The Turtle and the Hare
Steven C. Hayes
University of Nevada
A CBT Take on ACT
• From the point of view of some in the CBT
mainstream ACT is a newcomer seemingly
making bold new claims intended to
threatening the dominant paradigm
• After all CT / CBT folks have long talked
about [insert your ACT term here]
ACT and CBT
• From an ACT perspective, this response is off
point in many ways
• ACT is not a newcomer, not anti-CBT, and
not primarily a new set of terms or techniques
• While some of what is in ACT is in many
clinical traditions, it is also relatively distinct
• What is distinct?
ACT and CBT
• ACT is a specific model, linked to a specific
philosophy, theory, goal, and program of development
• It’s not just ACT, it is ACT, RFT, and Contextual
Behavioral Science (post-Skinnerian behavior analysis)
• And to the extent that there is something new about
ACT it is the entirety of it and most especially its
developmental approach
• That will be my focus today … just a little data
ACT is Part of CBT
• Under the heading “ACT as a Contextual
Cognitive-Behavior Therapy” we said
• [ACT] is a form of clinical behavior analysis or
a behaviorally-rationalized therapy. But the
content … is all about cognition and emotion,
even though the model is not cognitive in an
information processing sense. Thus, it is
reasonable to call it a cognitive-behavior
therapy.” Hayes, Strosahl, & Wilson, 1999)
ACT and CBT
• CBT can mean many things. It can mean an
overarching term for a tradition.
• If it is that, ACT is part of it, and it makes no
sense to compare a specific model to a loose
and evolving tradition that ACT itself is part of
and has helped over nearly 30 years to evolve
• It can mean a specific model and there you can
make comparisons but you need to define terms
and thus leave parts behind. For example Beck:
“cognitive therapy is best viewed as the
application of the cognitive model of a particular
disorder with the use of a variety of techniques
designed to modify the dysfunctional beliefs and
faulty information processing characteristics of
that disorder” (Beck, 1993).
That you can compare … but do know that if you do some
people will say “that’s not CBT” and they will trot out their
own favorites … often even brand new things. That is why
I said in a recent article “you cannot compare a model to a
scientific bowl of Jello”
Knowing the History Helps
• ACT has a unique history that is nearly 30 years old
• From the beginning we were very interested in
cognition but wanted a theory that worked, against
behavior analytic criteria
• In the mid-1980s we did a series of studies on what
accounted for cognitive therapy effects - the results
did not comport with a cognitive model
• And we did a component analysis of Beck’s
cognitive approach - the results also did not
comport with a cognitive model
History
• We developed an alternative approach based on our
early behavior analytic thinking
• Compared it to Beck’s approach and found
differences in outcomes and processes of change
• And committed firmly to our own developmental
path, spending 15 years on it before bringing the
results forward
• What is that path (white is common, yellow
uncommon, red is very uncommon or unique)?
Developmental Characteristics of ACT:
Clear Assumptive Base
• Be clear about your ultimate goals and
constantly work toward them
– a comprehensive psychology more adequate to
the challenge of the human condition
• Be clear about philosophical assumptions and
consciously link all work to them
– functional contextualism / prediction and
influence with precision, scope, and depth
Developmental Characteristics of ACT:
Clear Theoretical Base
• Be clear about key processes that account for
psychological problems
• Try to integrate these processes into a
pragmatically useful overall model of
psychological difficulties
• Be clear about key processes of
psychological change
• Integrate these processes into a pragmatically
useful overall model of psychological change
Thus the Ubiquitous
Hexagon
Contact with the
Present Moment
Acceptance
Values
Psychological
Flexibility
Defusion
Or Perhaps
it is a Turtle
Committed
Action
Self as
Context
Developmental Characteristics of ACT:
Basic Behavioral Principles
• Link all such processes to basic principles that describe
the manipulable contextual and historical factors that
account for them
• Develop additional basic principles of that kind if new
ones are needed – and we came to believe that cognition
required such additional principles
• Establish a basic research program on these principles
that is independently of interest to experimental
psychologists so as to expand that base
• Show that these basic principles can be used to model
the phenomena supposedly originating from them
Developmental Characteristics of ACT:
Process Focus
• Develop measures of these key problematic
processes and processes of change – e.g., AAQ
• Show that they help explain psychopathology in
naturalistic studies – approaching 10,000 Ss
• Document differences in processes of change and
conduct formal mediational analyses early on, if
these fail tweak the technology or model
• Do many component studies on the impact of
targeted techniques
Meta-Analysis of ACT Mediation
• 12 ACT RCTs (out, in press, or submitted)
have either formally tested ACT processes as
mediators or we could get the data and do
that using post mediators and follow up
outcomes
c’
a
b
c
The Resulting Study List
Study
Problem
Comparison Group
Outcome Measure
Mediation Measure
Wicksell et al. (in press)
Chronic pain
Wait list control
Satisfaction with life
scale
PIPS
Lillis et al. (under submission)
Weight
Maintenance
Wait list control
BMI
AAQ for weight
Gifford et al. (under submission)
Smoking
Bupropion
One year smoking status
AIS
Lundgren et al. (in press)
Epilepsy
Supportive treatment
Seizure frequency and
duration
AAQ-epilepsy,
Varra et al. (in press)
Resistance to
use EBT
Education
Current use of EBT
STA believability and
AAQ
Lazzarone et al. (2007)
General Distress
Wait list control
GHQ
AAQ, KIMS
Gregg et al. (2007)
Diabetes
Education
Blood glucose level
AAQ-D and selfmanagement
Lillis & Hayes, (2007)
Ethnic prejudice
Education
Positive action intentions
Acceptance and
Flexibility
Lappalainen et al. (2007)
Depression,
anxiety
CBT
SCL-90
AAQ
Hayes et al. (2004)
Stigma and
Burnout
Education Control
CASA
SAB
Block et al. (2002)
Social phobia
Wait list control
Speaking time
Willingness
Zettle et al. (1986)
Depression
Cognitive Therapy
BDI
ATQ-B
A Wide Variety of Problem Areas
• Mental Health: General psychological
distress; Social phobia; Depression; Anxiety
• Health: Weight maintenance, Smoking
cessation, Epileptic seizures, Diabetes
management; Chronic pain
• Social and employment: Ethnic prejudice,
Stigma and Burnout
• Learning and adoption: Resistance to using
evidence-based treatments
And Comparison Conditions
•
•
•
•
•
•
Traditional Behavior Therapy
Traditional Cognitive Therapy
Pharmacotherapy
Psychoeducation
Wait list control
Supportive treatment
And ACT Process Measures
• 50% used a specific measure of experiential
avoidance and psychological flexibility
targeted toward the treatment domain
• 25% of the studies used defusion mediators
• 25% used the AAQ
• Others mediators used included mindfulness,
willingness ratings, and values
Results
• All showed significant reduction of the direct
effect due to the mediator (73% at p < .05; the
rest at p < .1)
• A large portion of total effect of ACT at follow
up is accounted for by mediators at post that
are specified a priori by an ACT model (i.e.,
c’/c)
• That is not typical
c’
a
b
c
Developmental Characteristics of ACT:
Process Focus
• Develop measures of these key problematic
processes and processes of change – eg AAQ
• Show that they help explain psychopathology in
naturalistic studies – approaching 10,000 Ss
• Document differences in processes of change and
conduct formal mediational analyses early on, if
these fail tweak the technology or model
• From the start, do component studies on the impact
of targeted techniques
Component Studies
• We know of approximately 16 experimental
component studies on defusion, values,
acceptance, and self-as-context … and
• All have shown specific ACT techniques in
these specific areas to be psychologically
active and to work is a way that comports
with an ACT model
Developmental Characteristics of ACT:
Evaluation Strategy
•
•
•
•
Do intensive, small N outcomes studies
Yes, do randomized controlled trials
Attack very difficult problems early on
Use a wide variety of comparison conditions,
including empirically supported treatments
early on
Developmental Characteristics of ACT:
Practicality and Breadth
•
•
•
•
Conduct effectiveness studies from the beginning
Begin prevention trials early
Care about training methods and impact early on
Early on examine automated interventions and
bibliotherapy
• Challenge the model by wide extension to
applicable domains
– constantly extend the clinical breadth of application
– examine non-clinical applications early
Controlled Studies Since 2000 on …
•
•
•
•
•
Depression
Smoking
Anxiety
Psychosis
Substance
abuse
• Diabetes
• Chronic pain
•
•
•
•
•
Epilepsy
Burnout
Worksite stress
Racial bias
Self-stigma in
substance
abuse
• Weight loss
• PD
• Learning to use
MI
• Learning to use
pharmacotherapy
• Bias toward
mental patients
• Social anxiety
• OCD
• ASD
The Hare
• When BT stumbled in the mid 70s, CBT jumped into
clinical models of cognition, but to do so had to let go
of the basic principles tradition of behavior therapy
• The CBT mainstream then made other jumps – it
jumped into RCTs on packages, often without looking
closely at:
– how they worked
– whether “syndromes” really made sense as a way to
organize people into treatment responsive groups, or
– what functional components they contained
• It has lead us to shocking outcomes like this …
Dimidjian et al, High Severity Group
Pre to Post Decreases in BDI
0
5
10
15
20
25
30
ADM
Behavioral
Activation
CT
The Hare
• Seems to want to continue to jump. Into new
clinical theories without a basic foundation of
manipulable principles
• Or into new techniques often still hoping that
a progressive science can be built around
RCTs and empirically supported manuals
linked to syndromes
New Manuals!
New Theories!
New “Disorders”!
It’s All CBT,
CBT, CBT!!
The ACT Turtle
• Traditional CBT needs to get back to the lab …
(and I think it will) but when it does it will find
ACT / RFT turtle already there
• Walking its own path, with its slow focus on
philosophy, theory, basic principles, processes,
components, practicality, and breadth
Assumptions … uh
Principles … uh
Processes … uh
Outcomes … uh
It is Not “ACT versus CBT” because
• The way of the turtle is not advanced one iota
even if the hare collapses of manic
exhaustion or internal contradictions
• We are not in a race against each other. We
are in a race toward our own goals
• The hare’s goal have often seemed to the
turtle to be different. This is different:
“cognitive therapy is best viewed as the
application of the cognitive model of a
particular disorder with the use of a
variety of techniques designed to
modify the dysfunctional beliefs and
faulty information processing
characteristics of that disorder” (Beck,
1993).
The Way of the Turtle is Different
• We are trying to build from the bottom up
• And when we fail (and we have and we will!)
we will respond as we always have
The Way of the Turtle
•
•
•
•
Did the process move?
Did the process relate to the outcome?
Do we understand the process?
How can we move it or reformulate it?
The Turtle and Hare
• It is a difficult time for traditional CBT … as
one CBT leader in Sweden recently said –
ACT has given us a healthy kick in the teeth
• That is not what we came here to do: but it
also does no good just to “play nice”
• The point is not politics but progress
• So let’s discuss things together … even as we
follow the way of the turtle in the interests of
those we serve