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A Review of Acceptance and Commitment
Therapy (ACT) Empirical Evidence:
Correlational, Experimental,
Psychopathology, Component and
Outcome Studies
By Francisco J. Ruiz (2010)
ACT
 A psychological intervention
 Philosophically rooted in functional
contextualism
 Rooted in Relational frame theory
(RTF)
 Treatment of experiential avoidance
disorder (EAD)
 Functional dimensional approach to
psychopathology
Functional contextualism
 Generally contextualism observes
actions in a context
 Functional contextualism specific
way of contextualism which
undermines prediction and influence
of events with precision, scope and
depth.
 Thoughts or actions are not seen
correct or incorrect
 It focuses on usefulness
RFT
 Contextual behaviorism approach to
human language and cognition
 Based on laws
 Human beings learn to relate stimuli
under arbitrary contextual control
 It has three requisites for considering
the existence of relational frame
RFT
Mutual entailment
AB
BA
Combinational
Entailment
A>B, B>C
A>C
Transformation of
Functions
(Depends on function)
RFT
 Has large number of implication of
area of psychopathology and
psychotherapy
 Briefly nature of language and
cognition has more impact on
changing attempts focused on the
function of private events
Experiential Avoidance
 Deliberate effort to avoid and/or
escape from private events such as
thoughts, memories and bodily
sensations.
 When EA combined with psychological
inflexibility problems occur.
 EA works in short run.
 In long run, it provokes patients’ life.
Essential ACT Principles and
Methods
What does ACT provide ?
 Generates psychological flexibility
 Contact the present moment
 Proposes acceptance
 To involve oneself in valued action
Therapeutic Work in ACT
Promotes
Values clarification
and actions
Defusion
Values clarification and actions
 Creative hopelessness
 Values clarification
 Promotion of the willingeness to
experince
Defusion
To choose to behave in valued way
 Cognitive defusion
 Self as a context
- weakining the tendency- there is a YOU
behind all private
to treat them.
events
How ACT obtaion its objectives
metaphors
Experiential exercises
paradoxes
Classical exposure therapies
vs.
ACT
 Extinction of
discomfort
 Trains the patients
to be present with
their feared
experince
 Directs them to
behave in a valued
way.
ACT Empirical Reviews
First Critique: Corrigan (2001)
 ACT has not been developed with the usual rationale
--philosophical and theoretical roots were not used
First Review: Hayes et al
(2006)
• Correlation evidence
• Experiential avoidance, experimental psychopathology and
ACT component studies, randomized controlled trials and
processes of change studies
• ACT—superior to control conditions, wait-lists and
treatment
• ACT—superior to structured interventions
Other research:
 Öst (2008): Qualitative and quantitative review of the
ACT empirical evidence from RCT.
--Comparing ACT versus CBT (Cognitive Behavior
Therapy)
--Conclusion: ACT showed lower scores in a
methodological scale compared with CBT
--ACT does not fulfill the criteria for being considered as
an empirical validated treatment.
Re-analysis of Öst review: Gaudiano
(2009)
 %38 of the ACT studies could not be
matched with CBT study because:
--Studies were conducted over
different disorders
--Different population
 CBT studies were 4.5 more times
funding than ACT studies
Recent Review: Powers, Vörding &
Emmelkamp (2009)
 Meta-analytic review of ACT empirical evidence in
RCT studies
--Conclusion: ACT is better than wait-lists,
placebo attention conditions
BUT
not significantly better than established
treatments
HOWEVER
 Re-analyzed the data base: Levin & Hayes (2009)
--Conclusion: ACT was better than established
treatments
Emprical Evidence of ACT Model
 separated as a correlational, experimental psycpath.
and component studies, outcome studies and case
studies.
Correlational Studies;
 Aim to study relationship among experiential
avoidance and psychological symptoms.
 ‘’Acceptance and Action Questionnaire’’ is used in
studies.
 it measures experiential avoidance
 Experiential avoidance is analyzed with different types
of psychological construct and symptoms .
 Chronic pain is one of them
 Kratz, Davis,& Zatura (2007) have showed that
acceptance of pain predicted posterior positive affect.
 According to Wicksell, Renöfalt, Olsson, Bond & Melin
(2008), acceptance predicted pain severity , pain
interference in everyday life and physical and metal
well-being.
 In work setting, the level of experiential avoidance has
predicted mental health and performance in learning a
new software (Bond, & Flaxman, 2006).
 Experiential avoidance has been a mediator between
childhood psychological abuse and current mental
health symptoms (Reddy, Picket, & Orcutt, 2005).
 Experiential avoidance block the reduction of depression
in the treatment of borderline personality disorder.
Experimental psychopathology and ACT component
studies
3 types of studies : effect of experiental avoidance, effect of acceptance
coping instructions, effect of brief ACT protocol
Studies about effect of experiental avoidance repertoire in experimental
task:
Predictive power of the level experiental avoidance of
participants  selecting participants with high and low scores in
AAQ
 Cold pressor task (Zettle et al.,2005)
-High score of AAQ had lower tolerance and kept their hand in cold
water less time than participant with low AAQ score
 Effect of being drunk (Zettle,Petersen,Hocker&Provines,2007)
-Higher scores in AAQ were more discomforting and had
worse performance on challenging perceptual-motor task than
lower scores.
 Carbon dioxide-enriched air challenge (Feldner, Zvolensky, Eifert
&Spira (2003)
-High levels of AAQ showed more anxiety and emotional discomfort
but not more phsysiological activation
- High AAQ score, received suppression protocols, showed higher
levels of anxiety than those who received perceived acceptance
control
 Comparing emotional reactions (Sloan,2004)
-participants with high level of experiental avoidance showed higher
emotional experience and higher heart rate with the pleasent and
unpleasent films
THE EFFECT OF ACCEPTANCE
COPING INSTRUCTIONS
Nihan Kaymaz
 Several studies focused on the effects of
acceptance coping instructions
 Aim: to assess the psychopathology in terms of
comparing acceptance coping instructions and
other coping strategies
 Aversive stimulation, intrusive thoughts,
cardiovascular conditions, emotional contents
In terms of aversive stimulation:
 Keogh, Bond, Hanmer & Tilston (2005):
 Cold-pressor task
 Acceptance coping instruction obtained better results than one
‘distraction coping instruction’ with women
 The same effect with men
In terms of intrusive thoughts:
 Marks & Woods (2005):
 Acceptance instructions vs. suppression in the management of
intrusive thoughts
 Acceptance coping instruction group: less discomfort when
experiencing the intrusive thoughts.
 Suppression group: more intrusions, higher levels of anxiety,
negative evaluation compared with acceptance
(while doing a task which consisted in saying aloud and imagining that
a loved one were having a traffic accident)
 Najmi, Riemann & Wegner (2009):
 Similar effects with those with OCD
 Both acceptance and focused distraction coping instruction
groups had less distress than suppression group.
In terms of cardiovascular conditions:
 Low, Stanton & Bower (2008):
 Acceptance-oriented processing vs. evaluative emotional
processing on cardiovascular habituation and recovery
 Task: writing about an ongoing stressful experience
 Better efficient heart rate habituation and recovery in
acceptance condition
In terms of emotional contents:
 Campblell-Sills, Barlow, Brown & Hofmann (2006):
 Differential effect of suppression vs. acceptance instructions
 Task: viewing a highly emotional film
 Lower heart rate and less negative effect during the film in acceptance
condition than in suppression condition
 Liverant, Brown, Barlow & Roemer (2008):
 Depressed participants used
 Suppression produced short-term reduction in sadness with low levels
of anxiety
 However, not effective at moderate and higher levels
In terms of emotional contents:
 Hofmann, Heering, Sawyer & Asnaani (2009):




Suppression vs. cognitive reappraisal vs. acceptance instruction
Task: coping with an impromptu speech in front of a video-camera
Higher heart rate in suppression condition than in others
Also, subjective experience of anxiety was lower in cognitive
reappraisal than acceptance
 Dunn, Billotti, Murphy & Dalgleish (2009):
 Suppression vs. acceptance on processing distressing materials
 Suppression showed better results
 However, suppression was accepted similar to cognitive reappraisal
coping instruction
Limitations
 ACT does not instruct acceptance
 Metaphors and experiential exercises are used
 Coping strategies have some similarities among them
and there is still no a consensus about their verbal
processes
 Both acceptance and cognitive reappraisal involve distancing
from thoughts
 Acceptance coping protocols in these studies did not
include valued oriented behaviors or any valued context.
 In ACT, acceptance is always at the services of values
Effects of ACT Protocols
Cold-pressor task experiments:
Hayes, Bissett, et al(1999):
Acceptance-based protocol vs . Control-based protocol
Masedo& Esteve (2007):
Acceptance-based protocol vs. Suppression-based protocol
Branstetter-Rost et al (2009):
ACT-based acceptance with/without values
Pain-tolerance task experiments:
Takahashi et al (2002):
ACT exercises vs. CBT exercises
Gutierrez et al (2004):
Acceptance-based protocols vs. Cognitive-control-based
protocols
McMullen et al (2008):
Acceptance-based coping strategies vs. Control-based
strategies
Blarrina et al (2008):
ACT values protocol vs. Control values protocol
OUTCOME STUDIES
CLINICAL PSYCHOLOGY






Depression
Anxiety disorders
Psychotic symptoms
Personality disorders
Addictive behaviors
At-risk adolescents
CLINICAL PSYCHOLOGY
 Two studies: ACT and depression
 Zettle & Hayes, 1986:
 Comprehensive distancing vs. two versions of
cognitive therapy
 ACT was better after therapy and after 2 month
follow up.
• Zettle & Hayes, 1989:
 ACT in group format vs. the previous two CT
versions in groups
 Cognitive fusion mediated the results
(believability of depressive thoughs).
ANXIETY DISORDERS
 Two studies: ACT and OCD
 Twohig, Hayes & Masuda, 2006b:
 Positive results with all participants
 Twohig, 2007:
 ACT vs. Progressive Relaxation Training
 Less compulsions with ACT group than
relaxation group at post-treatment and
at 3 month follow-up.
ANXIETY DISORDERS
 Four studies: ACT and Social Phobia
 Block, 2002:
 ACT vs. CBT, participants with subclinical
social anxiety
 ACT group was better at public speaking
• In general, ACT is a promising
treatment for social phobia
ANXIETY DISORDERS
 Generalized Anxiety Disorder
 Roemer & Orsillo (2007): ACT obtained
large effect sizes in reducing GAD
symptoms.
• Hayes, Orsillo & Roemer (in press):
 Acceptance in private events and
engagement in meaningful activities
related to responder status and quality
of life at post-treatment.
 Trichotillomania and skin picking:
Studies reported positive results.
ANXIETY DISORDERS
 Diverse symptoms related to anxiety
and/or depression
 ACT vs. CBT or CT
 ACT obtained more improvements at
post-treatment and at the 6 month
follow-up
 Decrease of experiential avoidance
(Lappalainen et al., 2007).
PSYCHOTIC SYMPTOMS
 Bach & Hayes (2002):
 45 minute sessions of ACT and TAU vs.
only TAU to prevent rehospitalizations
 ACT and TAU condition decreased
rehospitalizations, hallucinations and
delusions believability.
• Gaudiano & Herbert (2006a &
2006b): same results.
PERSONALITY DISORDERS
 Gratz & Gunderson (2006): patients
with borderline personality disorder.
 TAU vs. ACT and TAU
 Even though both conditions have
significant effects, the latter one reached
normative functioning levels.
ADDICTIVE BEHAVIORS
 Hayes, Wilson et al. (2004):
polysubstance abusing individuals
being maintained on methadone
 ACT, Intensive Twelve Step Facilitation
vs. Methadone Maintenance only
 ACT condition showed greater decrease
in total drug use at the 6 month followup
AT-RISK ADOLESCENTS
 Gomez et al. (under review):
 In the treatment of at-risk adolescents
who are with a history of antisocial
behavior and current legal issues (n=5)
 Less impulsivity, higher self-control,
more value oriented actions
 Improvements increased in one year
follow-up
AT-RISK ADOLESCENTS
 Luciano et al. (2009):
 Adolescents with moderate or high risk (n=15)
of having impulsivity or emotional problems
 Values clarification protocol: promoting
choosing and taking responsibility for own
choices
 Showed a large effect only for moderate-risk
adolescents
 Defusion protocol: discriminating private
events
 Produced a large effect size for high-risk
adolescents and improved the effect of values
protocol.
ACT in Health Psychology
 Dahl, Wilson, & Nilsson (2004):
 Chronic pain, ACT vs. TAU
 Less sick days for ACT group at 6 month followup
 Wicksell et al. (2008):
 On people with Longstanding Pain –> significant
improvements in functioning, life satisfaction,
fear of movements and depression at 7 month
follow-up.
 Gifford et al. (2004):
 ACT>CBT -for chronic pain- (Smoking Cessation
ACT>Nicotine Replacement Therapy) at 1 year
follow-up.
ACT in Health Psychology
 Branstetter et al. (2004):
 Distress resulted from end-stage cancer
 ACT>CBT for alleviating distress levels
 Lundgren et al. (2006):
 Epilepsy
 ACT condition vs. Attention Placebo Condition
 At 12 month follow-up
 Less seizures, higher quality of life
 Forman et al. (2009):
 Weight loss in obese women
 At post-treatment 6.6% of body weight lost
 At 6 month follow-up 9.6% of body weight lost
ACT in Health Psychology
 Gregg et al. (2007):
 Type II Diabetes
 Diabetes Education vs. ACT + Diabetes
Education
 ACT condition was more succesful in promoting
self-management behaviours
 Hesser et al. (2009):
 ACT reduced Tinnitus Distress
 At 6 month follow-up symptom reduction
 Good outcomes in:
 Multiple Sclerosis (Sanchez & Luciano, 2005),
 Prevention of HIV (Gutiérrez et al., 2007),
 Systematic Lupus Erythematosus (Quirosa et al.,
2009)
Other Areas of Intervention
OTHER AREAS of INTERVENTION
Fernandez et al. (2004);
- sport performance enhancement
- carried out RCT
- ACT vs. hypnosis
RESULTs : ACT showed greater influence BUT
without reaching a statistical significant
differences.
OTHER AREAS of INTERVENTION
Chess players who showed the greatest
improvement in their performance were the ones
who had higher levels of experiental avoidance
during competitions at pretreatment
OTHER AREAS of INTERVENTION
Work Settings ;
Differential effect of ACT 3 hours session
intervention vs.
Innovation Promotion Program and wait-list
condition
ACT showed better effect in post treatment
and in the 3 month follow-up in the
improvement of general mental health
OTHER AREAS of INTERVENTION
Potential efficacy of ACT in reducing the
resistance to the use of emprical validated
treatments among professional councelors
Louma et al. (2007) compared the differential
effect of 8 ACT sessions with a control
condition
RESULTS: in the ACT condition, counselors
followed using the empirical validated
treatment at the 2 and 4 month follow-up
more frequently than control condition
OTHER AREAS of INTERVENTION
Reducing prejudice and stigma
Hyes et al. (2004)
Differential effect of ACT vs. Multicultural
Training and Biological Education in
diminishing the stigma and burnout among
substance abuse counselors
RESULTs: ACT obtained better results than the
other intervention of stigma, burnout and the
believability of stigmatizing attitudes at posttreatment and 3 months follow-up
OTHER AREAS of INTERVENTION
• Masuda et al. (2007)
- effect of an ACT intervention vs. educational
intervention in reducing stigma towards people with
mental disorders
- differential effect of the protocols among
participants with high and low AAQ scores
OTHER AREAS of INTERVENTION
RESULTS;
-in post-treatment and at the 1 month followup, ACT produced a decrease on stigma both
in participants with high and low AAQ scores
-Higher effect in the high avoidant
participants
-Educational intervention worked with
participants with low AAQ scores
Published case studies:
Depression
 GAD
 Anxiety
Agoraphobia
Panic disorder
PSTD
OCD
Psychotic symptoms
Anorexia nervosa
Schizotipic personality disorder
Familiar and couples problems
Patients with intellectual disabilities
Exhibitionism
Sexual dysfunction and orientation
Alcoholism
Heroin addiction
Chronic pain
Cancer
Swimming and weightlifting
Chess
Lacrosse
Discussion
 ACT is effective in a wide range of problems
 Typically better after follow-up
 Relevant effect when applied to extremely short
interventions
 The empirical evidence is compromising
 Some studies show that:
 ACT and CBT have similar effects
 Better results for ACT
However;
Still needed for more controlled studies with larger
samples!
 Coherent results with the literature of experiential
psychopathology
 The review of correlational studies strongly support the
ACT model
 Experiential avoidance as a mediator
 Some conclusions can be made out:
 Highly experiential avoidance participants responds
differently to several experimental challenges
 Acceptance values based protocols are effective in
improving the participants in the experimental
challenges
 More effect has been found in ACT protocols than in
control based ones
DISCUSSION
Although the RFT state of
evidence was out of the scope of
the current study, it is called to be
most differential characteristic
between ACT and other second
and third wave therapies.
DISCUSSION
 Although RFT definition of
acceptance, values, and cognitive
defusion is in its beginnings, it is the
most important area of research that
needs to be done in order ro improve
ACT results..
DISCUSSION
 For example, consider 2 specific
issues:
1. To better know what are the specific
transformations of functions involved
in cognitive defusion and values
clarification exercises would allow to
redefine or invent new exercises that
become more powerful
DISCUSSION
2. İf the therapist know the specific
verbal processes in the
transformation of functions through
analogical relations, he/she becomes
using more effective methapors in
practice
CONCLUSION
 ACT seems to have strong support in
view of the correlational, the
experimental psychopathology, and
the outcome evidence
 It is worth nothing that ACT is a
therapy with very singular
characteristic.
CONCLUSION
 Also, it is a good model of
psychopathology of EAD or
psychological flexibility
 ACT also have similarity with CBT or
between other types of therapies.