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ACT for depression




            Gerhard Andersson, professor
           Linköpings Universitet and Karolinska Institutet
                     www.gerhardandersson.se
Aims

    • The scope of depression
    • The fact that most treatments seem to work (or not?)
    • The ACT contribution
    • Future challenges for a CBS of depression




2
Depression

    • Widely prevalent
    • Higly costly
    • Projected by the WHO to be one of the most costly medical
      problems for society
    • More than one condition – can be chronic
    • Tend to relapse
    • Numerous theories: Biological, psychological and social.




3
In spite of all our efforts

    • All serious psychological treatments appear to work as well




4
Regardless of brand

    • CT as good as BT (perhaps not for more severe depression)
    • Format also makes little difference: Andersson, G., &
      Cuijpers, P. (2009). Internet-based and other computerized
      psychological treatments for adult depression: A meta-analysis.
      Cognitive Behaviour Therapy, 38, 196-205.
    • Cuijpers, P., van Straten, A., & Warmerdam, L. (2008). Are
      individual and group treatments equally effective in the
      treatment of depression in adults? A meta-analysis. European
      Journal of Psychiatry, 22, 38-51.




5
6
ACT and depression

    • Not much of a theory specific for depression
    • However the concept of experiential avoidance makes sense
      and so does cognitive fusion




7
Early on

    • Zettle and Hayes work on depression and ”distancing” set the
      stage for ACT




8
Act for depression

    • Behavioral analysis? Control is the problem – not the solution
    • Creative hopelessness
    • Metaphors




9
More to it

     • Experiential
     • Monitor thoughts and beliefs
     • Defusion
     • Acceptance
     • Reason giving
     • Mindfulness
     • Committed action
     • Willingness
     • Ok to use BA and other CBT techniques



10
Accept your reactions and be present, Choose
     a valued direction, and Take action.




11
Evidence in favour of ACT
     • Zettle, R. D., & Hayes, S. C. (1987). Component and process
       analysis of cognitive therapy. Psychological Reports, 61, 939-
       953.
     • Zettle, R. D., & Rains, J. C. (1989). Group cognitive and
       contextual therapies in treatment of depression. Journal of
       Clinical Psychology, 45, 436-445.
     • Zettle, R. D., Rains, J. C., & Hayes, S. C. (2011). Processes of
       change in acceptance and commitment therapy and cognitive
       therapy for depression: a mediation reanalysis of Zettle and
       Rains. Behavior Modification, 35, 265-283.
     • Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., &
       Geller, P. A. (2007). A randomized controlled effectiveness trial
       of acceptance and commitment therapy and cognitive therapy
       for anxiety and depression. Behavior Modification, 31, 772-799.
12
30               Pretreatment
     25
                      Posttreatment
     20
                      Follow-up
     15
     10
      5
      0
          Treatment                   Control

13
25                                              Pretreatment
     20                                              Posttreatment

     15                                              Follow-up

     10

      5

      0
          Treatment ext   Treatment mini   Control



14
Therapy form    Rationale   Therapy    Active      Home   Technique   Emotions

                                 relation   therapist   work

     Psychodynamic Yes           Yes        Nej         No     Yes         Yes

     Humanistic      Yes         Yes        Yes         No     Yes         Yes

     Interpersonal   Yes         Yes        Yes         No     Yes         Yes

     Behavioural     Yes         Yes        Yes         Yes    Yes         Yes

     activation

     Cognitive       Yes         Yes        Yes         Yes    Yes         Yes

     therapy

     ACT             Yes         Yes        Yes         Yes    Yes         Yes



15
What more is there to do?

     • Theory for depression
     • Choose target group where acceptance is key! Chronic
       depression, somatic comorbidity etc
     • Could RFT be useful as a framework?
     • Comparative RCTs are boring but RCTs per se
       are needed!
     • Integrate with behaviourism?
     • Basic science? At least some experiments




16
Be sceptical about generic treatments!

     • Mindfulness classes might not be the solution




17
Conclusions

 ACT is not evidence-based
 enough for depression
 But probably as good as the
 rest
 Theory and basic research
 needed!
 Do not feel tempted to apply
 the same approach to all

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Gerhard Andersson

  • 1. ACT for depression Gerhard Andersson, professor Linköpings Universitet and Karolinska Institutet www.gerhardandersson.se
  • 2. Aims • The scope of depression • The fact that most treatments seem to work (or not?) • The ACT contribution • Future challenges for a CBS of depression 2
  • 3. Depression • Widely prevalent • Higly costly • Projected by the WHO to be one of the most costly medical problems for society • More than one condition – can be chronic • Tend to relapse • Numerous theories: Biological, psychological and social. 3
  • 4. In spite of all our efforts • All serious psychological treatments appear to work as well 4
  • 5. Regardless of brand • CT as good as BT (perhaps not for more severe depression) • Format also makes little difference: Andersson, G., & Cuijpers, P. (2009). Internet-based and other computerized psychological treatments for adult depression: A meta-analysis. Cognitive Behaviour Therapy, 38, 196-205. • Cuijpers, P., van Straten, A., & Warmerdam, L. (2008). Are individual and group treatments equally effective in the treatment of depression in adults? A meta-analysis. European Journal of Psychiatry, 22, 38-51. 5
  • 6. 6
  • 7. ACT and depression • Not much of a theory specific for depression • However the concept of experiential avoidance makes sense and so does cognitive fusion 7
  • 8. Early on • Zettle and Hayes work on depression and ”distancing” set the stage for ACT 8
  • 9. Act for depression • Behavioral analysis? Control is the problem – not the solution • Creative hopelessness • Metaphors 9
  • 10. More to it • Experiential • Monitor thoughts and beliefs • Defusion • Acceptance • Reason giving • Mindfulness • Committed action • Willingness • Ok to use BA and other CBT techniques 10
  • 11. Accept your reactions and be present, Choose a valued direction, and Take action. 11
  • 12. Evidence in favour of ACT • Zettle, R. D., & Hayes, S. C. (1987). Component and process analysis of cognitive therapy. Psychological Reports, 61, 939- 953. • Zettle, R. D., & Rains, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45, 436-445. • Zettle, R. D., Rains, J. C., & Hayes, S. C. (2011). Processes of change in acceptance and commitment therapy and cognitive therapy for depression: a mediation reanalysis of Zettle and Rains. Behavior Modification, 35, 265-283. • Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behavior Modification, 31, 772-799. 12
  • 13. 30 Pretreatment 25 Posttreatment 20 Follow-up 15 10 5 0 Treatment Control 13
  • 14. 25 Pretreatment 20 Posttreatment 15 Follow-up 10 5 0 Treatment ext Treatment mini Control 14
  • 15. Therapy form Rationale Therapy Active Home Technique Emotions relation therapist work Psychodynamic Yes Yes Nej No Yes Yes Humanistic Yes Yes Yes No Yes Yes Interpersonal Yes Yes Yes No Yes Yes Behavioural Yes Yes Yes Yes Yes Yes activation Cognitive Yes Yes Yes Yes Yes Yes therapy ACT Yes Yes Yes Yes Yes Yes 15
  • 16. What more is there to do? • Theory for depression • Choose target group where acceptance is key! Chronic depression, somatic comorbidity etc • Could RFT be useful as a framework? • Comparative RCTs are boring but RCTs per se are needed! • Integrate with behaviourism? • Basic science? At least some experiments 16
  • 17. Be sceptical about generic treatments! • Mindfulness classes might not be the solution 17
  • 18. Conclusions ACT is not evidence-based enough for depression But probably as good as the rest Theory and basic research needed! Do not feel tempted to apply the same approach to all