Yvonne Barnes-Holmes & Dermot Barnes-Holmes

1. Understanding the Clinical Processes in ACT Yvonne Barnes-Holmes & Dermot Barnes-Holmes

2. Co-Authors • Ian Stewart • Louise McHugh • Kelly Wilson • Barbara Johnson • Brandy Fink • Andy Cochrane • Anne Kehoe • Hilary-Anne Healy • Claire Keogh • Jenny McMullen • Carmen Luciano • Francisco J. Molina Cobos • Olga Gutiérrez • Sonsoles Valdivia • Marisa Páez • Miguel Rodríguez • Francisco Cabello • Carmelo Visdómine • José Ortega • Francisco Montesinos • Mónica Hernández • Laura Sánchez

3. Introduction • There is no theory behind therapy, the former is a coherent set of theoretical constructs that hang together and make predictions, the latter is a coherent set of techniques that make a different set of predictions • Almost never in the history of psychology have they come together in a manner that was both theoretically consistent and technologically effective • ACT is no different, but as the field develops, there is growing reason to believe that there is considerable overlap between Relational Frame Theory (RFT) and ACT and that the former can make sound predictions about why the latter works, and to some extent about what the latter should look like

4. Overview • The current talk will review some of the predictions and empirical evidence that support processes and techniques identified in ACT • For the sake of simplicity, and in order to be consistent with the evidence, we will divide ACT into the following: • Acceptance vs. Avoidance • Acceptance vs. Cognitive Control • Values • Defusion

5. Acceptance vs. Avoidance

6. Acceptance vs. Avoidance • Our first place to start looking at ACT (Study 1) was to analyse the distinction between acceptance and avoidance – if this was not clear-cut, then the basic terminology might need to be reconsidered • ACT’s emphasis on the dichotomy between acceptance and avoidance and the development of the AAQ suggested that we might be able to functionally differentiate individuals in terms of their propensity towards acceptance or avoidance • We took 15 undergraduates who were low in acceptance (at least 1 SD below the mean on the AAQ) and 14 high in acceptance (at least 1 SD above the mean)

7. Acceptance vs. Avoidance • Participants were exposed to a simple automated task that required them to match nonsense syllables • During the task, however, matching on some trials resulted in the presentation of a horrible aversive image (e.g. mutilated bodies) for 6 seconds • Participants were required to rate each aversive picture • But, primarily we wanted to determine how long it took them to do the task when they had discriminated which type of picture would come next • Our prediction was that low accepters/high avoiders would take longer to complete tasks, which they had learned would be followed by an aversive picture • This, for us, was a type of avoidance

8. Median Reaction Times 3 • During the task, High Acceptance produced similar reaction times whether they expected to see either an aversive or a neutral image next, so anticipation or avoidance was limited • But, Low Acceptance exhibited significantly longer reaction times when they expected to see an aversive image (p = 0.015) 2.5 High Low 2 1.5 1 0.5 0 A N A N But could this be simply because the Low Acceptance Group perceived the neutral pictures to be more unpleasant and thus legitimtely more avoidable than the High Acceptance group?

9. Self-Report Ratings • No, because High Acceptance rated the aversive images as more unpleasant and more emotionally intense than Low Acceptance • But yet, Low Acceptance were less willing to look at either images than High Acceptance Pleasant Unpleasant Mild Intense Willing Unwilling

10. Discussion • So, the outcomes were consistent with ACT predictions regarding acceptance and avoidance and their dichotomy • Individuals low in acceptance/high in avoidance showed greater anticipatory avoidance of the negative pictures than those high in acceptance/low in avoidance • This avoidance was consistent with their own ratings of willingness to look at the pictures • Furthermore, this avoidance occurred even though these individuals rated the pictures as less unpleasant and less intense than the other group • The high acceptance groups, therefore, showed less avoidance and greater experiential willingness in the face of adversity – outcomes that are consistent with ACT predictions

11. ERP’s and Avoidance • Study 2 replicated Study 1, but incorporated Event Related Potentials (ERP’s) during the task with: • 6 High Acceptance • 6 Low Acceptance • 6 Mid-Range Acceptance • Once again, we predicted that level of avoidance would differentiate and we hoped it would be detected by the ERP’s

12. Median Reaction Times • Identical to Study 1, High and Mid Acceptance produced similar reaction times for both aversive and neutral images, showing no anticipation or avoidance • But, Low Acceptanceagain emitted longer reaction times when they expected to see an aversive, rather than a neutral, image (p = 0.0431) 3.5 3 2.5 2 Low 1.5 High Mid 1 0.5 0 A N A N A N

13. Mid Low High Pleasant Unpleasant Mild Intense Willing Unwilling Self-Report Ratings • Again, this was not because the pictures were less unpleasant, because theHigh and Mid Acceptance rated the aversive images as more unpleasant and emotionally intense than Low Acceptance • But,Low and Mid Acceptancewere less willing to look at the images

14. ERP’s Recordings • As expected, the ERP’s recordings discriminated between the two types of pictures, with the unpleasant pictures producing significantly more positive wave forms than the neutral pictures for all groups • And an interesting finding emerged with regard to the scalp locations . . .

15. Low Acceptance Area Dimensions (V • ms) High Acceptance

16. ERP’s Recordings • The fact that the Low Acceptance group showed greater negative activation for left hemisphere electrodescould suggest greater verbal activity for this group, which might indicate the use of verbal avoidance strategies (e.g. “This is not real, think of something else,” etc.)

17. Discussion • So again, the avoidance groups could be distinguished from one another on several predictable counts -- Low Acceptance showed greater anticipation of the aversive images than the others and were less willing to look at them -- and yet, they rated the pictures as less unpleasant • Some willingness distinctions even emerged between mid and high range accepters • The unwillingness and tolerance avoidance for Low Acceptance was associated with greater negative activation for left hemisphere electrodes, suggesting the activation of verbal areas • Again, the former outcomes are consistent with ACT’s emphasis on acceptance, avoidance and willingness and the ERP’s data were consistent with RFT’s emphasis on verbal behaviour

18. Acceptance vs. Cognitive Control

19. Acceptance • Up until the mid-90’s, CBT was still insistent that explicit attempts to control cognitive events directly would reduce their frequency and impact, and thus be associated with positive clinical outcomes • ACT has always offered a counter-approach because of its contextualistic underpinnings that argues that the only way to change verbal events is to change the context in which they occur and acceptance is the term we use to describe this broader target • In this regard, though not intentionally, ACT is more in line with Eastern traditions that emphasise acceptance/mindfulness • But Eastern traditions are not sciences and thus cannot be relied upon to provide scientific argument or evidence

20. Acceptance • Although in Eastern traditions and in ACT, we had reason to believe that acceptance was an active ingredient in positive clinical outcomes and psychological well-being generally, there was almost no empirical evidence to attest to this • Furthermore, positive empirical evidence for the impact of acceptance would to some extent undermine positivity for the main existing alternative that was cognitive control – which functionally may be seen as the opposite of acceptance • It should also be added that empirical evidence for cognitive control as an active ingredient in CBT is relatively scarce, in spite of its wide usage

21. Acceptance • So, thus far, we had some comfort in the terminology that suggested a dichotomy between acceptance and avoidance • But, acceptance as a clinical tool was something else • In our first empirical analysis of acceptance as a mechanism of change, we set out with a very simple aim -- to see if we could construct a short, but potent, acceptance intervention that would be functionally similar to what is presented in therapy, but which might just work in an experimental context • This was demonstration research of the simplest kind

22. Study 3 • During Study 3, ‘normal’ participants were simply presented with a computerised task in which they were asked to match a lot of neutral pictures and a small number of horrible aversive pictures (e.g. mutilated bodies) • The former pictures simply represented an experimental control, while the latter represented our core effort to provide participants with a clinical strategy they could use to deal with unpleasant psychological/visual content

23. Avoiding Negative Images • Because the matching was too simple to function as a dependent variable, we targeted participants’ willingness to look at the aversive pictures by: (1) giving them the option to avoid the pictures altogether before the trial and counting how many they looked at and (2) observing how long they would endure them on screen

24. Acceptance or Control • Participants were exposed to the baseline matching task, the intervention, and then the task again • Both interventions involved the presentation of a vignette in which participants were asked to --imagine that they had witnessed a horrific car accident in which they had to rescue the badly injured and bloodied victims from the car and to imagine that they found the sight of blood extremely aversive • They were then given a coping strategy/intervention to help them deal with the vignette (and to influence their subsequent performances on the negative pictures)

25. Acceptance vs. Control • Participants in CognitiveControlwere instructed to try to control their emotional reactions and to avoid feelings of discomfort (e.g. by imaging that the blood was just like tomato ketchup) • Participants in Acceptance were instructed to fully embrace their feelings of discomfort (i.e. to fully accept that trying to save the bloodied and mutilated victims would be the most horrific experience of their lives)

26. Experimenter Influence • Experimenter influence were also manipulated by altering the instructions and the extent to which the experimenter monitored the matching performances • DuringtheNo Instruction/No Monitoringconditions, participants were informed that it did not matter whether they looked at the negative pictures (i.e. no instruction) and the experimenter sat approximately 30 feet away and pretended to read a book (no monitoring) • During theInstruction/Monitoringconditions, participants were told that it wasvery important to look at the negative pictures (instruction) and the experimenter walked around actively monitoring performances (monitoring)

27. Results • The results of the study failed to differentiate between the two groups on the number of aversives observed • However, they did differ in their mean response latencies while the aversives were on the screen (i.e. aversive tolerance time)

28. 2200 2000 1800 Tolerance Time in ms. 1600 1400 1200 1000 Baseline Post-Intervention Mean Response Times: Neutral Pictures On the neutral pictures, there were no changes at all between Baseline and Post-intervention, as expected

29. Accept/Instruct 2200 2000 Accept/No Instruct 1800 1600 Control/No Instruct 1400 Control/Instruct 1200 Baseline Post-Intervention 1000 Mean Response Times: Aversive Pictures • But, on the aversive pictures, Acceptance and Control differed significantly when combined with Instruction/Monitoring (p = 0.002) • Strategy and Experimenter Influence interacted significantly

30. Discussion • The Acceptance strategy increased participants’ tolerance time in the presence of the aversive pictures (when combined with active experimenter influence) • Control did not and decreased tolerance in both cases • While both strategy outcomes appeared to be influenced by the social context, further analyses indicated that this primarily affected the extent to which participants applied the strategies, rather than affecting the strategies directly (i.e. the strategies were applied more when the experimenter attended) • This was our first empirical evidence that acceptance could be delivered as a brief therapeutic intervention in an experimental context and was associated with positive outcomes • Cognitive control was in fact counter-productive in terms of altering aversive tolerance when the images were present

31. Acceptance vs. Control with Pain • In Study 4, we were concerned that the data so far would not generalise to physical pain and the psychological content associated with that – perhaps different outcomes would emerge relative to coping with aversive visual imagery • So, we exposed participants to systematic electric shocks • This was based on a previous study by Gutierrez, Luciano, Rodriguez,and Fink who compared acceptance and control as coping interventions with electric shock with 40 undergraduates • They reported that Acceptance not only increased shock tolerance, but also reduced participants’ believability of their own subjective pain ratings

32. Our Study • Although the original study was entirely consistent with our own findings thus far, there was increasing concern within the community about experimental precision – but this was hard to offset against external validity • So in Study 4, we tried to come up with a format that was fully automated (hence experimentally ‘clean’), but that would still allow the interventions to be impactful • We did some refinement of the Acceptance and Control exercises and metaphors to remove possible confounds • And we began to look at values as an active addition to acceptance

33. Design • 40 ‘normal’ participants were assigned to four conditions

34. Play Video 1 Play Video 2 Play Video 3 Play Video 4 Play Video 5 Play Video 6 Play Video 7 Play Video 8 Delivery • The entire procedure was automated through a program containing a series of video clips • Participants progressed through the clips at their own pace, individually and alone • Clips were rated first by independent observers, for consistency, adherence and empathy and were found to not differ in any capacity

35. Delivery

36. Acceptance: High/Low Values A Participantswere provided with metaphors and experiential exercises indicating that the best way to deal with pain related thoughts and feelings was to accept them in the context of whatever action is being taken HV Participantswere asked to imagine that they suffered from chronic pain and that the task involving shock was one which they must do in order to support their family LVParticipantswere told that the aim of the experiment was to contribute to research on the relation between voltage level and perception of shock

37. Control: High/Low Values CParticipants were given metaphors and experiential exercises designed to teach them that the best way to deal with pain related thoughts and feelings was to distract themselves by imagining pleasant images HV Participantswere asked to imagine that they suffer from chronic pain and that the task involving shock was one which they must do in order to support their family LVParticipantswere told that the aim of the experiment was to contribute to research on the relation between voltage level and perception of shock

38. 15 12 9 Acceptance No. of Shocks Taken Control 6 3 0 Pre-Intervention Post-Intervention Shock Tolerance Data • The Acceptance participants significantly increased their shock tolerance from pre- to post-intervention • Control produced no change

39. High Value Low Value High Pain 100 90 80 70 60 50 40 Pre-Intervention Post-Intervention Self-Report Data Low Pain • There was an interesting effect for values – although there was no significant main effect, High Values participants rated the pain as greater across time, whereas Low Values rated it as less

40. Tolerating High Pain • We wanted to check whether some of the effects were driven by people who had different perceptions of how much pain they were in -- so we examined only those reporting great pain more closely • 100% of participants in Acceptance who reported greater experienced pain Post-Intervention showed an increase in tolerance levels, compared to only 50% of the same sub-set of Control (significant: p = 0.0455) • We also analysed the number of trials for which participants continued in the Post-Intervention task after reporting high levels of pain (>= 80) and found that the median number of trials for Acceptance was 4, compared to 2 for Control (significant: p = 0.0069)

41. Discussion • So as an intervention, Acceptance worked better than Control in the context of experimentally physical pain in the form of electric shock • Changes in tolerance were particularly strong for participants experiencing a lot of pain and using Acceptance • The effects were the same as those reported by other researchers even in a highly structured automated experimental environment • While the Values manipulation did not have a significant effect on shock tolerance, it did affect self-reports of pain, in thatparticipants in High Values reported more pain subsequent to the intervention (perhaps the values component oriented them more towards their pain, but not in an avoidant way)

42. Study 5: Simple Rules • One issue that had been emerging across experiments was the possibility that participants were not really engaging with the various features of the interventions (i.e. the exercises and metaphors), but that they were simply generating or following simple rules • So, in Study 5, we compared the full Acceptance and Control interventions used before, but added two new interventions that simply comprised of anAcceptance Rule and a Control Rule-- a brief and simple rule for accepting or distracting • In this study, we alsoemployed a Placebo Condition

43. Experimental Conditions

44. Acceptance Distraction Placebo Rule Acceptance Rule Distraction Self-Delivered Shocks 10 9 8 (p < .002) 7 6 5 4 (p < .03) 3 2 1 0 Pre-Intervention Post-Intervention Tolerance Data • Only Full Acceptanceincreased tolerance significantly from Pre- to Post-Intervention, but none of the other four • Distraction-Rule actually decreased tolerance significantly

45. Percentage of Participants More Pain & More Shocks • Again, we looked at those participants who reported more pain and still took more shocks and found that these were mostly in the Acceptance Conditions

46. Discussion • So, the positive acceptance outcomes thus far could not be explained in terms of simple rule following – the metaphors and exercises were essential • When these were absent, the moderate improvement in pain tolerance for an acceptance rule was non-significant • Although Distraction effects are again negligible • Distraction actually makes you worse when it comes in the form of a simple rule

47. The next study (Study 6) was also concerned acceptance, but attempted to broaden the generality of the work by employing a new type of pain induction, that might circumvent criticisms that electric shock is not a good analogue of clinical pain So, three groups of participants were assigned to: Acceptance Control Placebo And were exposed to the radiant heat pad in a fully automated procedure Different Pain Same Outcome

48. Heat Apparatus

49. Results • At baseline, the groups did not differ on a series of psychological measures • And the amount of heat tolerance was tightly controlled

50. 9 HeatTimeTolerance (Seconds) 8 7 6 5 4 3 Acceptance P = .005 Control 2 Placebo 1 0 Baseline Post-Intervention Reminder Tolerance Data • Both Acceptance and Control increased pain tolerance, but only Acceptance was significant