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Mechanisms of Change in Acceptance-Based Mechanisms of Change in Acceptance-Based InterventionsInterventions
Chair: Evan M. Forman, Drexel UniversityChair: Evan M. Forman, Drexel UniversityDiscussant: Steven C. Hayes, University of Nevada, RenoDiscussant: Steven C. Hayes, University of Nevada, Reno
Mindfulness and Behavior Change Processes in Acceptance and Mindfulness and Behavior Change Processes in Acceptance and Commitment TherapyCommitment Therapy
Akihiko Masuda & Steven C. Hayes, University of Nevada, RenoAkihiko Masuda & Steven C. Hayes, University of Nevada, Reno
The Relationship of Three Self-report Measures of Mindfulness to The Relationship of Three Self-report Measures of Mindfulness to Each Other and to Measures of Emotion, Cognition, and Each Other and to Measures of Emotion, Cognition, and
PsychopathologyPsychopathologyEmily A. Haigh, Shane A. Mares, Candace Croft, Michael T. Moore, & David M. Fresco, Emily A. Haigh, Shane A. Mares, Candace Croft, Michael T. Moore, & David M. Fresco,
Kent State UniversityKent State University
Differential Strategies in Coping with Induced Pain as a Function of Differential Strategies in Coping with Induced Pain as a Function of Experiential AvoidanceExperiential Avoidance
Robert D. Zettle, Tanya R. Hocker, Katherine A. Mick, Brett E. Scofield, Connie L. Robert D. Zettle, Tanya R. Hocker, Katherine A. Mick, Brett E. Scofield, Connie L. Petersen, Petersen,
Hyunsung Song & Ratna P. Sudarijanto, Wichita State UniversityHyunsung Song & Ratna P. Sudarijanto, Wichita State University
Learning is a Mechanism Through Which Psychological Acceptance Learning is a Mechanism Through Which Psychological Acceptance Affects Mental Health and Job PerformanceAffects Mental Health and Job Performance
Frank W. Bond, Goldsmiths College, University of London, United KingdomFrank W. Bond, Goldsmiths College, University of London, United Kingdom
Comparing Outcome and Mechanisms of Action in Cognitive Comparing Outcome and Mechanisms of Action in Cognitive Behavioral and Acceptance and Commitment TherapiesBehavioral and Acceptance and Commitment Therapies
Evan M. Forman, James D. Herbert, Peter D. Yeomans, Katie McGrath, Ethan Moitre & Evan M. Forman, James D. Herbert, Peter D. Yeomans, Katie McGrath, Ethan Moitre & Pamela A. Geller, Drexel UniversityPamela A. Geller, Drexel University
Comparing Outcome and Mechanisms Comparing Outcome and Mechanisms of Action in Cognitive Behavioral and of Action in Cognitive Behavioral and
Acceptance and Commitment Acceptance and Commitment TherapiesTherapies
Evan M. Forman, James D. Herbert, Peter D. Yeomans, Evan M. Forman, James D. Herbert, Peter D. Yeomans, Katie McGrath, Ethan Moitre & Pamela A. Geller, Katie McGrath, Ethan Moitre & Pamela A. Geller,
Drexel UniversityDrexel University
Corresponding Author:
Evan M. Forman, Ph.D.
Department of PsychologyDrexel University245 N 15th Street, MS 515Phila., PA 19102
(215) 762-4021
Paper presented at the AABT, New Orleans, November 19, 2004Paper presented at the AABT, New Orleans, November 19, 2004
ACT vs CBTACT vs CBT
CBTCBT ACTACT
FocusFocus reducing or eliminating reducing or eliminating distorted/unwanted distorted/unwanted thoughts, feelings, and thoughts, feelings, and bodily sensations bodily sensations
reducingreducing unwillingness unwillingness toto experience and experience and efforts to efforts to controlcontrol thoughts, feelings thoughts, feelings and sensationsand sensations
Efficacy studies:Efficacy studies:
DepressioDepressionn
Numerous (cf. DeRubeis & Numerous (cf. DeRubeis & Crits-Christoph, 1998)Crits-Christoph, 1998)
Growing (e.g. (Zettle Growing (e.g. (Zettle & Hayes, 2002; Zettle & Hayes, 2002; Zettle & Rains, 1989)& Rains, 1989)
AnxietyAnxiety Numerous (cf. DeRubeis & Numerous (cf. DeRubeis & Crits-Christoph, 1998)Crits-Christoph, 1998)
Growing (e.g. Block & Growing (e.g. Block & Wulfert, 2000; Wulfert, 2000; Roemer & Orsillo, Roemer & Orsillo, 2002; Zettle, 2003)2002; Zettle, 2003)
Theorized Mechanisms of Theorized Mechanisms of ActionAction
Empirical EvidenceEmpirical Evidence
CBTCBT
Reducing dysfunctional Reducing dysfunctional attitudesattitudes
AgainstAgainst: Barber & DeRubeis, : Barber & DeRubeis, 1989; DeRubeis, Evans, 1989; DeRubeis, Evans, Hollon, Garvey, & et al., Hollon, Garvey, & et al., 1990; Teasdale et al., 2001 1990; Teasdale et al., 2001
Increasing Meta-Increasing Meta-cognitive awarenesscognitive awareness
ForFor: : Teasdale et al., 2001Teasdale et al., 2001
ACTACT
Decreasing Experiential Decreasing Experiential AvoidanceAvoidance
Increasing Increasing Psychological Psychological AcceptanceAcceptance
ForFor: Bond & Bunce, 2000; : Bond & Bunce, 2000; Zettle, 2003Zettle, 2003
Increasing DefusionIncreasing Defusion
AwarenessAwareness
Study QuestionsStudy Questions
Disseminability?Disseminability? Efficacy (RCT)?Efficacy (RCT)? Effectiveness in real-world setting Effectiveness in real-world setting
(few exclusion criteria, comorbidity, (few exclusion criteria, comorbidity, subthreshold diagnostically) subthreshold diagnostically) [Strosahl et [Strosahl et al., 1998]al., 1998]
Mechanisms of action?Mechanisms of action?
… … of ACT relative to CBTof ACT relative to CBT
Study DesignStudy Design Setting: University counseling centerSetting: University counseling center Participants: health science students Participants: health science students
(nursing, medicine, physical therapy, etc.)(nursing, medicine, physical therapy, etc.) Therapists: Doctoral students (n = 13) in a Therapists: Doctoral students (n = 13) in a
CBT-oriented clinical psychology programCBT-oriented clinical psychology program Therapist Training/SupervisionTherapist Training/Supervision
– CBT: 4 weekly 2-hour trainingsCBT: 4 weekly 2-hour trainings– ACT: 6 weekly 2-hour trainingsACT: 6 weekly 2-hour trainings– 1-hour weekly ongoing group supervision1-hour weekly ongoing group supervision– 1-hour weekly ongoing individual supervision1-hour weekly ongoing individual supervision
Random assignment of participants to CBT / Random assignment of participants to CBT / ACTACT
Each therapist administered both CBT & ACTEach therapist administered both CBT & ACT
MeasuresMeasures Collection: Baseline & 3-mo follow-up Collection: Baseline & 3-mo follow-up (±8 sessions)(±8 sessions)
MediatorsMediators
Exper. Exper. AvoidanceAvoidance
AAQAAQ
MindfulnessMindfulness–ObserveObserve–AwarenessAwareness–DescribeDescribe–AcceptanceAcceptance
KIMKIMSS
Negative Negative ThoughtsThoughts
–FrequencyFrequency–BelievabilityBelievability
ATQATQ
Symptom/FunctioningSymptom/Functioning
DepressionDepression BDIBDI-II-II
AnxietyAnxiety BAIBAI
Functioning Diff.Functioning Diff. OQOQ-45-45
Global Global FunctioningFunctioning
CGICGI
Well-beingWell-being
Quality of LifeQuality of Life QOLIQOLI
Life SatisfactionLife Satisfaction SLSSLS
Self-EsteemSelf-Esteem RSESRSES
Participant Recruitment & Participant Recruitment & EnrollmentEnrollment
102 Subjects Screened102 Subjects Screened• 84 (82%) eligible84 (82%) eligible
• 74 (78%) administered 74 (78%) administered consentconsent• 51 (61%) agreed51 (61%) agreed
• 7 (14%) could not be assigned 7 (14%) could not be assigned • 22 (43%) assigned to ACT22 (43%) assigned to ACT
• 20 (91%) active20 (91%) active• 2 (9%) dropped out2 (9%) dropped out
• 22 (43%) assigned to CBT22 (43%) assigned to CBT• 19 (86%) active19 (86%) active• 3 (14%) dropped out3 (14%) dropped out
Reached 3-mo follow-
up
10 ACT
8 CBT
Intake DemographicsIntake Demographics AgeAge: M=27.6 yrs., Min = 19, Max = 46: M=27.6 yrs., Min = 19, Max = 46
GenderGender: 8 Males (18%), 36 Females (82%): 8 Males (18%), 36 Females (82%)
Marital StatusMarital Status:: Single = 22 (50%), Divorced = 1 (2%), Single = 22 (50%), Divorced = 1 (2%),
Married/Partnered = 12 (27%), Married/Partnered = 12 (27%),
Not Living with current spouse/partner = 9 (21%)Not Living with current spouse/partner = 9 (21%)
EthnicityEthnicity: Caucasian = 32 (73%), : Caucasian = 32 (73%),
African American/Black = 4 (9%), African American/Black = 4 (9%),
Latino = 1 (2%), Asian = 7 (16%)Latino = 1 (2%), Asian = 7 (16%)
Participants Reaching Time 2Participants Reaching Time 2
AgeAge: M=28.7 yrs., Min = 21, Max = 46: M=28.7 yrs., Min = 21, Max = 46
GenderGender: 7 Males (39%), 11 Females (61%): 7 Males (39%), 11 Females (61%)
Marital StatusMarital Status:: Single = 9 (50%), Divorced = 1 (6%), Single = 9 (50%), Divorced = 1 (6%),
Married/Partner = 5 (28%), Married/Partner = 5 (28%),
Not Living with current spouse/partner = 3 (17%)Not Living with current spouse/partner = 3 (17%)
EthnicityEthnicity: Caucasian = 13 (72%), : Caucasian = 13 (72%),
African American/Black = 1 (6%), African American/Black = 1 (6%),
Asian = 4 (22%)Asian = 4 (22%)
Baseline Diagnoses/Symptom LevelsBaseline Diagnoses/Symptom Levels
DiagnosiDiagnosiss
NN %%
Anxiety Anxiety DisordersDisorders
66 33%33%
Major Major Depressive Depressive DisorderDisorder
55 28%28%
Other Mood Other Mood DisordersDisorders
66 33%33%
Eating Eating DisordersDisorders
11 6%6%
No No DiagnosisDiagnosis
77 39%39%
MeasureMeasure MM SDSDBeck Depression Beck Depression Inventory (BDI)Inventory (BDI)
17.017.0 11.211.2
Beck Anxiety Beck Anxiety Inventory (BAI)Inventory (BAI)
10.710.7 11.011.0
Beck Beck Hopelessness Hopelessness Scale (BHS)Scale (BHS)
7.27.2 6.06.0
Problem Checklist: Main Problem Checklist: Main ConcernsConcerns
– Worried about my grades or academic workWorried about my grades or academic work– Concerned about my primary relationshipsConcerned about my primary relationships– Feel easily irritated, frustrated, and/or Feel easily irritated, frustrated, and/or
angryangry– Feeling depressed or unhappyFeeling depressed or unhappy– Not feeling close/connected to othersNot feeling close/connected to others– Worried about my physical healthWorried about my physical health– Concerned about my eating habits/nutritionConcerned about my eating habits/nutrition– Having fears/worries that occupy my mindHaving fears/worries that occupy my mind
ResultsResultsHighlyHighly Preliminary Preliminary
Enrollment Slowdowns Enrollment Slowdowns 18 participants have 18 participants have reached time 2reached time 2– Effect sizes > p valuesEffect sizes > p values– Clinical SignificanceClinical Significance
Groups not equal at baseline (randomization Groups not equal at baseline (randomization failure)failure)– Repeated measures compares Repeated measures compares slopes slopes of change not of change not
simple differencesimple difference– Stratification by symptom (BDI, BAI, BHS, OQ) Stratification by symptom (BDI, BAI, BHS, OQ)
threshold; participants with minimal symptoms threshold; participants with minimal symptoms discardeddiscarded
No midpoint assessment (No midpoint assessment (mediational analyses)mediational analyses)
Depression (BDI)Depression (BDI)Repeated Measures ANOVARepeated Measures ANOVA
F F (1,12)(1,12) pp pp22
TimeTime 19.919.944
.001.001**
.624.624
Time x Time x GroupGroup
4.964.96ACTACT
.046.046**
.293.293
BaselineBaseline 3 mo3 mo ReliableReliable ImprovemImprovem
ntnt
RecoverRecovereded
CBTCBT 14.6714.67(3.13)(3.13)
8.008.00(3.14)(3.14)
50%50% 50%50%
ACTACT 32.1332.13(2.71)(2.71)
12.112.188
(2.96)(2.96)
88%88% 50%50%
Clinical Significance
0
5
10
15
20
25
30
35
Baseline 3 mo
CBT ACT
Anxiety (BAI)Anxiety (BAI)Repeated Measures ANOVARepeated Measures ANOVA
F F (1,8)(1,8) pp pp22
TimeTime 33.533.588
.000.000**
.808.808
Time x Time x GroupGroup
4.964.96ACTACT
.298.298 .134.134
BaselineBaseline 3 mo3 mo ReliableReliable ImprovemImprovem
ntnt
RecoverRecovereded
CBTCBT 20.5020.50(4.49)(4.49)
10.510.500(3.16)(3.16)
50%50% 0%0%
ACTACT 19.5019.50(2.25)(2.25)
4.754.75(1.58)(1.58)
63%63% 63%63%
Clinical Significance
0
5
10
15
20
25
Baseline 3 mo
CBT ACT
Functioning Difficulties (OQ-45)Functioning Difficulties (OQ-45)Repeated Measures ANOVARepeated Measures ANOVA
F F (1,14)(1,14) pp pp22
TimeTime 11.411.477
.004.004**
.450.450
Time x Time x GroupGroup
4.114.11ACTACT
.062.062°°
.227.227
BaselineBaseline 3 mo3 mo ReliableReliable ImprovemImprovem
ntnt
RecoverRecovereded
CBTCBT 75.0075.00(9.20)(9.20)
68.868.800(7.37)(7.37)
0%0% 0%0%
ACTACT 91.4691.46(6.20)(6.20)
66.866.800
(4.97)(4.97)
46%46% 0%0%
Clinical Significance
60
65
70
75
80
85
90
95
100
Baseline 3 mo
CBT ACT
Therapists’ Clinical Global Impression Therapists’ Clinical Global Impression (CGI)(CGI)
Repeated Measures ANOVARepeated Measures ANOVA
F F (1,10)(1,10) pp pp22
TimeTime 8.008.00 .018.018**
.444.444
Time x Time x GroupGroup
4.114.11CBTCBT
.189.189 .167.167
BaselineBaseline 3 mo3 mo
CBTCBT 3.833.83(.401)(.401)
2.332.33(.459)(.459)
ACTACT 4.174.17(.401)(.401)
3.663.6677
(.459)(.459)
1
1.5
2
2.5
3
3.5
4
4.5
5
Baseline 3 mo
CBT ACT
Subjective Life Satisfaction Subjective Life Satisfaction (SLS)(SLS)
Repeated Measures ANOVARepeated Measures ANOVA
F F (1,12)(1,12) pp pp22
TimeTime 4.414.41 .058.058°°
.269.269
Time x Time x GroupGroup
1.931.93ACTACT
.190.190 .138.138
BaselineBaseline 3 mo3 mo
CBTCBT 11.4011.40(2.48)(2.48)
12.612.600
(3.09)(3.09)
ACTACT 6.116.11(1.85)(1.85)
12.012.000
(2.30)(2.30)
0
2
4
6
8
10
12
14
16
18
20
Baseline 3 mo
CBT ACT
Quality of Life (QOLI)Quality of Life (QOLI)Repeated Measures ANOVARepeated Measures ANOVA
F F (1,16)(1,16) pp pp22
TimeTime .421.421 .526.526 .026.026
Time x Time x GroupGroup
1.931.93CBTCBT
.473.473 .033.033
BaselineBaseline 3 mo3 mo
CBTCBT 2.762.76(.333)(.333)
3.153.15(.371)(.371)
ACTACT 2.772.77(1.85)(1.85)
2.752.75(.296)(.296)
1
2
3
4
5
Baseline 3 mo
CBT ACT
Self-Esteem (RSES)Self-Esteem (RSES)Repeated Measures ANOVARepeated Measures ANOVA
F F (1,16)(1,16) pp pp22
TimeTime .023.023 .881.881 .001.001
Time x Time x GroupGroup
.001.001 .973.973 .000.000
BaselineBaseline 3 mo3 mo
CBTCBT 20.5720.57(1.04)(1.04)
20.720.711
(.55)(.55)
ACTACT 20.6420.64(.83)(.83)
20.720.733
(.44)(.44)
10
15
20
25
Baseline 3 mo
CBT ACT
Mediational AnalysesMediational Analyses
1.1. Does mediational variable decrease Does mediational variable decrease as a function of treatment and as a function of treatment and differentially by treatment type (CBT differentially by treatment type (CBT vs ACT)?vs ACT)?
2.2. Does change in mediational variable Does change in mediational variable covary with change in outcome?covary with change in outcome?
3.3. Is treatment effect attenuated—Is treatment effect attenuated—differentially by treatment type—differentially by treatment type—when mediational variable is when mediational variable is statistically controlled?statistically controlled?
Automatic Thoughts – Believability Automatic Thoughts – Believability (ATQ-B)(ATQ-B)
BDIBDI BAIBAI OQOQ
pp22
CBTCBT ACTACT CBTCBT ACTACT CBTCBT ACTACT
Nothing Nothing covariedcovaried
.813.813 .694.694
ATQ CovariedATQ Covaried .748.748 .336.336
% decrease% decrease 8%8% 52%52%
F F (1,12)(1,12)
pp pp22
TimeTime 8.1228.122 .01.0155
.404.404
T x GroupT x Group 3.9853.985 .06.0699
.249.249
Repeated Measures analysis before and after covarying ATQ-B
ATQ-B Outcome Var?Treatment ATQ-B?Yes, particularly for ACT
Regrssn ATQ ATQ
BetaBeta ppIntrctIntrct
n n BetaBeta
pp
BDIBDI .30.30 .58.58 .32.32 .1.199
ACTACT
BAIBAI .69.69 .37.37 -.43-.43 .6.622
----
OQOQ .70.70 .14.14 .01.01 .9.988
----
Repeated Measures analysis, DV = ATQ-B
ATQ-B attenuates tx effect?
Decreases in believability are associated with decreases in depression, but only in the ACT condition.
Summary of Mediating Summary of Mediating EffectsEffectsTreatment mediator
mediator Outcome Var
mediator attenuates tx effect?
ATQATQBelievabilityBelievability Yes Yes (ACT)(ACT) BDI BDI (ACT)(ACT) BDI BDI (ACT)(ACT)
FrequencyFrequency very similar to ATQ-Bel; r = .91very similar to ATQ-Bel; r = .91
AAQAAQ Yes?Yes? (ACT)(ACT) BDI BDI (ACT)(ACT)
KIMKIMSS
ObserveObserve Yes?Yes? (ACT)(ACT) BDI BDI (ACT)(ACT)
BAI BAI (ACT)(ACT)
BAI BAI (ACT)(ACT)
DescribeDescribe Yes?Yes? (ACT)(ACT) BDI BDI ((ACTACT))
OQOQ (ACT) (ACT)
AwarenessAwareness NoNo
AcceptanceAcceptance Yes Yes (ACT)(ACT) OQ OQ (ACT)(ACT) OQOQ (ACT) (ACT)
SummarySummary DisseminableDisseminable EffectiveEffective Efficacious relative to CBTEfficacious relative to CBT
– DepressionDepression– FunctioningFunctioning– Subjective Life SatisfactionSubjective Life Satisfaction
Mechanisms of ActionMechanisms of Action– BelievabilityBelievability, for ACT, not CBT, on , for ACT, not CBT, on depressiondepression– ObserveObserve, for ACT, not CBT, on , for ACT, not CBT, on anxietyanxiety– AcceptanceAcceptance, for ACT, not CBT, on , for ACT, not CBT, on functioningfunctioning
( CGI )
FutureFuture
Increase nIncrease n Consider specific diagnosesConsider specific diagnoses Session-by-session data (BSQ)Session-by-session data (BSQ) Diffusion as a mechanism of actionDiffusion as a mechanism of action
