ACT for

thriving
young people

Louise Hayes, PhD,

Fellow Association for
Contextual Behavioural Science

Orygen Youth Research Centre,

The University of Melbourne

www.louisehayes.com.au

Dna-V Model Cannot Be Reproduced

Without Prior Permission

Please cite all work as:

Hayes, L. L., & Ciarrochi, J. (2015). The
Thriving Adolescent: Using Acceptance and
Com- mitment Therapy and Positive
P s y c h o l o g y t o H e l p Te e n s M a n a g e E m o t i o n s ,
Achieve Goals, and Build Connection.
O a k l a n d , C A : N e w H a r b i n g e r.
 A unified approach to improving the lives of young
people!
The Thriving
FOR
Adolescent
THERAPISTS,
TEACHERS
& SCHOOL Using Acceptance and Commitment
COUNSELORS Therapy and Positive Psychology
to Help Teens Manage Emotions,
Achieve Goals, and Build Connection

www.actforadolescents.com

Louise L. Hayes, PhD

Joseph Ciarrochi, PhD
uncorrected proof
Steven C. Hayes, PhD
Foreword by

Model

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Rationale

• Our question -How do people grow flexibly?

• ACT

• Based on psychopathology - originally

• For adults

• Did not account for growth in development

• Was top down, we wanted bottom up

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 Connection
• large portion of the human brain is devoted to recognizing
facial expressions and vocalisations

• recorded imitation of adult facial expressions as early as

42 minutes after birth

• by 6 months of age infants readily show the same

emotions as adults who are caring for them

• when we witness emotions in another, our brain shows that

same emotion; in other words, we mirror what others feel

• by the toddler years, spontaneously help others

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we all begin life the
same way

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as babies we
cry when we
are sad

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laugh when
we're happy

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we just feel.
even if it is.......

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• We all begin seeing, hearing, touching, tasting, smelling
• the world just as it is - a physical experience

• We call this the - Noticer

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Then we
discover

• the world can be moved

• manipulated

• changed

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Your words here... we soon set out to
discover the world

hey
what's out
here

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Psychological
Flexibility
 Mindfulness Psychologica
l Flexibility

Source, Hayes
2005

Behaviour
Psychologica
l Flexibility Change

Source, Hayes
2005
 we soon become
discoverers of all
sorts of things....

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 at first adults
speak for us

you are
tired

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then we take over

and speak for
ourselves

I'm not
tired!!!

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 quiet... I'm trying to
think

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slowly we create a new world, a

world made of our thoughts,
words, memories, ideas.....

it is unique to us and we create it

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and then, even if the we have the
physical world power to
looks like this. see this
instead......

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You should do
this!

you should do
that!

why don't you

slowly we create our very you did

own.... it
again!!!!

you got it
wrong!

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our best friend too….

one day
I'll ....

remember
when..

your advisor is also

your longest friend
and constant
companion

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Not this kind of DNA

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 Current situation and presenting issue
Why is the person seeking or needing help?
What are the important aspects of the person’s
environment (other than social context), such as sleep
patterns, medical conditions, a dangerous
environment, and nutrition?
Social and historical environment
Who is important to the person? Why?
Who can the person turn to for help?
Who is the person in conflict with?
Who is the person disappointed in?
What critical experiences have happened in the past?

Able to try new Able to generate beliefs,

behavior to discover
what works and builds
value.
Able to spot and
develop strengths.
predictions, evaluations,
reasons, justifications, self-
concepts, and so on.

Uses workable
beliefs to guide
action.

Exploration is driven
toward building values
rather than by impulses
that undermine values.
Tries new behavior when
old behavior doesn’t
work.
Has clear values.
Uses values to guide
action—connecting,
giving, being active,
challenging the self,
enjoying the moment,
and self-care.
Able to listen to the
advisor and unhook
from unhelpful beliefs,
such as beliefs about
emotion control and
justifications for
unworkable behavior.

Notices self, others, and events unfolding in the present

moment.
Able to notice and make space for difficult inner
experiences to come and go without immediately
reacting to them.

Self-view Social view

Recognizes that self is more than self-concepts.
Can see the self as holding self-concepts.
Sees that growth and improvement are possible.
Doesn’t view self-concepts as physical descriptions of
the self.
Can view himself or herself with compassion.
Recognizes the value of social connection.
Is able to have empathy and compassion for others.
Can cooperate, build friendships, and love.
Sees that history with others influences present
interactions, and believes he or she can change.
Sees personal agency: “I can choose” instead of “They
made me like this.”

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DNA-V is a CBS model

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CBS is a science with multiple levels

1. Evolution science and it’s principles of variation, selection and

retention as an adaptation for all living organisms

2. worldview of functional contextualism

3. behavioural principles from operant theory and relational frame

theory

4. applied realm with Acceptance and Commitment Therapy (and fellow

travellors)

• One goal:

• basic and applied scientific methods to predict and influence the

behaviour of humans with precision, scope and depth

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Evolution science

• variation, selection, and retention

• encouraging young people to flexibly try different things

(variation)

• to discover what works, or what is consistent with values

(selection)

• discover something that works, they are reinforced for

persisting in that behaviour (retention)

• need to be sensitive to ever changing context, that is,

psychologically flexible (adaptive)

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Functional Contextualism

• A view of the world - not the right view or the only

view, just our view

• Our subject is always behaviour-in-context

• Behaviour is - thoughts, feelings, sensations, memories

• Context is - everything else!

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physical
environment intrapersonal

ANTECEDENT → BEHAVIOR → CONSEQUENCE

interpersonal time
personal
history

Slide: J and M Villatte (2013)

38 ACBS Boot Camp Reno
Operant behaviour principles

• operant principles involve selection by consequences

• behavior that is reinforced gets selected (or is more likely to be

repeated)

• behavior that is not reinforced or is punished get selected

against (is less likely to be repeated)

• Years of research show these principals are well established in

humans and child development (Patterson, 1982, 2002)

• and are well established treatments for children (Brestan &

Eyberg, 1998; Ollendick & King, 2004)

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A detour

• Operant principles - what went wrong?

• abandoned

• no way of dealing with complex symbolic processes

• along comes….

• Relational frame theory

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RFT

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Relational Frame Theory

• new principle for verbal behaviour:

• arbitrarily applicable derived relational responding

• Arbitrarily applicable means that stimuli are related based on social convention or verbal history

• ‘derived’ refers to our capacity to infer relations without ever needing direct contact

• - in other words - relating

• an operant

• In depth read: S. C. Hayes, Barnes-Holmes, & Roche, 2001; S. C. Hayes, Strosahl, Bunting, Twohig, &
Wilson, 2004

• RFT now has over 100 studies (e.g., Barnes-Holmes, Barnes-Holmes, Stewart, & Boles, 2010; McHugh &
Stewart, 2012; Rehfeldt & Barnes-Holmes, 2009).

• Clinicians read: Torneke, N. (2011). Learning RFT. New Harbinger: Oakland CA

• For an easier RFT read - ironshrink.com

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Derived Relational Responding

Noticer’s bodily
sensations
fear

Earthquake

Earthquake -
antecedents - shaking
ground, hot sun, etc…

Advisor’s hearing - this is

quake, prior learning
danger, keep safe, etc
Transformation of Stimulus Function

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• Transformation of
stimulus function

• Allows you to learn fast

=

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Derived Relational Responding

discover - explore
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Derived Relational Responding

community

connection
love Noticer’s bodily
sensations
fear

Earthquake
Earthquake -
antecedents - shaking
ground, hot sun, etc…

Advisor’s hearing - this is

quake, prior learning
danger, keep safe, etc
agency

Transformation of Stimulus Function

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once we relate - we become insensitive
to changes in context
Problem with insensitivity

EXIT

Responses become overgeneralized and resistant

• Slide: J and M Villatte (2013) ACBS Boot Camp Reno
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to change

ACT allows us to bring new contexts

…… through experiences, ah-ha moments, we see new
relations and we transform meaning

• “Sadness means there is something wrong with me”

• “Sadness means it’s time to connect with others”

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DNA in clinical practice

An ACT model for young people

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Our goal
• psychological flexibility in adults:

• “the ability to contact the present moment more fully as a conscious

human being, and to change or persist in behavior when doing so serves
valued ends” (S. C. Hayes, Luoma, Bond, Masuda, & Lillis, 2006, p. 8)

• for young people we can say - flexible strength

• the ability to utilise DNA skills in a way that promotes growth and builds
vitality and valued action.

• no assumption that young people have values

• assumption that testing and exploration are necessary

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Ta k e t h e D N A w a l k o f l i f e

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what matters to you?

Va l u e s

• chosen

• quality of action

• not an outcome

• not a goal

• constructed from language

• held lightly

• dynamic

• intrinsically reinforcing

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variation in behavior
Discoverer

test themselves
explore their world
build strengths
find out what they value

W h a t ’s t h e
purpose?

• a time of physical and mental

maturing

• compared with children they are:-

• physically - faster, stronger,

bigger,

• psychologically - have greater

reasoning capacity, greater
capacity to handle stress,

• biologically - increased pain

tolerance, and better immune
function (Dahl, 2004)

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adolescents in a modern context

• Traditional societies - adolescence was a 2-4 year period,

• physical maturation key indicator

• learnt adult roles from adults

• spent time caring for small children and babies

• lived in larger family and community groups

• majority of their waking hours with adults of the same sex –

• in 66% of 161 cultures for boys and in 84% of 160 cultures for girls

• For boys, the father was the single most important agent in 79% of 173 cultures, while the
mother is the most important for girls in 85% of 171 cultures (Schlegel, & Barry. 1991).

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are we adapted for this?

• In just a few hundred years we have changed adolescence

• It now lasts 10 years,

• They spend more time than ever with peers, rather than adults

• % of children with one parent?

• Most of their adolescence is spent with people 12-18 months in age

range

• Families are smaller and more transient

• Internet and television sources of information

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What is the purpose of adolescence?


• Adolescence seen across 187 countries (Schlegel & Barry,

1991)

• shared characteristics –

• risk taking,

• love of novelty,

• sensation seeking,

• and changes in peer and family relationship

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And in non-human animals

• Non-human animal studies

• Adolescent animal behaviours include: risk taking, sensation seeking, and a preference for
novelty (Spear, 2004)

• For example, three age groups of mice were introduced to an elevated maze that had no
protective walls and a risk of falling (Laviola, Macrı,̀ Morley-Fletcher, & Walter, 2003)

• juvenile and adult mice avoided the maze, showing heightened stress response to it.

• Adolescent mice were attracted to the dangerous maze and didnt display any
heightened anxiety levels to it.

• Animal research - risk and attraction to novelty is needed to leave safe surroundings to
mate, especially for males (Spear, 2004)

• Risk has trade-off costs - attraction to novelty exposes animals to life threatening
situations (Kelley, et al., 2004; Spear, 2004)

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 Strength brings
v u l n e r a b i l i t y. . .
• morbidity and mortality rates increase
in adolescence by 200%

• major source of this difficulty is

emotional and behavioral problems

• psychiatric illness is most likely to begin

• greatest time for maladaptive risk

taking: sensation seeking and the onset
of alcohol, drug and substance use

• have good reasoning and problem

solving skills, yet are are more prone to
erratic and emotionally influenced
behavior with peers

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R i s k o p p o r t u n i t i e s i n t o d a y ’s m o d e r n
context

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variation in behavior

Noticer

aware their bodily sensations

able to label as feelings
enjoy the moment
experience their world
We Begin as Noticers
• As babies we experience the world as physical sensations - feelings and sensations are
there as signals

• By age 3 we have labels and can link emotions and events. Parents are their primary
source of information

• By the middle years, the Advisor dominates their interpretations of sensations - they
become their own information source.

• Adolescence is deeply emotional - a time more emotional than any other (Siegel, 2014)

• In our society we are taught to manage our bodies and emotions, we have been taught to
use cognition

• deficits in noticer skills can lead young people to respond to emotions in rigid ways,
reacting to them with either avoidance or impulsivity

• MAKE. THIS. FEELING. STOP!

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Noticer

• in 3 steps

• 1.Build awareness that ALL feelings are normal, and

control is the problem.

• Feelings do not need to be controlled,

eradicated, changed or managed

• 2.Coach emotion awareness and labelling

• 3. Practice allowing feelings rather than controlling.

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 Why become aware and label
sensations?
• Being able to label the incoming signal is enormously important

• It helps us ‘make sense’

• Some research examples:

• Young people who struggle to identify their feelings tend to develop emotional
problems and poor social networks (Ciarrochi, Heaven, & Supavadeeprasit, 2008)

• Adults who struggle to identify their feelings are much more likely to turn to
substance abuse to cope with emotions (Lindsay & Ciarrochi, 2009)

• Adults more likely to experience asthma, hypertension, chronic pain, and

gastrointestinal disorders (Lumley et al., 2005)

• Limited skills in emotion identification are associated with death due to increased
risk of cardiovascular disease, accidents, injury, and violence (Kauhanen, Kaplan,
Cohen, Julkunen, & Salonen, 1996; Tolmunen, Lehto, Heliste, Kurl, & Kauhanen,
2010)
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Why we need to allow?

1. Avoidance—the flip side of allowing— shown across

many studies to be problematic.

1. It doesn’t work and often makes things worse (S. C.

Hayes, Wilson, Gifford, Follette, & Strosahl, 1996).

• e.g. PTSD - avoid trauma from being remembered,

social anxiety - avoid negative evaluations

2. Expands people’s ability to respond and act in valued

ways = variation

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variation in behavior

Advisor

use your past learning flexibly

sees thoughts are guide - not fixed

unhook when not useful

 one day
I'll ....

Upsides of the Advisor remember

when..

your advisor is also

your longest friend

• protects us from danger

and constant
companion

• don’t want to rely on trial and error experience to learn everything

• promotes high-speed evolution

• e.g rapid scientific and technological advances

• promotes fast and efficient functioning

• while sitting in your living room you can surf the net and learn how to sail a
yacht.

• encourages us to follow helpful rules

• e.g. toddlers love to follow rules, teens less so

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You should do
this!

Downsides of the Advisor you should do

that!

why don't you

• unhelpful evaluations, beliefs, and rules—over reliance on the slowly we create our very you did
it

advisor—can limit variation

own....
again!!!!

you got it
wrong!

• can lead to rigid rule following

• rules tend to make us insensitive to the actual situations that exist in the physical world (S. C.
Hayes, 1989)

• absorbs others’ unhelpful ideas

• we often rely on socially transmitted ideas, such as other people’s advice and opinions

• can become decontextualized

• environments are typically heterogeneous and changing, so a verbal rule that works at
one time in one environment may be entirely useless in another

• can distort incoming information

• this distortion is all AADRR

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Unhooking from your advisor

• 1. We hear the advisor and experience those thoughts

as passing sounds, rather than literal truth. 


• 2. We recognize that the advisor may not be useful all

the time. 


• 3. We shift into noticer or discoverer mode in order to

test this and engage in valued action. 


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Self view

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 Where is the rest of the moon?

Self is always more than what you see now…..

Step into noticer and try new perspectives

Applying Behavioral Principles

to Examining the Self
• Self is merely the act of relating to oneself

• but with use it is over learned

• it can become us, but with variability in behaviour,

we can become free of this

• as behaviour, it therefore has ABCs

• Q to ask = how does the selfing work in this

context?
 Social view

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Conceptual using the DNA model

Current situation and Social and historical
presenting issue environment

What kind of person do you want to be in this

relationship?

What do I care about in this relationship?

Self-view Social view

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 loneliness image

. Young people report the highest rates of

loneliness in any age group (Hawkley & Cacioppo,
2010; Heinrich & Gullone, 2006).
79 percent of those under eighteen reported feeling
lonely sometimes or often. 


What does loneliness

predict? ….
• Heart disease

• Obesity

• Impaired cognitive performance

• Poor sleep quality

• Poor immune function

• Mental health problems

• Poor self-control

• ….and the list goes on

Meaney - Lick your young

Adolescent attachment
• Adolescence is a time of critical growth in biological, brain,
cognitive and social functioning (Sternberg, 2014)

• adult problems set their roots, with up to 40% of mental illness

(Mcgorry, 2012) in adults beginning in the adolescent period

• need a solid relationship with parents that facilitates

communication, and allows exploration but also providing fair rules
and boundaries (L. Hayes, 2004)

• does not mean absence of conflict

• Securely attached adolescents will have a strong relationship,

be able to express their opinions even while disagreeing,
validate other’s opinions and show empathy
 Changing relationships
• During adolescence, perceived parental support declines
and perceived support from friends increases until the point
where support from both sources are similar (Helsen et al.,
2000) (Furman & Buhrmester, 1992).

• Later adolescence is characterized by another shift, this time

away from peers towards romantic relationships (Helsen et
al., 2000) (Brown, Eicher, & Petrie, 1986).

• Importantly, support from parents is more strongly associated

with well-being and development than support from friends,
and having friends does not adequately compensate for a
lack of support from parents (Helsen et al., 2000)

rat licking for humans

=
nurture them,
connect,
appreciate,
in appreciation,
give them your TIME!
why might YP be lonely?
• Some suggestions:

• psychologically separating from their parents,

• moving outside the comfort and safety of a familiar relationship

• move beyond peer relationships based on activities to ones based on

loyalty, support, intimacy, and shared values

• many adolescents do not yet have the skills to develop and maintain
such intimate relationships

• busy families, working stressed parents

• Structure of our schools, changing classes, busyness, revolving teachers

why might YP be lonely?

Modern environments :

• may decrease the chance of young people forming

social connection

• young people don't have to interact with other

humans, use electronic gadgets or television

• don’t let them explore for fear they are in danger

 Academically smart,
emotionally and socially stupid
• Culture:

• We strive to build their IQ

• Good grades, good careers, study hard,

benchmarking tests, homework

• Social skills (for some) are squeezed into spare time

• 12 years developing their academic intelligence

• How many developing their social intelligence?

Social view

• The ability to shift between Discoverer, Noticer, and

Advisor, in the service of valued connection.

• need to guess what it’s like to be in another’s

shoes

• and then hold those guesses lightly while using

noticer and discoverer skills to learn about others
 setting the change
agenda

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Control is the problem

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setting the change
agenda

Use Noticing Skills to Draw Out the Unworkability

of Control Strategies - being stuck

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setting the change

agenda

Use the Discoverer to establish creative

Hopelessness

has it been working?

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setting the change
agenda

Connect DNA to V to promote willingness

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setting the change

agenda

Where possible, work with the social context, not

just individual in the room

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Willingness question

• Am I willing to allow ___________[internal states]

• in order to_________________ [do a valued activity]?

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Willingness research

• Gives people choice, and this can make experiencing

negative emotions less aversive (Bown, Read, & Summers,
2003; Smith, Jostmann, Galinsky, & van Dijk, 2008)

• e.g. rats and humans appear to experience electric

shocks as less aversive when they have some control over
when the shock occurs (Gliner, 1972)

• Connects negative emotions to valued actions.

• e.g. a difficult situation is less aversive if we can ascribe

meaning to it (Coutu et al., 2010)

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101

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Follow - up:

1. S l i d e s - g o t o w w w . h t t p : / / w w w . l o u i s e h a y e s . c o m . a u /

f r e e - r e s o u r c e s - f o r- p r o f e s s i o n a l s /

2. P r o f e s s i o n a l D e v e l o p m e n t w o r k s h o p -

w w w. l o u i s e h a y e s . c o m . a u

3. R e a d i n g a n y t h i n g a b o u t C B S / A C T - b e s t b o o k i s H a y e s ,

Strasahl and Wilson 2102 Acceptance and Commitment

Therapy

4. C o n f e r e n c e - A N Z i n N e w Z e a l a n d i n N o v e m b e r

w w w. a n z a c t . c o m

Thank you,
The Thriving
Louise Hayes FOR
THERAPISTS,
Adolescent
TEACHERS
& SCHOOL Using Acceptance and Commitment
COUNSELORS Therapy and Positive Psychology
to Help Teens Manage Emotions,
Achieve Goals, and Build Connection

Louise L. Hayes, PhD

Joseph Ciarrochi, PhD
uncorrected proof
Steven C. Hayes, PhD
Foreword by

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Va l u e s

• basis for selection and retention of behavior

• values as bookends

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The research

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ACT as a contextual behavioural model

• Psychological flexibility is the ability to be mindful of

ones thoughts and feelings and to act in the services
of one’s values even when thoughts and feelings
discourage taking valued action (S. Hayes et al,
2012).

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ACT Model of Psychological Flexibility
(S. C.Hayes, Luoma, Bond, Masuda, Lillis, J. (2006). Behaviour Research and Therapy)

Psychologica
l Flexibility

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ACT as a contextual behavioural model

• Psych flex is the target in ACT:

• traditional CBT targets symptom reduction as

the target (i.e exposure for the purposes of
habituation)

• ACT aims to disentangle people from the cycles

of avoidance, not by challenging or changing,
but by learning to react mindfully toward valued
ends (i.e exposure for the purposes of deriving
valued living)

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Our goal

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ACT as a contextual behavioural model

• ACT has a goal of prediction-and-influence

• Measured by conceptual standards of precision,

scope and depth

• In other words, an applied psychology, that is clear,

simple and generally applicable

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Tr a n s - d i a g n o s t i c - S c o p e

• Depression, work stress, psychosis, test anxiety, pain, smoking

cessation, stigma, polysubstance abuse, self-harm, epilepsy,
trichotillomania, anxiety, diabetes management, cancer
patients, clinician training, obesity, weight-loss,
methamphetamine use, OCD, promoting physical activity,
college adjustment, bariatric surgery, tinnitus, body
dissatsifaction, disordered eating, shame, methadone detox,
borderline PD, for unemployed on sick-leave, tinnitus,
teachers well-being, headache sufferers

• Format - individual, group, self-help bibliotherapy, online,

work-place training, school educators

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Scope

ACT - 100
RCTs to mid
2014

• Pre 1999 ACT book, N=2

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Tr a n s - d i a g n o s t i c - S c o p e

• APA Div 12 Clinical psychology

• Strong support - chronic pain

• Modest support - depression, psychosis, OCD, and “mixed

anxiety” (a sample composed of panic disorder, social phobia,
OCD, and generalised anxiety disorder (GAD),

• US Substance Abuse and Mental Health Services Administration

(SAMSHA)

• recognised as “empirically supported” for OCD, depression,

general mental health, and rehospitalisation

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Yo u t h R C Ts
• Schools

• Livheim, F., Hayes, L., Ghaderi, A., Magnusdottir, T., Högfeldt, A., Rowse, J., Turner, S., Hayes, S. C. & Tengström, A. (2014). The
Effectiveness of Acceptance and Commitment Therapy for Adolescent Mental Health: Swedish and Australian Pilot Outcomes. Journal
of Child and Family Studies. doi: 10.1007/s10826-014-9912-9

• Two studies -Australia and Sweden - testing ACT in school groups. Australian study showed significant reductions in depression with a
medium effect, when compared to the control group who received usual care. The Swedish study, when compared to the control
group, reported significantly lower level of stress with a large effect size and increased mindfulness skills, also with a large effect size.

• Mental health settings

• Hayes, L., Boyd, C. P., & Sewell, J. (2011). Acceptance and Commitment Therapy for the treatment of adolescent depression: A pilot
study in a psychiatric outpatient setting. Mindfulness, 2, 86-94.

• RCT (N = 30) of ACT for adolescent depression compared to treatment as usual. Good outcomes (about 60% showed clinically
significant change in ACT; d = .38 at post and 1.45 at follow up).

• Pain

• Wicksell, R. K., Melin, L., Lekander, M., & Olsson, G. L. (2009). Evaluating the effectiveness of exposure and acceptance strategies to
improve functioning and quality of life in longstanding pediatric pain - A randomized controlled trial. Pain, 141, 248-257.

• Small RCT (n = 32) comparing a brief ACT intervention (10 individual sessions) to multidisciplinary treatment plus amitriptyline (MDT)
for chronic pediatric pain. ACT performed significantly better than MDT on perceived functional ability in relation to pain, pain
intensity and pain related discomfort (intent-to-treat analyses). At post-treatment, before the dose differences happened, significant

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C h i l d / P a r e n t R C Ts
Ghomian, S. & Shairi, M. R. (2014). The effectiveness of Acceptance and Commitment Therapy for children with
chronic pain on the quality of life of 7 to 12 year-old children. International Journal of Pediatrics, 2, 47-55.

RCT (N = 20) comparing ACT and a control condition on the quality of life of children with chronic pain. At 5
mo. Follow up better physical, psychological and school outcomes.

Brown, F. L. Whittingham, K., Boyd, R. N., McKinlay, L., & Sofronoff, K. (in press). Improving child and parenting
outcomes following paediatric acquired brain injury: A randomised controlled trial of Stepping Stones Triple P plus
Acceptance and Commitment Therapy. The Journal of Child Psychology and Psychiatry. doi: 10.1111/jcpp.12227

RCT (N = 59) with parents of children with acquired brain injury randomly assigned either to treatment as
usual or Stepping Stones Triple P: Positive Parenting Program (SSTP) plus Acceptance and Commitment
Therapy (ACT) workshop. Better outcomes in treatment condition in number and intensity of child behaviour
problems, child emotional symptoms, and parenting laxness and overreactivity. Most improvements were
maintained at 6 months.

Whittingham, K. Sanders, M., McKinlay, L., & Boyd, R. N. (in press). Interventions to reduce behavioral problems in
children with cerebral palsy: An RCT. Pediatrics, 133, 1-9. doi: 10.1542/peds.2013-3620

RCT (N = 67) parents of children with CP randomly assigned to Stepping Stones Triple P (SSTP), SSTP plus
ACT, or waitlist. SSTP with ACT was associated with decreased behavioral problems including hyperactivity
as well as decreased parental overreactivity and verbosity (PS MD = 0.68, CI 0.17 to 1.20, P = .01). SSTP alone
was associated with decreased behavioral problems but ACT delivered additive benefits.

119

R u i z ( 2 0 1 2 ) A C T a n d t r a d i t i o n a l C B T:
Systematic review and meta-analysis
• Meta-analysis, 16 studies, (N= 954) of ACT and ‘traditional’ CBT

• Primary outcomes - significantly favoured ACT, Hedges’s

 g= 0.40, p=.001.

• Anxiety outcome - mean effect sizes, g= 0.14, not

significant

• Depression outcome - positive trend for ACT, g= 0.27,

p=.12

• Quality of life outcome - positive trend, g= 0.25, p=.14

120
R u i z ( 2 0 1 2 ) A C T a n d t r a d i t i o n a l C B T: S y s t e m a t i c r e v i e w a n d
meta-analysis ACT veRsus CBT 347

Study Time Point Hedges’s g and 95% CI

Brown et al. (2011) Post-treatment

Páez et al. (2007) Combined
Zettle & Hayes (1986) Combined
Rost et al. (in press) Post-treatment
Hernández López et al. 2009 Combined
Bond & Bunce (2000) Combined
Twohig et al. (2010) Combined
Zettle & Rains (1989) Combined
Lappalainen et al. (2007) Combined
Block 2002 Post-treatment
Arch et al. (in press) Combined
Smout et al. (in press) Combined
Flaxman & Bond (2010) Post-treatment
Forman et al. (in press) Combined
Wetherell et al. (2011) Combined
Zettle 2003 Post-treatment

-2.00 -1.00 0.00 1.00 2.00

FAVORS CBT FAVORS ACT
Figure 1. Forest plot of the mean effect sizes on primary outcomes.

size at post-treatment was medium (g+= 0.45,121 p

the follow-up (g+= 0.10). When comparing time points combined, the mean effect size
g+= 0.38, p= .034). Finally, CBT and ACT did not impact
differently in the CBT putative processes of change (time points combined: g+= 0.05;
post-treatment: g+= 0.06; follow-up: g+= 0.04).
The effect sizes at pre-treatment were explored to analyze whether ACT and CBT

Precision
differed at pre-treatment. If that were the case, the above-mentioned effect size values
would provide a biased estimate of the differential treatment effects. Table 4 shows
that ACT and CBT were equated at pre-treatment in the primary outcome, anxiety, and
quality of life outcome measures as well as in the ACT and CBT process measures.

• S. Hayes, Barnes-Holmes, Wilson (in press) Creating a science more adequate to the
Table 4. Summary results for the effect size at pre-treatment as a function of the outcome or
human condition. Journal of Contextual processBehavioral
measure. Science A limited number of
analytic concepts
Outcome or process measure k g+ (95% C.I.) Z Q I2
Primary outcome 15 0.003 (-0.186; 0.193) 0.04 23.39 40.14
a
Depression outcome
• BA - operant and respondent principles 9 -0.148 (-0.320; 0.024) -1.69 2.86 0.00
Anxiety outcome 8 0.006 (-0.169; 0.182) 0.07 3.94 0.00
Quality of life outcome 10 -0.066 (-0.216; 0.085) -0.86 6.21 0.00
• RFT - arbitrary applicable derived relational responding
ACT processes 9 0.037 (-0.145; 0.220) 0.40 6.78 0.00
CBT processes 5 -0.099 (-0.509; 0.311) -0.47 7.28 45.08
Mutual
• Notes: entailment,
k= number of studies;combinatorial entailment,
g+= weighted mean effect transformation
size; 95% C.I.: of stimulus
95 per cent confidence functions
interval around
2 2
the mean effect size; Q= heterogeneity Q statistic; I = I heterogeneity index (%); *p <.05; **p <.01; ***p
a
.001; p= .091.
• ACT - Psychological flexibility
http://www. ijpsy. com © INTERNATIONAL JOURNAL OF PSYCHOLOGY & PSYCHOLOGICAL THERAPY, 2012, 12, 2
• 6 core processes of acceptance, defusion, values, committed action, present
moment awareness, and self as context

• mid-level terms, some precision is lost in order to achieve scope and utility

122
 Methodological
Precision
• Review n=17 studies. (Smout, L. Hayes, Atkins, Klaussen, Duguid (2012).
Clinical Psychologist)
• Follows from the Ost review (2008) and criticisms of methodology in ACT
early studies
• On average methodology has improved :
• Especially monitoring treatment adherence and competence of ACT
• Issues to address:
• Use of treatment as usual continues to be widespread, unmatched for
contact and unmonitored for competence a problem
• Increases in competence and attention need to be ruled out
• CBS model for working makes sense that some of these issue were present
in early work

123

Component Analysis -
Precision
• Need to move away from the comparison between
treatment packages, to understand the
theoretically-specified components
• (Levin, Hildebrandt, Lillis & S. Hayes. (in press)
Behavior Therapy)
• Testing the psychological flexibility model
• Experimental test of precision of 6 core concepts
• Meta-analysis of 66 lab-based component studies
124
 Component Analysis -
Precision
• Compared to inactive conditions:
• Psych flex components have significant medium effect on targeted
outcomes - task persistence, willingness, believability of thoughts (g = .68,
95% CI = .50, .85, z = 7.53, n = 28)
• + Small effect size on non-targeted outcomes - frequency/intensity of
distressing internal experiences (g = .25, 95% CI = .08, .41, z = 2.91, n =
30)
• Compared to theoretically distinct conditions:
• Favoured psychological flexibility components over control conditions on
all outcomes (g = .20, 95% CI = .07, .33, z = 2.98, n = 39) and primary
targeted outcomes (g = .48, 95% CI = .29, .67, z = 4.90, n = 26).
• (Levin, Hildebrandt, Lillis & S. Hayes. (in press) Behavior
Therapy)

125

META-ANALYSIS OF LAB-BASED COMPONENT STUDIES 40

Table 2. Effect Sizes Comparing ACT Components to Inactive Conditions

Component Number of Effect Size 95% CI z-Score Outcomes

Studies (Hedge’s g)

All Components 44 .44 .31, .58 6.33*** All outcomes

28 .68 .50, .85 7.53*** Targeted outcomes

Acceptance 3 .32 -.03, .68 1.80† All outcomes

3 .81 .45, 1.18 4.38*** Targeted outcomes

Defusion 6 .74 .37, 1.11 3.90*** All outcomes

4 .77 .16, 1.37 2.49* Targeted outcomes

Values 8 .61 .19, 1.04 2.81* All outcomes

5 .41 .01, .82 2.00* Targeted outcomes

Present Moment 8 .22 .03, .40 2.29* All outcomes

4 .64 .30, .98 3.74*** Targeted outcomes

Mindfulness Combinations 15 .27 .14, .40 4.04*** All outcomes

8 .46 .29, .64 5.27*** Targeted outcomes

Mindfulness/Values Combination 5 .78 .19, 1.36 2.59** All outcomes

5 1.37 .74, 2.00 4.26*** Targeted outcomes

†p < .10, *p < .05, **p < .01, ***p < .001
126
 Process Analysis -
Precision
• Mediational analysis (Ruiz, (2012). ACT and traditional
CBT: Systematic review and meta-analysis. International
Journal of Psychology & Psychological Therapy)
• 9/16  included mediation
• ACT  showed a greater impact on its putative
processes of change, g= 0.38, p=.03
• No differences were found regarding CBT
putative processes, g= 0.05, NS
• Suggesting ACT seemed to work through its
proposed processes of change, t-CBT did not.

127

CBS - Depth
• Contextual behavioural science - a broad paradigm for the science
of psychology
• Assumptions - Functional contextualism
• Behavioural principles - Operant/respondent
• RFT - Relating as an operant for verbal behaviour
• ACT - therapeutic technology
• Integrated into the larger fabric of science
• Evolutionary science
• linking up genetic, epigenetic, behavioural, cultural streams
(See Eva Jablonka, David Sloan Wilson)
S. Hayes, Barnes-Holmes, Wilson (in press) Creating a science more adequate to the human condition. Journal of Contextual
Behavioral Science
128
 FC - Depth
• Functional Contextualism - the act-n-context is central
• A pre-analytic assumption, not more right than others,
• other pre-analytic assumptions (world views) include
mechanism, organicism, formism (from Pepper, 1942)
• Act-in-context is a holistic unit
• We can examine parts of this unit, but cannot lose sight of the
whole
• We can extend out, e.g sociological and anthropological domains
• We can extend in to finer units, e.g. genetic, epigenetic,
behaviour and symbolic streams (as per the work of Eva
Jablonka)
S. Hayes, et al. (in press), S. Hayes et al, (2006), S. Hayes, Strosahl, Wilson,
(2012)

129

FC - Depth
• Functional Contextualism
• Explicitly reject ontological statements
• Goals explicitly stated as - “what works”
• Not interested in what is “true”
• ACT we explicitly state that workability
is measured against valued action,
rather than reasoned action
S. Hayes, Barnes-Holmes, Wilson. (in press). Creating a science more adequate to the human condition. Journal of Contextual
Behavioral Science
130
 Reticulated development
- Depth
• How can we move from principles and
theories to practices?
• Bottom up, although rigorous is often slow,
not always applicable to practical use
• Top down, can leave us leaping from one
new product to the next
• ACT rests within a reticulated development
that is web-like
S. Hayes, Barnes-Holmes, Wilson (in press) Creating a science more adequate to the human condition. Journal of Contextual
Behavioral Science
131

Reticulated development
- Depth
• Development at the practitioner level:
• Unrealistic to expect every worker to be fully competent in
behavioural principles and then to apply them in complex,
new situations
• Models
defusion
that use mid-level terms - like acceptance and

• Orient
domain
the practitioner to the contextual features of each

• Each can be nested within the overall web-like scientific

paradigm
• Maintain a constant effort to anchor them to technical terms
S. Hayes, Barnes-Holmes, Wilson (in press) Creating a science more adequate to the human condition. Journal of
Contextual Behavioral Science
132
 Depth - Multi-level
development beyond ACT
• Reticulated development can be seen in
recent work linking ACT into CBS
• and then CBS into evolution science
• Multi-level selection (within and
between groups)
• Multi-dimensional selection (selection
across multiple streams of genetic,
epigenetic, behavioural and symbolic)
S. Hayes, Barnes-Holmes, Wilson (in press) Creating a science more adequate to the human condition. Journal of Contextual
Behavioral Science
133