Acceptance & Commitment Therapy (ACT): Empirical Investigations

1. Acceptance & Commitment Therapy (ACT): Empirical Investigations Ian Stewart

2. INTRODUCTION • Q. What is Acceptance Commitment Therapy? • A. A form of psychotherapy that claims that experiential avoidance is a centrally important feature of many forms of psychopathology

3. ACT derives from the philosophy of functional contextualism…and contemporary behavior analysis (Hayes & Wilson, 1993). ACT argues that humans are unique to the degree they substitute cognitions for direct experience (cognitive fusion) and work to avoid negatively evaluated private experiences despite significant costs of doing so (experiential avoidance). From an ACT perspective, many forms of psychopathology can be conceptualized as (a) unhealthy attempts to control emotions, thoughts, memories and other private experiences…(b) unhealthy examples of the domination of cognitively based functions over those based in actual experience and (c) a lack of clarity about core values and the ability to behave in accordance with them. The general goal of ACT is to diminish the role of literal thought (cognitive defusion), and to encourage a client to contact psychological experience - directly, fully and without needless defense (psychological acceptance) - while at the same time behaving consistently with one’s chosen values. Hayes, Masuda, Bissett, Luoma, Guerrero (2004)

4. Many traditional forms of psychotherapy employ strategies that focus on controlling negative thoughts and feelings, but ACT based researchers and others have argued against this generic approach (Friman, Hayes, & Wilson, 1998) • Results from a number of studies now suggest that these methods of cognitive and/or emotional control may often be ineffective or even counterproductive (e.g., Hayes, Bissett, Korn, Zettle, Rosenfarb, Cooper, & Grundt, 1999)

5. Gutierrez, Luciano, Rodriguez & Fink (In press) • This study compared an acceptance based intervention with a cognitive-control-based intervention for coping with experimentally induced pain • 40 participants were randomly assigned to an acceptance based protocol (ACT), the goal of which was to disconnect pain-related thoughts and feelings from literal actions, or to a control-based protocol (CONT) that focused on changing or controlling pain-related thoughts and feelings • Ps took part in a nonsense-syllables-matching task that involved successive exposures to increasingly painful shocks

6. Gutierrez, Luciano, Rodriguez & Fink (In press) • In both conditions, the task involved an overall value-oriented context that encouraged participants to continue with the task despite pain • At times throughout the task, participants were asked to continue with the task and be shocked or stop and avoid shock; each choice had specific costs and benefits • Participants performed the task twice, both before and after receiving the assigned experimental protocol

7. Gutierrez, Luciano, Rodriguez & Fink (In press) • Two measures were obtained at pre- and post-intervention • Tolerance of shocks • Self-reports of pain • ACT ps. showed significantly higher tolerance to pain and lower believability of experienced pain compared to the CONT condition

8. Johnson et al. (under submission) • Aimed to replicate and extend the Gutierrez et al research • Automated delivery of ACT and CONT intervention • Direct manipulation of the values-oriented context • Refining of the ACT and CONT exercises and metaphors to remove possible confounds

9. Method • 40 ps. balanced for gender across 4 conditions • The design was a 2X2X2 mixed factorial design PRE - INTERVENTION POST - INTERVENTION HI V ACT LO V HI V CONT LO V

10. Schematic of Experiment Pre-Experimental Stage Calibrate Pain Threshold Pre-Intervention Task Intervention Post-Intervention Task Adherence Measures Debriefing

11. Pre-Experimental Stage • Before the start of the experiment, participants were provided with general instructions • They were then required to • (1) Sign a consent form • (2) Complete a medical screening form • (3) Complete 2 self-report questionnaires: • Acceptance and Action Questionnaire [AAQ] (Feldner, Zvolensky, Eifert, & Spira, 2002) • Valued Living Questionnaire [VLQ] (Wilson, 2002)

12. Pain Calibration Click here to end experiment Click here to continue 1 (No pain) 100 (Pain as bad As it could be) Click here when you have entered your pain rating Click here to continue

13. Click here to receive a shock and continue Click here to end 1 1 (No pain) 100 (Pain as bad As it could be) Click here when you have entered your pain rating 1 5 8 Pre-Intervention Task Score 1 Click here to continue

14. Click here to receive a shock and continue Score 1 Click here to end 1 1 5 8 Post-Intervention Task

15. Click here to receive a shock and continue Click here to end Post-Intervention Task

16. Intervention Play Video 1 Play Video 2 Play Video 3 Play Video 4 Play Video 5 Play Video 6 Play Video 7 Play Video 8

17. Intervention Play Video 1 Play Video 2 Play Video 3 Play Video 4 Play Video 5 Play Video 6 Play Video 7 Play Video 8 1: Acceptance / High Values A Ps. are given metaphors and experiential exercises designed to teach them that the best way to deal with pain related thoughts and feelings is to accept them in the context of whatever action is being taken HV Ps. are asked to imagine that they suffer from chronic pain and that the task involving shock is one which they must do in order to support their family

18. Intervention Play Video 1 Play Video 2 Play Video 3 Play Video 4 Play Video 5 Play Video 6 Play Video 7 Play Video 8 2: Acceptance / Low Values A Ps. are given metaphors and experiential exercises designed to teach them that the best way to deal with pain related thoughts and feelings is to accept them in the context of whatever action is being taken LV Ps. are told that the aim of the experiment is to contribute to research on the relation between voltage level and perception of shock

19. Intervention Play Video 1 Play Video 2 Play Video 3 Play Video 4 Play Video 5 Play Video 6 Play Video 7 Play Video 8 3: Control / High Values C Ps. are given metaphors and experiential exercises designed to teach them that the best way to deal with pain related thoughts and feelings is to distract themselves from them by imagining pleasant images HV Ps. are asked to imagine that they suffer from chronic pain and that the task involving shock is one which they must do in order to support their family

20. Intervention Play Video 1 Play Video 2 Play Video 3 Play Video 4 Play Video 5 Play Video 6 Play Video 7 Play Video 8 4: Control / Low Values C Ps. are given metaphors and experiential exercises designed to teach them that the best way to deal with pain related thoughts and feelings is to distract themselves from them by imagining pleasant images LV Ps. are told that the aim of the experiment is to contribute to research on the relation between voltage level and perception of shock

21. Adherence Measures • Measures of whether the participant adhered to the particular intervention delivered included the following • During the video intervention stage, subjects were required, after the playing of each video, to describe briefly and in their own words what it was they had been told and what they were required to do • After the pain tasks were over, ps. were asked to describe what they thought they had had been required to do during the post-intervention task, what they had done in order to do it, and whether they thought it had been successful

22. Debriefing • When the experiment finished, participants were provided with a debriefing sheet which thoroughly described the nature of the experiment in general as well as the purpose of each of the experimental manipulations

23. RESULTS: Outline • Pre-check • Analyses • Shock Tolerance • Self-Reports • Pain Believability

24. RESULTS: Pre-check • ANOVAs revealed that the conditions did not differ significantly in terms of • Age • Pre-Intervention shock tolerance • Pre-Intervention self reports of pain • AAQ scores • VLQ scores • All variables on which ANOVAs were conducted met the assumption of homescedasticity (as per the Levene test)

25. RESULTS: Shock Tolerance Increase No Change Decrease ACT / Hi V 9 1 0 ACT / Lo V 9 0 1 CONT / Hi V 4 3 3 CONT / Lo V 4 2 4

26. RESULTS: Shock Tolerance • A 3-way mixed ANOVA with (i) ACT/CONT and (ii) Hi/Lo Values as Between-Ss variables, and (iii) Pre-/Post Intervention as the Within-Ss variable revealed • A significant main effect for Pre-/Post- Intervention (F(1, 36) = 13.785, p = 0.0007) • A significant interaction effect between Pre-/Post-Intervention and ACT/CONT (F(1, 36) = 10.628, p = 0.0024)

27. RESULTS: Shock Tolerance • To investigate the interaction between Pre-/Post Intervention and ACT/CONT, we grouped the two Acceptance conditions together and the two Control conditions together and conducted a paired t-test • This revealed a highly significant difference (t(19) = -4.529, p = 0.0002) for the Acceptance condition with no difference for the Control condition (t(19) = -.374, p =0.7125)

28. RESULTS: Shock Tolerance

29. RESULTS: Self-Reports

30. RESULTS: Self-Reports • A 3-way mixed ANOVA with (i) ACT/CONT and (ii) Hi/Lo Values as Between-Ss variables and (iii) Pre-/Post Intervention as the Within-Ss variable revealed • A significant interaction effect between Pre-/Post Intervention and Hi/Lo Values (F(1, 33) = 9.621, p = 0.0039)

31. RESULTS: Self-Reports • To investigate the interaction between Pre-/Post Intervention and Hi/Lo Values, we grouped the two Hi Value conditions together and the two Low Value conditions together and conducted a paired t-test • This revealed a significant difference (t(18) = -2.621, p = 0.0173) for the Hi Value condition with no difference for the Lo Value condition (t(17) = 1.822, p =0.0861)

32. RESULTS: Self-Reports

33. RESULTS: Pain Believability • Two analyses were conducted to explore the relationship between both measures of pain (shock tolerance and self-reports), which was used as a behavioural measure of the believability of pain, or in other words, the degree to which ps. considered experienced pain to be a barrier to continuing the pain task

34. RESULTS: Pain Believability • Analysis 1: Change in tolerance levels of ps. who reported an increase in experienced pain during the Post-Intervention task • In the Acceptance conditions, 100% of such ps. showed an increase in tolerance levels • In the Control conditions, only 50% of such ps. showed an increase in tolerance levels • A Chi-Square analysis showed this difference between Acceptance and Control to be significant (c2 (1, N=12) = 4, p = 0.0455)

35. RESULTS: Pain Believability • Analysis 2: Number of trials for which ps. continued the Post-Intervention task after reporting high levels of pain (>= 80) • Across the two Acceptance conditions, the median number of trials was 4, while across the two Control conditions, the median was 2 • A Mann Whitney U-test showed the difference between conditions to be significant (U=16, df = 20, p = 0.0069)

36. DISCUSSION • The current findings suggest that the acceptance but not the control strategy increased the participants’ tolerance for pain • This finding supports previous work using a highly controlled and precise experimental procedure in which experimenter cuing and other artifacts could not play a significant role • The values manipulation did not have a significant effect on shock tolerance, though it did have on self-reports of pain; those in the ‘Hi-Value’ conditions reported more pain subsequent to the intervention

37. DISCUSSION • This result may be a function of valuing something highly; the more one values something the greater the associated emotional affect and perhaps greater affect increases perception of pain • An alternative explanation might be that the Hi-Values manipulation was perceived by participants as being somewhat coercive or manipulative, which produced negative affect (e.g., Pretty & Seligman, 1984), thus again increasing perception of pain • In any case, further research is needed to explicate more fully the relationship between acceptance and values in coping with pain

38. Cochrane, Barnes-Holmes, Barnes-Holmes, Stewart, Luciano & Wilson (under submission) • This study examined acceptance and avoidance of negative and neutral imagery using a variety of empirical measures including reaction times, accuracy and events related potentials

39. Method • A short version of the Acceptance and Action Questionnaire (AAQ-2, Hayes et al., 2002) was administered to 144 undergraduate students to identify those predisposed to acceptance or avoidance • 15 participants low in acceptance (scoring at least 1 SD below the mean on the AAQ) and 14 that were high in acceptance (at least 1 SD above the mean) were exposed to a match-to-sample procedure in which arbitrary stimuli were paired with either aversive (e.g., mutilations, violence etc.) or neutral (e.g., neutral faces, household objects etc.) visual images from the International Affective Picture System (IAPs)

40. The Task (1) A1 WRONG CORRECT B1 B2 Aversive Image Presented for 6 secs Aversive Image Presented for 6 secs 1 Pleasant 100 Unpleasant Plus Two Other Sliding Scales: 2. Emotional Intensity 3. Willingness to Look

41. The Task (2) A1 WRONG CORRECT B1 B2 Neutral Image Presented for 6 secs Neutral Image Presented for 6 secs 1 Pleasant 100 Unpleasant Plus Two Other Sliding Scales: 2. Emotional Intensity 3. Willingness to Look

42. Experiment 1: Results • Both groups demonstrated similar correct response rates in the match to sample task • However, whereas the high acceptance group produced similar reaction times whether they expected to see either an aversive or a neutral image, the low acceptance group exhibited significantly longer reaction times when they expected to see an aversive rather than a neutral image (z = -2.432, p = 0.015) Median Reaction Times Taken by Both Groups to select Aversive and Neutral Images

43. Experiment 1:Results • The participants rated the images viewed using 3 bi-polar scales for: (a) pleasantness (b) emotional intensity (c) willingness to look • The high acceptance group rated the aversive images as more unpleasant and emotionally intense than the low acceptance Group. But the low group were less willing to look at either the aversive or neutral images than the participants in the high acceptance group Pleasant Unpleasant Mild Intense Willing Unwilling Mean Ratings for Aversive Images on the 3 Scales

44. Experiment 2 • Replicated Experiment 1 with an additional measure to assess psycho-physiological response to the visual stimuli • Although event related potentials (ERPs) have not traditionally been used to examine emotion, Cuthbert et al. (2000) demonstrated that ERPs could reliably discriminate responses to aversive versus neutral stimuli • Event related potentials (ERPS) recorded during the task (n = 18): • 6 High Acceptance • 6 Low Acceptance • 6 Mid-Range

46. Experiment 2: Results • Findings of Experiment 1 replicated • Similar correct response rates in the match to sample task • Both the high and mid acceptance group produced similar reaction times for both aversive or neutral images • Only the low acceptance group exhibited significantly longer reaction times when they expected to see an aversive rather than a neutral image (z = -2.023, p = 0.0431) Median Response Times Taken by Each Group to Select Aversive and Neutral Images

47. Experiment 2: Results Mid • Both the high and mid acceptance groups rated the aversive images as more unpleasant and emotionally intense than the low acceptance group • Whereas the low and mid groups were less willing to look at either the aversive or neutral images than the participants in the high acceptance group Low High Pleasant Unpleasant Mild Intense Mean Ratings for Aversive Images on the 3 Scales Willing Unwilling

48. Experiment 2: Results Aversive Images Neutral Images

49. Experiment 2: Results Aversive Images Neutral Images

50. Experiment 2: Results • Area dimensions (V • ms) were analysed with a 4-way 2x2x3x3 Mixed ANOVA: • Between (AAQ Level: High/Mid versus Low Acceptance) • Within (Picture Content: Aversive versus Neutral Pictures) • Within (Laterality: Left, Middle, Right). • Within (Position: Frontal, Central, Parietal) • Main effects for • Picture Content (F(1, 7) = 53.837, p = .0002, partial eta squared = 0.9) • Laterality (F(2, 14) = 8.247, p = .0043, partial eta squared = 0.54) • A 3-way interaction was identified for • AAQ * Content * Position (F(4, 28) = 3.950, p = .0115, partial eta squared = 0.36) • Thus two separate repeated measures ANOVAs were conducted for each AAQ group