DOING ACT RESEARCH: AN INTERACTIVE PRIMER FOR BEGINNERS

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. The Primary ACT Model of Treatment Psychological Flexibility

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. DefusionMasuda, 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 StudyMasuda, Hayes, Twohig, Cardinal, & Lillis (2009) BMod

25. AcceptanceLevitt, 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% CO2 challenge (panic provocation)

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

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

30. Mediation Analysis ACT Intervention Acceptance Depression

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

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

34. Control ACT Stigma (WSQ) F = 24.3, p<.001 η2= .23 60 50 40 Baseline 3 Month FU

35. Control ACT Quality of Life (ORWELL) F = 27.4, p<.001 η2= .25 60 45 30 Baseline 3 Month FU

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

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 TreatmentHayes, 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 Control Multicultural ACT

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

44. Racial PrejudiceLillis 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

46. Results

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

48. Effectiveness

49. The Effectiveness ProjectStrosahl 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. Treatment was Faster