DOING ACT RESEARCH: AN INTERACTIVE PRIMER FOR

BEGINNERS

Jason Lillis, Ph.D.University of Nevada, Reno

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

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

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

Creating an Agenda

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

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

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

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

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

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

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

The Primary ACT Model of The Primary ACT Model of PsychopathologyPsychopathology

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

Psychological

Flexibility

The Primary ACT Model of TreatmentThe Primary ACT Model of Treatment

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

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

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

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

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

Highlight Differences

Components Mediation emphasis Scope Creation/ use of measures Early effectiveness/ training

Components

Small scale, focused Few resources needed, lab-based Allows isolation of process Test whether techniques or components

are “active” Test parameters

Defusion Masuda, 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

Defusion Reduces Distress and Believability

1

.6

.2

1 .4

1 .8

1 2 3 4 5 6

P e r io d s

Participan t 7

Stan

dard

ized

Lev

el o

f D

isco

mfo

rt

1

.6

.2

1 .4

1 .8

D efus ion

1 2 3 4 5 6

P e r io d s

Participan t 7

Stan

dard

ized

Lev

el o

f B

elie

vabi

lity

D isc o m fo rt B e liev ab ility

D efus ion

T hough t C on tro l

T hough t C on tro l

Cohen’s d = 1.98

(distract) and 2.63 (control)

Follow-up StudyMasuda, Hayes, Twohig, Cardinal, & Lillis (2009) BMod

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)

Anxiety During the Challenge

Accept Suppress Control

0

1

2

3

4

Cohen’s d at post = .5

(suppress) and .45 (control)

Willingness to do it Again

Accept Suppress Control

0

1

2

3

4

Cohen’s d at post = .67

(suppress) and .81 (control)

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

Mediation Analysis

Treatment Conditions

OutcomeMediator

Mediation Analysis

ACT Intervention

DepressionAcceptance

Mediation Analysis

ACT Treatment

Depression

Acceptancea b

c

c’

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)

Weight Status at Follow-up

% gaining 5+ lbs

% losing 5+ lbs

35

25

15105

0

x² = 8.8, p<.003

d = 1.2130

20

AC

T

Con

trol

Stigma (WSQ)

Baseline 3 Month FU

60

40

50

AC

T

Con

trol

F = 24.3, p<.001

η2 = .23

Quality of Life (ORWELL)

Baseline 3 Month FU

60

30

45

AC

T

Con

trol

F = 27.4, p<.001

η2 = .25

Mediation Analysis: Weight Control

Treatment Conditions

BMI change

Experiential Avoidance

r = .34

p = .002

r = .54

p = .0001

r = .44

p = .0027

r = .11

p = .242

c

c’

a b

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

Areas with mediation evidence Treatment Outcome Studies Depression, OCD, Worksite Stress Rehospitalization (SMI) x2 Weight Loss, Smoking Cessation,

Diabetes Management, Epilepsy, Chronic Pain?

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%?

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?

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

Effects on Stigma

Presence of Stigmatizing Attitudes

35

40

45

50

55

60

Pre Post Follow -up

ACT

Multicultural

Control

Change in BurnoutACT

Pre-

Post

Pre-

F-up

MulticulturalEducation

4

0

-4Pre-

Post

Pre-

F-up

Pre-

Post

Pre-

F-up

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

Results

Education

-25

-15

-5

5

15

25

35

45

Pre Post Follow-Up

Bias Awareness

Bias Does not Aff ect Me

Acceptance

Defusion and Action

Positive Action

Results

ACT

-15

-5

5

15

25

35

45

Pre Post Follow-UpCh

ang

e in

Sca

le S

core

(1-

100)

Bias Awareness

Bias Does not Affect Me

Acceptance

Defusion and Action

Positive Action

Other areas: Limit testing

Psychosis, Epilepsy, Adjustment to College

Effectiveness

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

04/22/23

Treatment was Faster

Treatment was Cheaper

No Training

Treatment was Better

Other Important Issues

ACT targets Counterintuitive findings Incubation effects ACT measures Single case

ACT Outcome Targets

ACT model suggests that mindfulness, acceptance, defusion, self, values, and behavioral commitment is psychological flexibility = positive life functioning

Nowhere in the model is symptom reduction Nowhere in the model is syndrome amelioration This has lead to problems with acceptability and

validation in the main stream What is more convincing to you? Ultimately, me must play both games

ACT Targets

Functional improvement Sick days (chronic pain), job performance,

diabetic control, use of ESTs, health care utilization

Quality of Life Successful, vital living- consistent with values

Not “happy”, but targeting ACT processes does improve traditional targets as well Depression (BDI, Hamilton), OCD, GHQ (Psyc

distress)

Exercise

Start shaping your own idea Pairs/ Groups Pick an interesting question Goals of your study (to learn?) Identify a population Pick a setting Design a methodology Issues of practicality Consultation

Counterintuitive Findings

Related to issue of targets ACT not targeting symptoms, in fact

targeting more mindful awareness of thoughts and feelings, flexibility in relating to thoughts and feelings, and behavior tied to values

Sometimes leads to model consistent, but a-typical findings

Adopting ESTsVarra, Hayes, Roget, & Fisher, 2008, JCCP

59 drug and alcohol counselors randomly assigned to One day ACT workshop focused on defusing from the

psychological barriers to learning new treatment approaches, and acceptance of the emotions they bring up

Control condition: One day workshop on matters not linked to empirically supported treatments (EAP policies; etc)

Both groups then do a one day educational workshop (the following day) on empirically supported treatments in the drug and alcohol area focusing particularly on the use of agonists and antagonists

Frequency of Perceived Barriers to Using Empirically Supported Treatments

Pre Post

75M

ean

Sco

re

Phase

70

ACT plus ACT plus EducationEducation

Control Control plus plus

EducationEducation65

ACT group acknowledges the presence of significantly more barriers to using these treatments

p < .05

Believability of Perceived Barriers to Using Empirically Supported Treatments

Pre Post

70M

ean

Sco

re

Phase

65

ACT plus ACT plus EducationEducation

Control Control plus plus

EducationEducation

60

ACT group is significantly less likely to believe that these barriers are real

p < .05

Willingness to Use Pharmacotherapy

Pre Post

3.5

3.25

2.25

Mea

n S

core

on

1-5

Sca

le

Phase

3

2.75

2.5

ACT plus ACT plus EducationEducation

Control Control plus plus

EducationEducation2

ACT group reports being significantly more willing actually to use empirically supported treatments (pharmacotherapy score is shown)

p < .01

Subsequent Use of Pharmacotherapy

Three months later ACT group reports a large increase in actually using pharmacotherapy more frequently.

p < .001

Pre 3 month Follow - up

3.5

3.25

2.25

Phase

3

2.75

2.5

ACT plus ACT plus EducationEducation

Control Control plus plus

EducationEducation

2

Coping with Psychotic Symptoms Coping with Psychotic Symptoms Bach & Hayes, JCCP, 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

Impact on Rehospitalization

ACTACT

.6

.7

.8

.9

1.0

40 80 120

Days After Initial Release

Treatment as UsualTreatment as Usual

Pro

port

ion

Not

Hos

pita

lize

d

Processes of Change: Symptoms

Pre F-up

100

75

25

ControlControl

ACTACT

50

Per

cent

age

Rep

orti

ng

Sym

ptom

s

Phase

Processes of Change:Symptom Reporting and Acceptance

50%

40%

30%

20%

10%Reh

ospi

taliz

atio

n R

ate ACT TAU

Ad

mit

De

ny

Ad

mit

De

ny

Findings Summary

ACT is targeting changing one’s relationship to thoughts and feelings, in particular the willingness to experience them in the service of valued ends

Thus, participants may acknowledge more symptoms, or more barriers, but the impact on behavior is much less

This kind of finding is very cool as it is consistent with the ACT model

But keep in mind what would be predicted by the model when designing study and analyzing data

Incubation

Sometimes ACT effects are not seen at post

Severe Substance AbuseHayes, Wilson, et al, 2004

124 polysubstance abusers 3 conditions

ACT + Methadone ITSF + Methadone Methadone only

ACT + ITSF 16 weeks/ 3 sessions per week Methadone + counseling

Post 6 Mo Follow Up

Per

cent

age

Neg

ativ

e Q

As

Phase

45

55

35

25

ACTACT

MMMM

ITSFITSF

55

Objectively Assessed Opiates

Pre

Post 6 Mo Follow Up

Per

cent

age

Neg

ativ

e Q

As

Phase

45

55

35

25

ACTACT

MMMMITSFITSF

Pre

Total Drug

15

Smoking CessationGifford et al, 2004, BT

Nicotine Replacement Therapy Initial education meeting Weekly contact for assessment

Acceptance and Commitment Therapy Weekly and group meeting 10 Weeks

Outcomes

Post 1Yr Follow Up

55

45

5

Per

cent

age

Not

Sm

okin

g

Phase

35

25

15

ACTACTCompletersCompleters

AllAll

NRTNRT

AllAll

CompletersCompleters

Incubation Summary

What seems to happen: ACT lays seeds of acceptance, defusion, willingness, values and over time natural contingencies take over and patterns of behavior become larger

Post treatment is a muddy picture for outcomes

Process data is key

ACT Measures

Acceptance and Action Questionnaire (AAQ) Most widely used Experiential avoidance/ psychological

flexibility

Origin of the AAQ

Although the AAQ is often said to be a measure of experiential avoidance, the original item pool focused on all major ACT processes

These 9-16 items (depending on the version) cover a wide range of issues, including acceptance, defusion, and action

There are now 30+ studies using the AAQ, involving 6000+ participants

04/22/23

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

ALMOST ALMOST EVERYTHINGEVERYTHING

Quantitative Summary

All reported correlations are positive for the model BDI (8 studies) .50 SCL 90 (3 studies) .53 BAI or STAI (3 studies): .49 GHQ (3 studies): .40 Overall effect size .42

(CI: 0.40– 0.44) Hasn’t been updated in a few years

AAQ-II

ACT Measures- Specific AAQs Specific Measures adapted and used

successfully AAQD- Diabetes AAQW- Weight AAEpQ- Epilepsy BI-AAQ- Body Image CPAQ- Chronic Pain AIS- Smoking TAQ- Tinnitus VAAS- Auditory Hallucinations

AAQD- Diabetes

Other ACT Process Measures Bulls Eye (Values) PVQ (Personal Values Questionnaire) ATQ-B (Automatic Thoughts-Believability:

Fusion) CFQ (Cognitive Fusion Questionnaire) FFMQ (Five Facets Mindfulness) PMS (Philadelphia Mindfulness) AAQ measures covers acceptance, or

acceptance and defusion, or psyc flexibility

ATQ-B

Bull’s Eye

Far from

In the vicinity

Close

Bullseye

Very close

Other ACT Process Measures Also child measures Thought suppression Internalized shame Coping measures http://contextualpsychology.org/act-

specific_measures

Brief Idiographic Measures

E.g. Masuda study on defusion Distressing thought- turned into one

word Distress and Believability scales 100 millimeters, mark from low to high |------------------------------------------------|

Single Case

4 OCD patients 8 sessions of ACT w/o exposure

Obsessive Compulsive DisorderObsessive Compulsive Disorder Twohig, Masuda, & Hayes, Behavior Therapy, 2006

Days

P 2 - Hoarding

P 1 - Checking

Com

puls

ions

per

day

P 3 - Cleaning

P 4 - Checking

3 Mo FU

Summary

Pick something you care about Know CBS principles Start small, use resources (website!) Kinds of studies:

Correlational Component Measures Outcomes Mediation

Effectiveness Training Single Case Multiple baseline Limit testers

Consultation

Ideas? What can we help help with? ACT specific or broad design issues

The End

Mediation

A good way to test the significance of the difference between c and c’ is the Sobel test

The Sobel test looks at the significance of the cross-product of the a and b regression coefficients

In general a*b = c – c’ so a significant Sobel = significant mediation

Mediation

A less sophisticated way is to infer mediation from causal steps, especially that

there is a significant treatment effect on outcome treatment influences the mediator The mediator is related to outcome controlling for

treatment and treatment does not impact outcome

significantly if variability due to the indirect path is extracted

Racial PrejudiceLillis et al

Replicated with racial bias in a college student population

Within subject test (A/B/A/C/A) comparing racial bias education and ACT

16 participants in a racial differences class 90 minute class period 1 week follow up

Assessment Items

Bias Awareness I feel that I am aware of my own biases

Bias Does Not Affect Me I feel that my prejudicial thoughts are a significant

barrier to me being culturally sensitive My biases and prejudices affect how I interact with

people from different racial and ethnic backgrounds.

Assessment Items Acceptance

It is OK to have prejudiced thoughts or racial stereotypes

I try not to think negative thoughts I have about people from different racial or ethnic backgrounds.

Defusion and Action When I evaluate someone negatively, I am able to

recognize that this is just a reaction, not an objective fact.

It’s ok to have friends that I have prejudicial thoughts about from time to time.

Assessment Items

Positive Action I would attend a social event where I was the only

person of my race/ ethnic background. I believe that I am able to transcend racial boundaries

with my actions. I plan to actively seek out experiences that could expose

me to people who have a different cultural, racial, or ethnic background than me.

I am likely to join a campus organization or participate in a campus event that is focused on cultural diversity.

MODEL

MODEL

Correlation Longitudinal

Component Studies

Measure Development

Outcomes & Mediation

Effectiveness Training

Dissemination

Limit Testing Transdiagnostic