Nic Hooper, PhD

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The Early Days of ACT

I understand why human beings chase happiness. Quite simply, feeling happy feels good. Yesterday, upon returningphoto 3 home from a 2-week holiday spent in the hills of Tuscany, the feeling I had when I saw my two dogs for the first time was truly one to savour. If you’re not a ‘dog person’ then you won’t get it, but I almost had tears in my eyes as Henry Hooper (black dog) and Dora Thickett (brown dog) jumped around me with utter joy in their hearts.

I can therefore understand why we would want to recreate this wonderful happiness experience over and over again. However, what I don’t understand is why human beings expect happiness to be the normal state of affairs, so that any time feelings of sadness, anxiety, anger etc come along, we feel abnormal. The reason why I can’t understand this is because life is hard. When we are at the early stages of the rat race we tend to think it photowill be simple, but half way through we know different (the picture to the left nicely illustrates this). Why? Because bad things happen all the time. Not just on a big scale either. Forget about death, divorce, trauma and financial loss, every day little frustrating events gradually fill our bucket. I’ll give you an example; if you go on my Facebook page and have a look at my pictures of Italy (like the one below) you will think ‘Wow, he is so lucky, he had a great time visiting some beautiful places, I wish I could go there’. But even a holiday as amazing as Italy brought stressful experiences. For example, I nearly killed us a few times on the roads over there, faulty air conditioning units and soft mattresses affected our sleep, we photo 4spent much time worrying about money and mosquito’s turned my beautiful fiancé into the equivalent of a flee filled dog (I’m banking on her not reading this!). Sometimes I think Facebook and other such sites can be dangerous as we see people post wonderful pictures, but rarely do we see that peoples lives are riddled with both small and large frustrating and negative events that make happiness unlikely.

With the increasing numbers of people reporting ‘mental health problems’, there is no doubt that negative feelings infiltrate our lives. It is how we react to them that really matters. As you may have deduced from previous posts, ACT clinicians encourage their clients to be willing to experience negative thoughts and feelings without managing them in maladaptive and value inconsistent ways i.e. drinking excessively, taking drugs excessively, becoming a hermit, or my personal favourite – going on long dog walks when one should be writing a book (I sometimes dress that up as a value consistent move but it’s really just avoidance!). From my reading in the past couple of months research seems to suggest that the ACT model works in treating various issues. However, ACT would not be where it is today if it were not for a couple of absolute classic studies that every ACT person should know. Conducted by some inspirational human beings, below is a few rough paragraphs from our upcoming book (‘The ACT Journey’) that details this research.

Research, written on a blackboard.

“Zettle and Hayes (1986) conducted the earliest investigation in the area of depression when they compared Cognitive Therapy (CT) and Comprehensive Distancing (CD) in the treatment of depression. Comprehensive Distancing was the early formulation of the ACT model, it involved three themes; challenging the control agenda, questioning the causal relationship between thoughts and behavior, and developing the ability to distance oneself from ones thoughts. In each condition 6 depressed women received 12 weekly sessions. Results indicated that both groups improved, however, CD was most effective at reducing depression (assessed via typical outcome measures and interviewer rated depression) at post-treatment and 2-month follow-up. Most importantly, the researchers found that the improvements made in each condition occurred via different mechanisms, where those in the CD condition experienced greater reductions in believability. This paper is a classic and underpins much of the ACT rationale that was to develop in the following 20 years. For example, it was one of the first empirical articles to suggest that many clients enter therapy with reasons for their behavior that point towards emotions (‘I cannot go to the shopping center because it makes me anxious’). In instances like this people use their feelings as reasons for behavior. According to the authors statements like these have become accepted and reinforced by the verbal social community such that they exert control over behavior. But from the viewpoint of a radical behaviorist, the behavior of reason giving cannot by itself cause subsequent behavior (a behavior-behavior relationship), but is maintained via environmental contingencies (reinforcement of reason giving behavior). Therefore instead of attempting to alter someone’s feelings or thoughts, which is arguably a difficult thing to achieve, it is possible to change ones relationship to them such that a therapist can encourage a client to experience anxiety and still make that trip to the shopping centre. Interestingly, from this early stage the authors inadvertently pointed towards the issues of measurement that have been previously mentioned in this volume; the utility of most clinical interventions is measured by symptom reduction, yet ACT does not aim to reduce symptoms, but to lower the way in which negative thoughts and feelings exert influence over behavior.

The take home message from the Zettle and Hayes (1986) study was that CD decreased depression and reason giving via the lowering of believability, without reducing the frequency of unwanted private events. Zettle and Rains (1989) later conducted a similar study when they compared the application (in group format) of CT, CT without distancing (PCT: Partial Cognitive Therapy) and CD to depressed clients. Although results indicated that all three interventions significantly reduced depression, Zettle, Rains and Hayes (2011) later suggested that those in the ACT group tended to record better scores on the depression outcome measure (BDI), whilst those in the PCT group came in a close second. This is an interesting finding as CD involved explicit distancing and PCT involved no distancing, yet both approaches worked. This suggested that clinical improvement might have occurred via different pathways. Indeed this assertion was substantiated by the finding that dysfunctional attitudes were reduced in both the cognitive therapy groups but not the CD group. In other words, although clinical improvement was made in the CD group, like Zettle and Hayes (1986), this did not happen due to altering the form or frequency of negative thoughts.

Given that these studies were published so early, it is not surprising that the authors did not run a formal mediational analysis to determine the mechanisms underlying clinical improvement. Luckily they did keep the data, so were able to publish a re-analysis of both papers 20 years later. Hayes, Luoma, Bond, Masuda and Lillis (2006) found that outcome differences between the CT and CD conditions in the Zettle and Hayes (1986) article were mediated by the believability of depressive thoughts and not the occurrence of these thoughts. Zettle, Rains and Hayes (2011) published a slightly more detailed re-analysis of the Zettle and Rains (1989) article. In the original paper the results did not take into account participants who dropped out of therapy. The re-analysis therefore adjusted for the impact of missing data, it also ran a mediational analysis to determine the mechanisms of change. The intent-to-treat analysis indicated that CD produced greater reductions in depression whilst the process analysis found that believability (cognitive defusion) mediated the outcome effects observed at follow-up. Importantly, the occurrence of depressive thoughts and levels of dysfunctional attitudes were not mediators. For information about the leading researcher and his thoughts on the future for ACT see Dr. Rob Zettle’s research profile below.”

Note: the Research Profile of Dr. Rob Zettle is not here – though it will be found in the book ; )

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