Acceptance and Commitment Training:
A BRIEF THERAPEUTIC APPROACH
FOR DEPRESSION AND DISABILITY
IN MEDICAL SETTINGS
LILIAN DINDO, PH.D.
I O W A P S Y C H O L O G I C A L A S S O C I AT I O N
APRIL 2015
ACKNOWLEDGEMENTS
NO DISCLOSURES
Co-Investigators/Collaborators/Mentors
 James Marchman, PhD
 Jess Fiedorowicz, MD
 Ana Recober, MD
Funding
 NIH KL2RR024980
 NCCR UL1RR024979
Carolyn Turvey, PhD
Mike O’Hara, PhD
Chronic Medical Conditions
 Often require active participation in one’s care
 Making significant changes to one’s lifestyle
 eating healthfully
 exercising regularly
 self-monitoring of blood glucose
 Adhering to treatment recommendations that
might be challenging

taking medications correctly
Co-Occurrence of Depression & Anxiety
 Adherence become even more difficult when there is co-
occurring depression or anxiety


Interfere with motivation and drive
Inflammation
 20% of patients with chronic medical conditions suffer
from major depressive or anxiety disorders
 Comorbidity adversely impacts quality of life, prognosis,
and is associated with shortened life expectancy
 The causal relationship between medical and psychiatric
conditions  bidirectional.
Why Target Distress In Medical Populations
 Highly prevalent
 Underdiagnosed & undertreated
 Lead to worse outcomes
 Economic burden of medical problem 2-4x when
there is depression
Negative Affect States
Detrimental impact of depression and anxiety seen with
other negative affect states:
• Anger/hostility
• Neuroticism/negative affectivity
• Social inhibition
• Type A Personality
• Psychosocial distress
A question…..
 If we are to implement psychological treatment…
What would we want to treat?
Coping strategies
 The way one copes with chronic illness and
associated stress  long-term effects
 Cognitive and behavioral avoidant coping
strategies:


avoiding reminders related to the medical condition,
distraction techniques, mental disengagement, denial
associated with poorer psychological and health outcomes
 Interventions that counter avoidance and
encourage engagement in important activities

improve health outcomes
Example from Chronic Pain
 Natural response to pain: to resist and avoid pain
and suffering
 “Its important to keep fighting this pain.”
92% of CP patients endorsed as “Always True”
or “Almost Always True” (McCracken, Vowles, & Eccleston, 2004, Pain)

 However, struggling to change something that is
uncontrollable/intractable leads to more harm
than good.
Pain and Disability
 Relationship between pain intensity and
functioning: weak
 Pain (including migraine pain) does not per se lead
to depression or impairment.
Problems:
 Struggle with pain
 Preoccupation with avoiding unpleasant
experiences (i.e., pain, fatigue, activities, places)
Adaptive/reinforcing in short-term
 Long term decrease functioning, QOL (w/o decease in
symptoms)  depression

The Impact of Frequent Struggling
 Struggling is best predictor of:





Worse Pain
Poorer Activity
Greater Disability
Worse Depression
Greater Avoidance
 Attempt to suppress pain tends to increase it
(Cioffi & Holloway, 1993)
McCracken, Eccleston & Bell, 2005, Eur J Pain
McCracken, Vowles, & Gauntlett-Gilbert, 2007, J Behavioral Medicine
Vowles & McCracken, 2011
Pain Acceptance
Acceptance-based coping associated with:
 less distress across chronic medical conditions
 reduced psychopathology
 enhanced physical and social functioning
↑ levels of pain-related acceptance (willingness):


↓ levels of catastrophizing , ↓ pain-related interference
↓ avoidance
↑ increased perceived control, ↑ Pain Tolerance,
↑ engagement in activities
Unified Approach To Treat Comorbidity
 ACT provides a unified model of behaviour change
applicable to human beings in general
 Transdiagnostic
 By targeting 6 core psychological processes that are
related to diverse unhealthy behaviors.

Acceptance/Mindfulness & Behavioral Change
Evidence Supporting ACT
August 2014: 104 ACT RCT’s
N= 8,636 (avg: 84)
100
80
60
40
20
0
1985
1990
1995
2000
2005
2010
2014
First Author
Problem
Comparison
Measure
N
Sessions
Post
F-up
Processes
Zettle (1986)
Depression
CT
BDI
18
12
1.23
.92 (8)
ATQ-B*
Zettle (1989)
Lappalainen
(2007)
Depression
CT
BDI
21
12
0.53
.75 (8)
ATQ-B*
Anx-Depr
CBT
SCL-90
28
10
0.62
.47 (24)
AAQ
Forman (2007)
Anx-Depr
CT
GAF
101
15
0.08
Twohig (2006)
OCD
MBL
OCI Distress
4
8
3.08
4.63 (12)
AAQ
Twohig (2007)
OCD
Relaxation
Y-BOCS
34
8
?
? (12)
AAQ*
Block (2002)
Social Anxiety
CBT
Public speaking
26
6
0.49
---
Willingness
Ossman (2006)
Social Phobia
---
SPAI-DIFF
12
10
0.86
---
AAQ, VLQ
Dalrymple (2006)
Social Phobia
---
SPAI-SP
16
12
1.05
1.41 (12)
AAQ*
Kocovski (2009)
Social Phobia
---
LSAS
29
12
1
1 (12)
---
Roemer (2007)
GAD
---
GAD-CSR
16
16
2.42
1.93 (12)
Accep. and
Roemer (2008)
GAD
Wait-list
GAD-CSR
31
16
2.97
2.34 (36)
values*
Zettle (2003)
Montesinos
(2006)
Math Anxiety
S. Desens.
Math anxiety
18
6
-0.55
- .12 (8)
Initial AAQ
Worries
Control
Fear Interference
20
1
0.33
1.38 (6)
AAQ
Twohig (2004)
Trichotillomania
MLB
MGH-HS
6
7
30.5
2.91 (12)
AAQ
Woods (2006)
Trichotillomania
Wait List
MGH-HS
25
10
2.22
.98 (12)
AAQ
Twohig (2006)
Skin Picking
MBL
Skin picking
5
8
2.81
1.64 (12)
AAQ
Bach (2002)
Psychotic S.
TAU
Rehospitalization
70
4
---
.45 (16)
Believability
Gaudiano (2006)
Psychotic S.
ETAU
BPRS
29
3
1.19
---
Believability*
Gratz (2006)
BPD
TAU
DSHI
22
14
1.01
---
---
Hayes (2004)
Poliadiction
M. Methad.
Analitic
51
48
0.41
.95 (24)
ATQ-B
Twohig (2007)
Marijuana
MLB
Self-report
3
8
---
---
---
Gomez (subm.)
Antisocial Beh.
---
self-control
5
12 h.
1.29
---
---
Luciano (2009)
High risk adol.
---
Prob. behaviors
8
5
1.55
1.1 (16)
Acceptance
AAQ, KIMS
First Author
Dahl (2004)
Greco (submitted)
McCracken (2005)
Wicksell (2006)
McCracken (2007)
Vowles (2007)
Vowles (2008)
Vowles (2009)
Vowles (2009)
Wicksell (2008)
Wicksell (2009)
Gifford (2004)
Hernandez Lopez
(2009)
Gregg (2007)
Lundgren (2007)
Lundren (2008)
Sanchez (2006)
Branstetter (2004)
Montesinos (2005)
Paez (2007)
Fernandez (subm.)
Gutierrez (2006)
Lillis (2009)
Tapper (2009)
Forman (2009)
Quirosa (2009)
Hesser (2009)
Problem
Comparison
Measure
Chronic pain
Chronic pain
Chronic pain
Chronic pain
Chronic pain
Chronic pain
Chronic pain
Chronic pain
Chronic pain
Chronic pain
Chronic pain
Smoking
TAU
----------------Wait-list
TAU
Nicotine Repl.
Smoking
CBT
Abstinence
Diabetes
Epilepsy
Epilepsy
Multiple
sclerosis
Psychoed.
Placcebo att.
---
N
Sessions
Post
F-up weeks
Processes
4
12-14
3-4 weeks
16
3 weeks
3-4 weeks
3-4 weeks
8
4
10
10
14
1.17
1.28
.95
1.25
.75
.49
.65
1.28
.77
.96
.53
.06
1.0 (24)
1.48 (4)
.61 (12)
2.11
--.47
.56 (12)
----.68 (16)
.38 (26)
.57 (48)
----CPAQ
----CPAQ
----------Smoking AAQ*
81
7
.46
.58 (48)
---
HbA1C
Seizures
Seizures
78
27
9
7 h.
9 h.
12 h.
--1.43
---
.15 (12)
1.23
1.3 (48)
Diabetes AAQ*
Epilepsy AAQ*
---
TAU
Valued areas
7
4
?
?
---
Cancer
CBT
Distress
31
12
.9
---
Mental
disengagement*
Cancer
Wait-list
12
1
---
2.53 (12)
---
Cancer
CBT
12
8
.53
1.78 (48)
---
Postsurgical
TAU
13
1
1.42
---
---
HIV prevention
Obesity stigma
Weight loss
Weight loss
Lupus
Tinnitus
Information
Control
Control
--Wait-list
---
45
84
47
29
17
19
1
6 h.
8 h.
12
11 h.
10
?
----.42
----
? (24)
1.07 (12)
.20 (24)
.58 (24)
-- (24)
.91 (24)
--Weight AAQ*
Binge eating*
Food AAQ
--Defusion & acceptance
Sick days
19
FDI
15
Pain intensity 108
Pain intensity 15
Pain intensity 54
Pain intensity 252
Pain intensity 114
MGPQ
11
MGPQ
11
PDI
21
Pain intensity 32
Abstinence 62
Worries
interf
Valued areas
Days
recovery
Risk HIV
WSQ
BMI
Bodily mass
?
Distress
First Author
Problem
Comparison
Measure
N
Sessions
Post
F-up
Processes
Canoeing
Hypnosis
Strength rowing
16
3
?
?
---
Ruiz (subm.)
Chess performance
Control
ELO performance
10
4 h.
---
.79 (28)
Chess AAQ
Ruiz (2009)
Chess performance
Control
ELO performance
14
4 h.
---
.52 (36)
Chess AAQ
Bond (2000)
Worksite stress
IPP
GHQ-12
60
9 h.
.8
.72
AAQ*
Bond (2000)
Blackedge
(2006)
Worksite stress
Wait list
GHQ-12
60
9 h.
.72
.7
AAQ*
Parents autism children
---
GSI
20
14 h.
1.8
.81 (12)
ATQ-B
Hayes (2004)
Stigma & Burnout
Biological ed.
MBI
64
6 h.
.74
.61 (12)
SAB*
Hayes (2004)
Stigma & Burnout
Multicultural T.
MBI
59
6 h.
.26
.57 (12)
SAB*
Masuda (2007)
Stigma (high AAQ)
Education
CAMI
24
2.5 h.
.80
.88 (4)
---
Masuda (2007)
Stigma (mid AAQ)
Education
CAMI
61
2.5 h.
-.13
-.37 (4)
---
Luoma (2008)
Adiction Stigma
---
ISS
48
6 h.
.66
---
AAQ
Lillis (2007)
Racial prejudice
Education
PBADAQ
32
1
?
? (1)
Acceptance*
57
6 h.
---
1.03 (12)
AAQ &
believability*
30
8
---
1.45 (16)
---
Fernandez
(2004)
Varra (2008)
Luoma (2007)
Use validated
treatments
Use validated
treatments
Education
Control
Use of
treatments
Use of
treatments
Research Support for ACT
 Research support

American Psychological Assoc.  ACT listed as Empirically
supported treatment for depression, mixed anxiety, chronic
pain, psychosis, and OCD.

SAHMSHA  ACT Listed on Nat’l Registry of Evidence-Based
Programs and Practice
 Has shown preliminary efficacy as a 1-day treatment
Why 1 Day? Why Group Workshop?

Ensures treatment adherence and completion

NIMH: Deployment Focused Interventions Research
Pragmatic Clinical Trials (PCTs)

More suitable for patients not presenting for psychiatric care
Implemented more
easily in primary care
Less stigmatizing/threatening

More accessible/feasible for:
rural
patients (1/4 US; ½ Iowa)
functionally impaired individuals

Cost effective
Acceptance and Commitment Therapy (ACT)
 Incorporates acceptance and mindfulness strategies with
behavioral change techniques.
 Promotes acceptance of what cannot be directly changed
(private experiences such as thoughts, emotions, bodily
sensations, pain)
 Thought & Emotion Suppression Literature (e.g., Wegner)
 Engagement in previously avoided situations
 Discussion of values and valued-based action
Goal of ACT
Goal is psychological flexibility


Changing/Persisting in
behavior in the service of
important goals or values
Awareness and willingness to
experience unpleasant or
unwanted internal stimuli
Goal is not symptom reduction

This is often a by-product
ACT – Basic Principles
 We get to choose our actions – where we go, what we do
with our hands and feet, what comes out of our mouth.
 We have relatively little choice about the memories,
feelings (including pain), or thoughts that show up in a
situation.
 So the most effective way to change our lives is to focus on
changing our actions and learning new ways to deal
with troubling memories, thoughts, and feelings
ACT Principles:
DO NOT HAVE TO WAIT TO FEEL BETTER
BEFORE DOING SOMETHING
 I can do something I don’t want to do because doing
it is important
 I can not do something I want to do because not
doing it is important
Work in Therapy: always placed within context of
individual values
Fairy Tales... What do they tell us?
 Myth 1: Happiness is the
natural state of all humans
 Myth 2: If you’re not happy
you’re defective
 Myth 3: To create a better
life, we must get rid of
negative feelings and
thoughts
 Myth 4: You should be able
to control what you think &
feel.
The Model
Contact with the
Present Moment
Acceptance
Values
Psychological
Flexibility
Defusion
Committed
Action
Self as
Context
Contact with the
Present Moment
Be here now
Acceptance
Values
Know what matters
Open up
Open
Psychological
Flexibility
Aware
Defusion
Active
Committed
Action
Watch your thinking
Do what works
Self as
Context
Perspective Taking
Contact with the
Present Moment
Be here now
Acceptance
Values
Know what matters
Open up
Open
Psychological
Flexibility
Defusion
Committed
Action
Watch your thinking
Do what works
Self as
Context
Perspective Taking
Acceptance and Defusion
Acceptance/Willingness
Alternative to Control/Struggle: Acceptance
 Imagine you are stuck in quicksand.
 What is your first reaction?
Pain versus Suffering
PAIN
SUFFERING
PAIN
SUFFERING
MORE SUFFERING
PAIN = Physical Sensations of Headache
SUFFERING = “THIS IS AWFUL; I CAN’T BEAR THIS”
PAIN = Physical Sensations of Anxiety
SUFFERING = “This is awful”
Experience of distress exacerbated + person feels they have to do
something to avoid this feeling.
Pain and Suffering
Pain + Non-Acceptance
(struggling)
Pain + Acceptance
Suffering
Pain
Steps to Acceptance
Ask yourself: What thoughts, feelings and sensations
are you willing have to complete a goal?
 Step 1: Observe



Notice what you are feeling and where.
Look for the sensation that is bothering you the most.
Focus your attention on it and observe it with curiosity
 Step 2: Breathe
 Breathe slowly and deeply.
 Imagine you are breathing directly into the sensation, making
room for it. This won’t remove the feelings, but it will create a
center of calm within you.
Steps to Acceptance
 Step 3: Expand
 Make room for those feelings. Create some space for them.
 Step 4: Allow
 Allow the sensations to be there with you, even if you don’t
want or like them. Acknowledge the thoughts and sensations,
as if nodding to them, without giving into them.
Imagine you’re walking in the rain
Cognitive Fusion
 Thoughts are: Reality, the truth, important, orders,
wise.
 When a thought, belief, or story organizes a
person’s behavior in a limiting and unhelpful way
 Fusion with thoughts limits one’s ability to be
present and flexibly responsive
Identifying Fusion
 Rules (e.g., shoulds, must)
 Reasons (e.g., I’m too busy, tired, etc.)
 Judgments (e.g. I’m bad, anxiety is awful)
 Past (rumination)
 Future (worry)
 Self (e.g., I am weak, I can’t cope, I don’t need help)
Fusion  Defusion
Defusion is the act of responding flexibly to
thoughts, beliefs, conceptions, assumptions, and stories
as thoughts, beliefs, conceptions, assumptions, and
stories rather than taking them literally as truths that
must guide one’s actions. It is discriminating between
the product (words or thoughts) and the process
(generating thoughts).
Defusion
 Defusion does not aim to change content of
thoughts. Aims to change the way one relates to
their thoughts.
(not getting rid of…changing relationship to…)
 Seeing our thoughts vs. being our thoughts
Defusion
 Cues
 Able
to let go of being right / looking good
 Disentangles from stories and reasons in the
interest of effective action
 Evaluates thoughts primarily on the basis of
workability rather than “truth” in a literal sense
 Thinking seems open, penetrable, and flexible
Contact with the
Present Moment
Be here now
Acceptance
Values
Know what matters
Open up
Psychological
Flexibility
Aware
Defusion
Committed
Action
Watch your thinking
Do what works
Self as
Context
Perspective Taking
Present Moment Awareness
 Living Life While Paying Attention
 Being present promotes vitality, creativity and
spontaneity.
 “How much do you find yourself thinking about
the past or the future?”
 Flexible
attention/focus, or ability to effectively
shift focus of attention
Skiing Metaphor: Adventure is in the journey, not the
destination. How you get there matters.
Mindfulness
“What day is it?”
“It’s today,”
squeaked Piglet.
“My favorite
day,” said Pooh.
-A.A. Milne
Awareness
Distant
Past
Recent
past
Present Moment
Near
Future
Distant
Future
Question:
What percentage of time were your
thoughts simply in “Present Moment?”
Question:
Which place on the timeline do you notice
that you tend to ‘visit’ when you are not
simply in the “Present Moment?”
Strosahl, Robinson, Gould
Perspective Taking
 Perspective Taking requires….
o Ability to “step back” and become an observer of
events.
o Ability to imagine the point of view of someone else
You are the SKY, not the CLOUDS
...JI , ,/J;(
...... I.
Perspective-Taking
Perspective-Taking
Things change over time – this includes your body, your
thoughts and your feelings.
 Changes will happen, due to the passage of time, gaining
experience, and knowledge.
 When you think back in time, was there something you
once thought was too hard, or too scary, yet now you do it?
 Can you think of anything you used to see one way, but
now see another?
 Did this change just happen through time? Or did you do
something, take some action?
Perspective-Taking
Think of a current situation you are struggling with:
 How would another person possibly see it?
 How would a younger/older version of you see it?
 How would a version of you who isn’t struggling with it
anymore see it?
 What actions would each of these people be able to take?
Contact with the
Present Moment
Be here now
Acceptance
Values
Open up
Know what matters
Psychological
Flexibility
Defusion
Active
Committed
Action
Watch your thinking
Do what works
Self as
Context
Perspective Taking
Values: The key question
How do you want to live your life?
Values
 Your heart’s deepest desires for how you want to
behave as a human being.
 How you want to act on an ongoing basis.
Questions:
 Deep down, what is most important to you?
 What sort of relationships do you want to build- with others
and with yourself?
 If you could live your life, in any way you wanted, how
would you be living it?
 In a world, where it could be about anything, what do you
want your life to be about?
Values
Imagine you are 80 Years
old and you have
continued to live your life
exactly as you do now:
 I spent too much time worrying
about….
 I spent too little time doing things
such as …..
 If I could go back in time, what I
would do differently from today
onward is….
Values-Based ACTions
Actions directed towards personally meaningful purposes,
rather than towards the elimination of unwanted experiences
Step 1: Summarize your values
Step 2: Set an immediate goal
Step 3: Set a medium-range goals
Step 4: Set a long-term goals
“The Journey of 1,000 miles Begins
with a Single Step” ~ Lao-tzu
Values-Based Goals
 Don’t want “Dead Man Goals”
 Chocolate, Depressed, Panic attacks
 Living Person Goals
 So let’s suppose that happens, what would you do
differently? Do more of? How would you behave different
towards friends/family?
 If you weren’t yelling at your kids, how would you be
interacting with them?
 If you weren’t having panic attacks, what would you be
doing differently with your life?
Magic Wand  No longer a problem for you…
Committed ACTion: Doing What Matters
Activity
Go out to eat with
mom
w/w/w/w
Obstacles
Call mom from home May forget to call
on Monday at 6pm
to see if she wants to
go out for dinner this She might not have
time this week
week.
Solutions to Obstacles
Outcome
Write a note to remind
self to call
Went out to dinner
with mom on
Wednesday night.
If mom is busy this week,
suggest lunch or dinner
next week
THE WORLD INSIDE / YOUR MIND
Depression/Migraine Study
Comorbid Migraine/Depression
 Depression 3-5 x more common in migraine than
in general population.
 Decreased QOL, worse prognosis, increased risk
for suicidality, medication overuse, and disability.
Comorbid Migraine and Depression Study
 Quasi-randomized treatment trial
 Goals:
1. Evaluate the efficacy of 1-day ACT intervention,
compared to TAU on:
Depression
 General functioning.
 Migraine-related disability
 Headache

2. Examine process variables associated with depression and
disability
2-Step Screening
 Online via web survey or by phone
 4-12 Migraines in Previous Month
 3 > ID Migraine: PPV 93.3%. False positive rate 19%.
 10 > PHQ-8
 Exclusion: Patients with serious psychiatric illness,
brain injury leading to headache, new medication in
previous 4 weeks.
Intake Assessment (in-person)
Interview to Confirm Presence of Depression:
 SCID Depression Module
 HAM-D (>17)
Self-Report
 Inventory of Depression and Anxiety Symptoms (IDAS)
 World Health Organization Disability Assessment Schedule (WHO-DAS)
 Headache Disability Inventory (HDI)
Process Measures
 Chronic Pain Acceptance Questionnaire
 Chronic Pain Values Inventory
Participant Flow
Screened for
Eligibility N= 1284
Eligible at
Screening N = 173
Enrolled (full intake)
N = 93
Excluded (N=33)
•Didn’t meet inclusion criteria (22)
•Hospitalized/Suicidal (2)
•Not interested (9)
ACT-IM (N=38)
Wait List (N=22)
Week 2: N=37
Week 6: N=36
Week 12: N=37
9-Month: N=32
1-year: N=26
Week 2: N=22
Week 6: N=21
Week 12: N=21
9-Month: N=8
1-Year: N=6
Attended workshop = 7
Intervention
 9:30 am – 3:30 pm on a Saturday
 6-10 participants of all ages
 5 Hours Acceptance and Commitment Training
 1 hour of Illness Management
Structured Clinical Interview for DSM Disorders
(SCID) at 12-Week Follow-Up
Major Depression
No
Yes
Condition
ACT-IM
WL
N= 60
29
2
9
19
Fisher’s Exact: p<.0001
Number Needed to
Treat: =1.5
(Dindo et al., 2012)
Hamilton Depression Rating Scale (HAM-D)
Diff btwn Baseline and Wk 12
Mean (SD)
Trt: 14.0 (1.5)
WL: 4.7 (2.0)
Mixed Model
Condition F=.69, p=.40
Time F= 59.26, p < .01
Time * Condition F=14.71, p <.01
Effect Size= 1.0
(Dindo et al. 2012)
IDAS: General Depression
Diff Btwn Baseline and Wk 12
Mean (SD)
Trt: 15.1 (2.1)
WL: 6.1 (2.8)
Mixed Model With 4 Time Points
Condition F=11.16, p <.001
Time F=19.2, p < .001
Condition * Time F=2.96, p < .05
Effect Size= .71
Headache Disability Inventory
Diff Btwn Baseline and Wk 12
Mean (SD)
Trt: 25.1 (2.9)
WL: 10.3 (3.8)
Mixed Model With 3 Time Points
Condition F=1.42, p = .22
Time F=27.92, p < .01
Condition * Time F=4.88, p<.01
Effect Size= .84
(Dindo et al. 2012)
HAM-D: Recovery Rate
70%
66%
GLIMMIX For Binary Variables
(not normally distributed)
65%
ACT-IM
60%
60%
WL/TAU
50%
40%
33%
30%
36%
24%
20%
Model
Condition F=11.25, p <.01
Time F=.39, p = .67
Condition * Time F= .45, p =.64
ODDS RATIO
3Mo: 6.2 (1.3-28.8) **
9Mo: 2.5 (.44-13.8)
12Mo: 4.8 (.5-45) *
10%
(not depressed)
0%
3-Mo
9-Mo
12-Mo
Results: Headaches
Example of Headache Diary Sheet
Headache
(yes/no)
Severity
1,2, or 3
(see below)
Medication
taken, if any
Effect of
medication
Disability
Work
Leisure
1,2,3,or 4(see below)
1
2
3
4
5
6
7
8
9
Saw a
healthcare
provider?
Y/N
Headache
Frequency
Headache
Severity
(Dindo et al., 2014)
Leisure
Disability
and
Work
Disability
(Dindo et al., 2014)
Medication
Usage
&
Visits to
Healthcare
Provider
Dindo et al., 2014
Role of Pain Acceptance & Values-Based
Behavior in Prediction of
Depression/Disability
N=93
SCID Diagnosis of MDD
Depressed
Non-Depressed
Mean (SD) Mean (SD)
t-test
Effect
Size
Pain Acceptance
57.05 (16.3)
73.8 (14.2)
t=4.1 (p<.01)
d=1.05
Values-Based
Behavior
2.40 (.81)
3.25 (.76)
t=3.8 (p<.01)
d=1.05
Headache
Disability
67.43 (18.8)
48.4 (19.7)
t=3.6 (p<.01)
d=1.0
WHO-DAS
35.7 (14.2)
20 (14.5)
t=3.9 (p=<.01)
d=1.1
(Dindo et al., 2014)
Hierarchical Regression Analyses
Δr2
Predictors
R2
Headache Disability Inventory (HDI)
1. Depression (Self Report)
2. Pain Acceptance
.22**
.20**
.42**
1. HRSD
2. Pain Acceptance
.15*
.25**
.40**
WHO-Disability Assessment Schedule (WHO-DAS)
1. Depression (Self Report)
2. Pain Acceptance
.38**
.10**
.48**
1. HRSD
2. Pain Acceptance
.24**
.16**
.40**
(Dindo et al., 2014)
Chronic Pain Acceptance Questionnaire
1.
2.
3.
4.
5.
6.
Keeping my pain level under control takes first priority
whenever I’m doing something.
Before I can make any serious plans, I have to get some
control over my pain.
I avoid putting myself in situations where my pain might
increase.
My worries and fears about what pain will do to me are
true.
I need to concentrate on getting rid of my pain.
I lead a full life even though I have chronic pain.
Conclusions
 1-day group treatment of ACT-IM can reduce
depressive symptoms and headache frequency, and
improve functioning.
 Targeting pain-acceptance may be particularly
important
Primary Care Effectiveness
Study
Vascular Disease/Mood Comorbidity
World Mental Health Surveys: Risk of heart disease
double in those with mood disorders (major depression
and dysthymia).
Ormel J et al. Gen Hosp Psych 2007.
Primary Care Patient Study
 Randomized treatment trial for patients with
 High Cholesterol, Diabetes, Hypertension, Obesity, Heart
Attack, Stroke, Metabolic Syndrome
 Depression or Anxiety (10 > PHQ-8 or GAD-7)
 Goals
 Establish Feasibility/Acceptability of Treatment,
Randomization.
 Evaluate impact of 1-day ACT intervention on:
Primary: Quality of Life/Functioning
 Secondary: Depression and Anxiety

Completed Screening
(N=827)
Enrollment
Excluded (n=685)
•Low PHQ/GAD (n=635)
•New Med (n=28)
•No Vascular Risk Factor(n=22)
Eligible at screening
(N=142)
Initial Assessment (N=47)
Not scheduled (n=95)
•Could not reach (n=58)
•Declined (n=22)
•Could not make workshop date
Ineligible(n=15)
after first interview (n=3)
• No vascular risk factor (n=1)
• Active Suicidal Ideation (n=1)
• TBI (n=1)
Follow-Up
Allocation
Randomized (N=44)
ACT/IM (N=30)
TAU/WL (N=14)
Intent to Treat (N=4)
Attended Workshop (N=26)
Week 2: (n=26)
Week 6: (n=26)
Week 12: (n=26)
Week 24: (n=26)
Did not Attend Workshop
Week 2: (n=3)
Week 6: (n=3)
Week 12: (n=3)
Week 24: (n=3)
Week 2: (n=14)
Week 6: (n=14)
Week 12: (n=14)
Week 24: (n=13)
Demographic Variables
ACT-IM
TAU
(N=26)
(N=14)
45.0 (11.4)
45.7 (13.1)
Gender, N(%) female
18 (69%)
9 (64%)
Race/Ethnicity, % Caucasian, Not
Hispanic
18 (69%)
12 (86%)
Education, % completed college
18 (69%)
10 (71%)
Working or in school, % yes
22 (85%)
10 (71%)
Currently on an antidepressant
medication
12 (46%)
9 (64%)
Age (mean/SD)
Note. ACT-IM = Acceptance and Commitment Training plus Illness
Management; TAU = Treatment as Usual.
Hamilton Rating Scale for Depression
Diff btwn Baseline and Wk 24
Mean (SD)
Trt: 11.7(1.4)
WL: 0.8 (2.0)
HRSD Score
20
15
Mixed Model
Time * Condition F=9.4, p <.01
10
ACT-IM
Effect Size= 1.4
TAU
5
Baseline
12-Week FU
24-Week FU
Time at Follow-Up
% of participants with > 50% drop on HAM-D
HAM-D: Recovery Rate at 24-wk
90%
Recovery:
Dropped 50% or more in
score.
80%
70%
60%
50%
77% in ACT-IM
21% in TAU
40%
30%
20%
χ2= 11.5,df=1, p < 0.01
10%
0%
ACT-IM
TAU
Treatment Condition
Self-Rated Depression
Diff btwn Baseline and Wk 24
60
Mean (SE)
Trt: 16.7 (2.2)
WL: 1.7 (3.1)
General Depression
55
50
Mixed Model
45
Time * Condition F=8.5, p <.01
40
Effect Size= 1.3
ACT-IM
TAU
35
Baseline
12 Wk FU
24 Wk FU
Time at Follow-Up
Hamilton Rating Scale for Anxiety
Diff btwn Baseline and Wk 24
Mean (SD)
Trt: 12.2 (1.6)
WL: 2.8 (2.3)
HRSA Score
20
15
Mixed Model
Time * Condition F=9.4, p <.01
10
ACT-IM
Effect Size= 1.5
TAU
5
Baseline
12-Week FU
24-Week FU
Time at Follow-Up
HAM-A: Recovery Rate at 24-wk
Recovery:
Dropped 50% or more in
score.
% of participants with >
50% drop on HAM-A
70%
60%
50%
40%
65% in ACT-IM
7% in TAU
30%
20%
χ2= 12.5, p < .01
10%
0%
ACT-IM
TAU
Treatment Condition
Psychological Flexibility Measure (EQ)
1
2
3
4
5
never
rarely
sometimes
often
all the time
1. I am better able to accept myself as I am.
2. I can observe unpleasant feelings without being drawn into them.
3. I notice that I dont take difficulties so personally.
4. I can treat myself kindly.
5. I can separate myself from my thoughts and feelings.
6. I can slow my thinking in times of stress.
7. I can see that I am not my thoughts.
8. I view things from a wider perspective.
9. I can take time to respond to difficulties.
Psychological Flexibility (EQ)
Change in
Psychological
Flexibility
ACT
Intervention
0.47 0.002 (0.34) 0.01
Change In
HamD
Standardized regression coefficients for the relationships between
the ACT Intervention and Changes in Psychological Flexibility and
Ham-D-17 at 24 weeks. The standardized beta for the Intervention
and change in Ham-D-17 controlling for changes in psychological
flexibility is in parentheses. p-value in superscript.
Psychological Inflexibility (AAQ)
1
2
3
4
5
6
7
never
very seldom
seldom
sometimes
frequently
almost always
always
true
true
true
true
true
true
true
1.
My painful experiences and memories make it difficult for me to live a life
that I would value.
1
2
3
4
5
6
7
2.
I’m afraid of my feelings.
1
2
3
4
5
6
7
3.
I worry about not being able to control my worries and feelings.
1
2
3
4
5
6
7
4.
My painful memories prevent me from having a fulfilling life.
1
2
3
4
5
6
7
5.
Emotions cause problems in my life.
1
2
3
4
5
6
7
6.
It seems like most people are handling their lives better than I am.
1
2
3
4
5
6
7
7.
Worries get in the way of my success.
1
2
3
4
5
6
7
Psychological Inflexibility & Distress
 PHQ-GAD: r=.75 (p < .01)
 PHQ-AAQ: r=.66 (p < .01)
 GAD-AAQ: r= .71 (p < .01)
N=919 (SCREENING)
Qualitative Feedback
 Ratio of didactic to experiential work was good
 People empowered by idea of acceptance of emotions
(not fighting) & present-moment connectedness
 2 Facilitators kept things engaging and variable
 6-Hour span was adequate but a follow-up 1-3
months later would be good.
Challenges/Lessons Learned
 Feasible, credible, acceptable, and possibly
efficacious




Randomization acceptable.
Follow-Up retention rates are excellent.
Recruiting people that may otherwise not get help
Severe group.
Questions?
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Dr. Dindo`s Hand-out - Iowa Psychological Association