Dr. David Gillanders University of Edinburgh / NHS Lothian Chronic Pain Service

Dr. David GillandersDr. David Gillanders

University of Edinburgh / University of Edinburgh /

NHS Lothian Chronic Pain ServiceNHS Lothian Chronic Pain Service

Acceptance & Commitment Acceptance & Commitment Therapy: Empirical StatusTherapy: Empirical Status

University of Edinburgh / NHS Scotland Training Programme in Clinical Psychology

The Empirical Base for ACTThe Empirical Base for ACT

• This is very brief and selective

• There are references on the reading list to pursue to see more of the evidence base

• In particular Hayes et. al., 2006 in BRAT and Ost (2008)

Experimental & Theoretical Work:

Experimental work in experimental pain tolerance, panic induction, distressing thoughts,

7 published component and experimental psychopathology studies (N = 199)

Several more are done and on the way and so far the results are quite supportive of the act model

Evidence base for ACTEvidence base for ACT

Experimental & Theoretical Work:

Questionnaire studies using the Acceptance & Action Questionnaire:

There are now 27 studies using the AAQ, involving 5,616 participants


AAQ Scores Are Associated With ….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

Outcome Studies

Across diverse clinical areas: depression, anxiety, OCD, psychosis, chronic pain, smoking, substance abuse, diabetes, cancer, epilepsy

20 randomized controlled trials are now done containing 24 planned between group comparisons. 23 of the 24 favor ACT (not all significantly, just in terms of effect sizes).

Several controlled time series designs

Control conditions include minimal comparisons (placebo; TAU; wait list) as well as structured active treatment comparisons


The first RCT: Depression

Zettle and Hayes, 1987

Done at the Centre for Cognitive Therapy in Philadelphia with Aaron T. Beck

Surprisingly…


Significantly Better OutcomesSignificantly Better Outcomes

Pre Post 2 mo Follow up

0

5

10

15

20

CT

ACT

Hamilton Rating Scale (BDI was similar)

Cohen’s d at F-up = .92

Not only that, but process too!Not only that, but process too!

0 %

10 %

20 %

30 %

40 %

50 %

60 %A

CT

AC

T

CT

CT

Pre to Post

Pre to Follow up

Pre-Post Reductions in the Believability of Depressive Thoughts

ACT For PsychosisACT For Psychosis

Bach & Hayes, 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

ACT

.6

.7

.8

.9

1.0

40 80 120

Days After Initial Release

Treatment as Usual

Proportion Not Hospitalized

Processes of Change: SymptomsProcesses of Change: Symptoms

Pre F-up

100

75

25

ControlControl

ACTACT

50

Percentage Reporting Symptoms

Phase

Processes of Change:Processes of Change:BelievabilityBelievability

Pre F-up

80

60

ControlControl

ACTACT40

Literal Believability of

Psychotic Symptoms

(0-100)

Phase

Chronic PainChronic Pain McCracken, Vowles, & Eccleston, BRAT, 2005

108 chronic pain patients

Average of 132 months of Chronic pain

6.3 treatment programs

Multidisciplinary in-patient program

Within subject analysis: Preassessment; 3.9 months later (on average) pretreatment assessment; 3-4 week residential program; 3 month follow-up


-10%

0%

10%

20%

30%

40%

50%

Pe

rce

nt

Imp

rov

em

en

t

Impact on Chronic PainAss't to Pre (M=3.9 mo) and Pre to F-Up (M=3.9 mo)

Correlation between Changes in Acceptance and Improved Outcomes

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7


Refractory Epilepsy Refractory Epilepsy Lundgren, Dahl, Melin & Kies (2006) Epilepsia

• Small RCT: n = 27; 14 in ACT, 13 supportive therapy

• ACT intervention: values, reasons, acceptance of seizure, defusing ‘self as stigmatised,’ contact with self, plus standard behavioural procedures

• Supportive Therapy: Talking about epilepsy and its impact on living, what it means to have epilepsy etc.


• Limitations: non blinded outcome measurers , small numbers.

• Main outcome measure: nursing records of daily seizures frequency and length – multiplied to give seizure index.

• Here’s the data:


Interestingly the seizures reduce before the delivery of the behavioural technologies.

Evidence base for ACT:Evidence base for ACT:Overall effect sizes across all RCT’sOverall effect sizes across all RCT’s

Vs. #Post

d NF-Up

d NF-Up weeks

No Rx/ TAU

99 .99.99 248248 .72.72 176176 2121

Active Rx

1515 .56.56 793793 .82.82 727727 3636

CT / CBT

66 .55.55 205205 .55.55 120120 4444

All 2424 .66.66 10411041 .8.8 903903 3333

“Overall ACT seems to be producing consistently positive gains, sometimes quickly, across an unusually broad range of problems including notably severe ones, and at times better than existing empirically supported procedures

It seems to work through at least some of its theoretically specified processes and components, not just through general processes of change”

Steven Hayes, 2005


First external meta analysis of ACT versus CBT

Effect Sizes:

Overall 0.68 (15 studies)WL Control 0.96 (2 studies)TAU 0.79 (5 studies)Active Treatment 0.53 (8 studies)

Lars Goran Ost (BRAT 2008)


Also:Background variables

ACT CBT p valueNumbers starting 52.1 76.5 NSAttrition (% starters) 15.4 16.1 NSNo of weeks 8.2 17.2 <0.01No of hours 10.7 22 NSMonths follow up 4.2 9.6 NS



However:

Using a scale to rate methodological rigour

ACT studies on average are significantly poorer quality than recent CBT studies:

Total quality score (max 44)

ACT = 18.1 (SD = 5.0) CBT = 27.8 (SD = 4.2)p <0.0001



ACT studies are poorer on criteria such as;

Representativeness of the sample, reliability of diagnosis, reliability and validity of outcome measures, assignment to treatment, number of therapists, therapist training and experience, treatment adherence checks, control of other treatments.



ACT studies are equivalent on other criteria:

clarity of sample description, severity / chronicity of disorder, specificity of measures, use of blind assessors, assessor training, design, power analysis, assessment points, manualised specific treatments, checks for therapist competence, handling of attrition, statistical analyses and presentation of results, clinical significance of results.



In conclusion;

The ACT literature is promising, shows moderate to large effect sizes across a range of conditions in a notably briefer time scale than existing therapies.

The literature is not yet as mature as existing psychotherapies literature and is not as methodologically rigorous in some areas.

Future studies should benefit from Ost’s review as he gives specific guidance as to how RCT’s involving ACT could improve.


Dr. David Gillanders University of Edinburgh / NHS Lothian Chronic Pain Service

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