frame theory (RTF)  Treatment of experiential avoidance disorder (EAD)  Functional dimensional approach to psychopathology

3. Functional contextualism  Generally contextualism observes actions in a context  Functional contextualism  specific way of contextualism which undermines prediction and influence of events with precision, scope and depth.  Thoughts or actions are not seen correct or incorrect  It focuses on usefulness

4. RFT  Contextual behaviorism approach to human language and cognition  Based on laws  Human beings learn to relate stimuli under arbitrary contextual control  It has three requisites for considering the existence of relational frame

5. RFT Mutual entailment A  B B  A Combinational Entailment A>B, B>C A>C Transformation of Functions (Depends on function)

6. RFT  Has large number of implication of area of psychopathology and psychotherapy  Briefly nature of language and cognition has more impact on changing attempts focused on the function of private events

7. Experiential Avoidance  Deliberate effort to avoid and/or escape from private events such as thoughts, memories and bodily sensations.  When EA combined with psychological inflexibility problems occur.  EA works in short run.  In long run, it provokes patients’ life.

8. Essential ACT Principles and Methods

9. What does ACT provide ?  Generates psychological flexibility  Contact the present moment  Proposes acceptance  To involve oneself in valued action

10. Therapeutic Work in ACT Promotes Values clarification and actions Defusion

11. Values clarification and actions  Creative hopelessness  Values clarification  Promotion of the willingeness to experince

12. Defusion To choose to behave in valued way  Cognitive defusion - weakining the tendency to treat them.  Self as a context - there is a YOU behind all private events

13. How ACT obtaion its objectives metaphors paradoxes Experiential exercises

14. Classical exposure therapies vs. ACT  Extinction of discomfort  Trains the patients to be present with their feared experince  Directs them to behave in a valued way.

15. ACT Empirical Reviews

16. First Critique: Corrigan (2001)  ACT has not been developed with the usual rationale --philosophical and theoretical roots were not used First Review: Hayes et al (2006) Correlation evidence Experiential avoidance, experimental psychopathology and ACT component studies, randomized controlled trials and processes of change studies ACT—superior to control conditions, wait-lists and treatment ACT—superior to structured interventions

17. Other research:  Öst (2008): Qualitative and quantitative review of the ACT empirical evidence from RCT. --Comparing ACT versus CBT (Cognitive Behavior Therapy) --Conclusion: ACT showed lower scores in a methodological scale compared with CBT --ACT does not fulfill the criteria for being considered as an empirical validated treatment.

18. Re-analysis of Öst review: Gaudiano (2009)  %38 of the ACT studies could not be matched with CBT study because: --Studies were conducted over different disorders --Different population  CBT studies were 4.5 more times funding than ACT studies

19. Recent Review: Powers, Vörding & Emmelkamp (2009)  Meta-analytic review of ACT empirical evidence in RCT studies --Conclusion: ACT is better than wait-lists, placebo attention conditions BUT not significantly better than established treatments HOWEVER  Re-analyzed the data base: Levin & Hayes (2009) --Conclusion: ACT was better than established treatments

20. Emprical Evidence of ACT Model  separated as a correlational, experimental psycpath. and component studies, outcome studies and case studies. Correlational Studies;  Aim to study relationship among experiential avoidance and psychological symptoms.  ‘’Acceptance and Action Questionnaire’’ is used in studies.  it measures experiential avoidance  Experiential avoidance is analyzed with different types of psychological construct and symptoms.  Chronic pain is one of them

21.  Kratz, Davis,& Zatura (2007) have showed that acceptance of pain predicted posterior positive affect.  According to Wicksell, Renöfalt, Olsson, Bond & Melin (2008), acceptance predicted pain severity, pain interference in everyday life and physical and metal well-being.  In work setting, the level of experiential avoidance has predicted mental health and performance in learning a new software (Bond, & Flaxman, 2006).  Experiential avoidance has been a mediator between childhood psychological abuse and current mental health symptoms (Reddy, Picket, & Orcutt, 2005).  Experiential avoidance block the reduction of depression in the treatment of borderline personality disorder.

22. Experimental psychopathology and ACT component studies 3 types of studies : effect of experiental avoidance, effect of acceptance coping instructions, effect of brief ACT protocol Studies about effect of experiental avoidance repertoire in experimental task: Predictive power of the level experiental avoidance of participants  selecting participants with high and low scores in AAQ  Cold pressor task (Zettle et al.,2005) -High score of AAQ had lower tolerance and kept their hand in cold water less time than participant with low AAQ score

23.  Effect of being drunk (Zettle,Petersen,Hocker&Provines,2007) -Higher scores in AAQ were more discomforting and had worse performance on challenging perceptual-motor task than lower scores.  Carbon dioxide-enriched air challenge (Feldner, Zvolensky, Eifert &Spira (2003) -High levels of AAQ showed more anxiety and emotional discomfort but not more phsysiological activation - High AAQ score, received suppression protocols, showed higher levels of anxiety than those who received perceived acceptance control  Comparing emotional reactions (Sloan,2004) -participants with high level of experiental avoidance showed higher emotional experience and higher heart rate with the pleasent and unpleasent films

24. THE EFFECT OF ACCEPTANCE COPING INSTRUCTIONS Nihan Kaymaz

25.  Several studies focused on the effects of acceptance coping instructions  Aim: to assess the psychopathology in terms of comparing acceptance coping instructions and other coping strategies  Aversive stimulation, intrusive thoughts, cardiovascular conditions, emotional contents

26. In terms of aversive stimulation:  Keogh, Bond, Hanmer & Tilston (2005): Cold-pressor task Acceptance coping instruction obtained better results than one ‘distraction coping instruction’ with women The same effect with men

27. In terms of intrusive thoughts:  Marks & Woods (2005): Acceptance instructions vs. suppression in the management of intrusive thoughts Acceptance coping instruction group: less discomfort when experiencing the intrusive thoughts. Suppression group: more intrusions, higher levels of anxiety, negative evaluation compared with acceptance (while doing a task which consisted in saying aloud and imagining that a loved one were having a traffic accident)  Najmi, Riemann & Wegner (2009): Similar effects with those with OCD Both acceptance and focused distraction coping instruction groups had less distress than suppression group.

28. In terms of cardiovascular conditions:  Low, Stanton & Bower (2008): Acceptance-oriented processing vs. evaluative emotional processing on cardiovascular habituation and recovery Task: writing about an ongoing stressful experience Better efficient heart rate habituation and recovery in acceptance condition

29. In terms of emotional contents:  Campblell-Sills, Barlow, Brown & Hofmann (2006): Differential effect of suppression vs. acceptance instructions Task: viewing a highly emotional film Lower heart rate and less negative effect during the film in acceptance condition than in suppression condition  Liverant, Brown, Barlow & Roemer (2008): Depressed participants used Suppression produced short-term reduction in sadness with low levels of anxiety However, not effective at moderate and higher levels

30. In terms of emotional contents:  Hofmann, Heering, Sawyer & Asnaani (2009): Suppression vs. cognitive reappraisal vs. acceptance instruction Task: coping with an impromptu speech in front of a video-camera Higher heart rate in suppression condition than in others Also, subjective experience of anxiety was lower in cognitive reappraisal than acceptance  Dunn, Billotti, Murphy & Dalgleish (2009): Suppression vs. acceptance on processing distressing materials Suppression showed better results However, suppression was accepted similar to cognitive reappraisal coping instruction

31. Limitations  ACT does not instruct acceptance Metaphors and experiential exercises are used  Coping strategies have some similarities among them and there is still no a consensus about their verbal processes Both acceptance and cognitive reappraisal involve distancing from thoughts  Acceptance coping protocols in these studies did not include valued oriented behaviors or any valued context. In ACT, acceptance is always at the services of values

32. Effects of ACT Protocols Cold-pressor task experiments: Hayes, Bissett, et al(1999): Acceptance-based protocol vs. Control-based protocol Masedo& Esteve (2007): Acceptance-based protocol vs. Suppression-based protocol Branstetter-Rost et al (2009): ACT-based acceptance with/without values

33. Pain-tolerance task experiments: Takahashi et al (2002): ACT exercises vs. CBT exercises Gutierrez et al (2004): Acceptance-based protocols vs. Cognitive-control-based protocols McMullen et al (2008): Acceptance-based coping strategies vs. Control-based strategies Blarrina et al (2008): ACT values protocol vs. Control values protocol

34. OUTCOME STUDIES

35. CLINICAL PSYCHOLOGY  Depression  Anxiety disorders  Psychotic symptoms  Personality disorders  Addictive behaviors  At-risk adolescents

36. CLINICAL PSYCHOLOGY  Two studies: ACT and depression  Zettle & Hayes, 1986:  Comprehensive distancing vs. two versions of cognitive therapy  ACT was better after therapy and after 2 month follow up. Zettle & Hayes, 1989:  ACT in group format vs. the previous two CT versions in groups  Cognitive fusion mediated the results (believability of depressive thoughs).

37. ANXIETY DISORDERS  Two studies: ACT and OCD  Twohig, Hayes & Masuda, 2006b:  Positive results with all participants  Twohig, 2007:  ACT vs. Progressive Relaxation Training  Less compulsions with ACT group than relaxation group at post-treatment and at 3 month follow-up.

38. ANXIETY DISORDERS  Four studies: ACT and Social Phobia  Block, 2002:  ACT vs. CBT, participants with subclinical social anxiety  ACT group was better at public speaking In general, ACT is a promising treatment for social phobia

39. ANXIETY DISORDERS  Generalized Anxiety Disorder  Roemer & Orsillo (2007): ACT obtained large effect sizes in reducing GAD symptoms. Hayes, Orsillo & Roemer (in press):  Acceptance in private events and engagement in meaningful activities related to responder status and quality of life at post-treatment.  Trichotillomania and skin picking: Studies reported positive results.

40. ANXIETY DISORDERS  Diverse symptoms related to anxiety and/or depression  ACT vs. CBT or CT  ACT obtained more improvements at post-treatment and at the 6 month follow-up  Decrease of experiential avoidance (Lappalainen et al., 2007).

41. PSYCHOTIC SYMPTOMS  Bach & Hayes (2002):  45 minute sessions of ACT and TAU vs. only TAU to prevent rehospitalizations  ACT and TAU condition decreased rehospitalizations, hallucinations and delusions believability. Gaudiano & Herbert (2006a & 2006b): same results.

42. PERSONALITY DISORDERS  Gratz & Gunderson (2006): patients with borderline personality disorder.  TAU vs. ACT and TAU  Even though both conditions have significant effects, the latter one reached normative functioning levels.

43. ADDICTIVE BEHAVIORS  Hayes, Wilson et al. (2004): polysubstance abusing individuals being maintained on methadone  ACT, Intensive Twelve Step Facilitation vs. Methadone Maintenance only  ACT condition showed greater decrease in total drug use at the 6 month follow- up

44. AT-RISK ADOLESCENTS  Gomez et al. (under review):  In the treatment of at-risk adolescents who are with a history of antisocial behavior and current legal issues (n=5)  Less impulsivity, higher self-control, more value oriented actions  Improvements increased in one year follow-up

45. AT-RISK ADOLESCENTS  Luciano et al. (2009):  Adolescents with moderate or high risk (n=15) of having impulsivity or emotional problems  Values clarification protocol: promoting choosing and taking responsibility for own choices  Showed a large effect only for moderate-risk adolescents  Defusion protocol: discriminating private events  Produced a large effect size for high-risk adolescents and improved the effect of values protocol.

46. ACT in Health Psychology  Dahl, Wilson, & Nilsson (2004):  Chronic pain, ACT vs. TAU  Less sick days for ACT group at 6 month follow- up  Wicksell et al. (2008):  On people with Longstanding Pain –> significant improvements in functioning, life satisfaction, fear of movements and depression at 7 month follow-up.  Gifford et al. (2004):  ACT>CBT -for chronic pain- (Smoking Cessation ACT>Nicotine Replacement Therapy) at 1 year follow-up.

47. ACT in Health Psychology  Branstetter et al. (2004):  Distress resulted from end-stage cancer  ACT>CBT for alleviating distress levels  Lundgren et al. (2006):  Epilepsy  ACT condition vs. Attention Placebo Condition  At 12 month follow-up  Less seizures, higher quality of life  Forman et al. (2009):  Weight loss in obese women  At post-treatment 6.6% of body weight lost  At 6 month follow-up 9.6% of body weight lost

48. ACT in Health Psychology  Gregg et al. (2007):  Type II Diabetes  Diabetes Education vs. ACT + Diabetes Education  ACT condition was more succesful in promoting self-management behaviours  Hesser et al. (2009):  ACT reduced Tinnitus Distress  At 6 month follow-up symptom reduction  Good outcomes in:  Multiple Sclerosis (Sanchez & Luciano, 2005),  Prevention of HIV (Gutiérrez et al., 2007),  Systematic Lupus Erythematosus (Quirosa et al., 2009)

49. Other Areas of Intervention

50. OTHER AREAS of INTERVENTION Fernandez et al. (2004); - sport performance enhancement - carried out RCT - ACT vs. hypnosis RESULTs : ACT showed greater influence BUT without reaching a statistical significant differences.

51. OTHER AREAS of INTERVENTION Chess players who showed the greatest improvement in their performance were the ones who had higher levels of experiental avoidance during competitions at pretreatment

52. OTHER AREAS of INTERVENTION Work Settings ;  Differential effect of ACT 3 hours session intervention vs. Innovation Promotion Program and wait-list condition  ACT showed better effect in post treatment and in the 3 month follow-up in the improvement of general mental health

53. OTHER AREAS of INTERVENTION  Potential efficacy of ACT in reducing the resistance to the use of emprical validated treatments among professional councelors  Louma et al. (2007) compared the differential effect of 8 ACT sessions with a control condition  RESULTS: in the ACT condition, counselors followed using the empirical validated treatment at the 2 and 4 month follow-up more frequently than control condition

54. OTHER AREAS of INTERVENTION  Reducing prejudice and stigma  Hyes et al. (2004) Differential effect of ACT vs. Multicultural Training and Biological Education in diminishing the stigma and burnout among substance abuse counselors RESULTs: ACT obtained better results than the other intervention of stigma, burnout and the believability of stigmatizing attitudes at post- treatment and 3 months follow-up

55. OTHER AREAS of INTERVENTION Masuda et al. (2007) - effect of an ACT intervention vs. educational intervention in reducing stigma towards people with mental disorders - differential effect of the protocols among participants with high and low AAQ scores

56. OTHER AREAS of INTERVENTION  RESULTS; -in post-treatment and at the 1 month follow- up, ACT produced a decrease on stigma both in participants with high and low AAQ scores -Higher effect in the high avoidant participants -Educational intervention worked with participants with low AAQ scores

57. Published case studies:  Depression  GAD  Anxiety  Agoraphobia  Panic disorder  PSTD  OCD  Psychotic symptoms  Anorexia nervosa  Schizotipic personality disorder  Familiar and couples problems  Patients with intellectual disabilities  Exhibitionism  Sexual dysfunction and orientation  Alcoholism  Heroin addiction  Chronic pain  Cancer  Swimming and weightlifting  Chess  Lacrosse

58. Discussion  ACT is effective in a wide range of problems  Typically better after follow-up  Relevant effect when applied to extremely short interventions  The empirical evidence is compromising

59.  Some studies show that: ACT and CBT have similar effects Better results for ACT However; Still needed for more controlled studies with larger samples!

60.  Coherent results with the literature of experiential psychopathology  The review of correlational studies strongly support the ACT model Experiential avoidance as a mediator

61.  Some conclusions can be made out: Highly experiential avoidance participants responds differently to several experimental challenges Acceptance values based protocols are effective in improving the participants in the experimental challenges More effect has been found in ACT protocols than in control based ones

62. DISCUSSION  Although the RFT state of evidence was out of the scope of the current study, it is called to be most differential characteristic between ACT and other second and third wave therapies.

63. DISCUSSION  Although RFT definition of acceptance, values, and cognitive defusion is in its beginnings, it is the most important area of research that needs to be done in order ro improve ACT results..

64. DISCUSSION  For example, consider 2 specific issues: 1.To better know what are the specific transformations of functions involved in cognitive defusion and values clarification exercises would allow to redefine or invent new exercises that become more powerful

65. DISCUSSION 2. İf the therapist know the specific verbal processes in the transformation of functions through analogical relations, he/she becomes using more effective methapors in practice

66. CONCLUSION  ACT seems to have strong support in view of the correlational, the experimental psychopathology, and the outcome evidence  It is worth nothing that ACT is a therapy with very singular characteristic.

67. CONCLUSION  Also, it is a good model of psychopathology of EAD or psychological flexibility  ACT also have similarity with CBT or between other types of therapies.