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Mechanism Assignment – Depression + Acceptance and Commitment Therapy
Major Depressive Disorder (MDD) is a depressive disorder “characterized by [the] presence of sad, empty, or irritable mood,” (p. 155) alongside physical and mental changes that have a large impact on an individual’s ability to function (American Psychiatric Association, 2013). The diagnostic criteria for MDD under the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 is divided into five categories. Criteria A requires the presence of five or more symptoms, with at least one of them being depressed mood or loss of interest/pleasure, within a two week period that are different from previous behaviour. Aside from lost pleasure or depressed mood, the other possible symptoms include significant (5%+/-) changes in body mass or appetite, hypersomnia or insomnia, lack of or excessive motion that is observable by others, tiredness or loss of energy, feelings of worthlessness or guilt, reduced concentration or ability to think, and recurrent thoughts relating to death such as suicidal ideation. Criteria B requires that the symptoms have a significant negative impact on functioning in important areas of living such as social or occupational. Criteria C requires that the episodes of depression not be caused by external influences such as drugs or medical conditions. Criteria D requires that the episode is not better explained by another condition. Finally, Criteria E requires that there was never a hypomanic or manic episode (American Psychiatric Association, 2013).
Acceptance and Commitment Therapy (ACT) in the context of the depression therapist guidebook states that it is likely that language plays a unique role in depression in humans. This goes back to relational theory which ACT is based on which is best described as how we contextualize and frame things using language (Zettle, 2007). In a therapeutic context, ACT works to reduce fusion and experiential avoidance which are key in psychological inflexibility (Zettle, 2007). These will be explained in depth in a later section. An example of the format of how ACT is usually conducted for depression is over the course of 12 individual, in person sessions (Zettle, 2007). The population in this case is adults with MDD.
Evidence for the efficacy of ACT in reducing symptoms of depression can be seen in a 2016 meta-analysis conducted by Hacker & Macbeth. Of the randomized controlled trials (RCTs) used in the study, 439 examined the effects of ACT on symptoms of depression (Hacker & Macbeth, 2016). Based on the 1987 total participants across all RCTs related to depression, Hacker & Macbeth (2016) found that for the primary outcomes, “cumulative meta-analysis yielded large significant effects for pre-post treatment reduction in [….] depression (d=.92, p<.001) scores” (p. 7). Comparison of moderation conditions found that the format of ACT (individual vs group) for depression had no significant differences in outcome, both were significant (Hacker & Macbeth, 2016). Of notable interest however, was that in comparison to Cognitive Behavioural Therapy (CBT), ACT did not have a larger impact in reducing symptoms of depression (Hacker & Macbeth, 2016).
According to Zettle (2007), “[t]he ‘problem’ with depression is not so much dysphoric mood or depressive thoughts themselves, but the contexts that link such private events into an overall pattern of ineffective living” (p. 6). Examples of this can be seen in the behaviours typical of MDD, such as negative thought patterns, rumination, isolation, and negative self-concept (American Psychiatric Association, 2013). Hence, the goal of ACT is not to necessarily cure depression, but promote a more effective way of living and thinking. This is achieved through the strengthening of psychological flexibility. In the context of ACT, it’s the ability to use 6 different mechanisms which include: cognitive defusion, acceptance, contact with the present moment, the observing self, values, and committed action (Zettle, 2007).
Cognitive defusion are the methods used to reduce a tendency of solidifying ideas in one’s mind. Acceptance is when one permits unwanted personal experiences to occur from start to finish without stressing. Contact with the present moment is the avoidance of having negative past experience affect expectations and interpretations of what you are currently experiencing. The observing self is when one attains a constant awareness of themselves. Values are the things which one considers important. Committed action is setting goals to improve your life and then completing those goals (Zettle, 2007). Of the six mechanics, defusion and values have demonstrated to be key mechanisms in terms of changes (Bramwell & Richardson 2017).
Mechanism 1 – Cognitive Defusion:
The goal of cognitive defusion is to help people change the relationship of their thoughts and feelings by observing them (Hayes et al. 2006). Cognitive defusion is important because it helps reduce experiential avoidance of negative occurrences (Hayes, Masuda, Bissett, Luoma & Guerrero, 2004; Hofmann, Sawyer & Fang, 2010). Cognitive defusion is a specific factor for ACT. Cognitive defusion is thought to work by removing the negative association with an event from reality, and strengthening the objective view of what actually occurs. In the context of therapy, this is accomplished through a direct shaping process, in which patients build up a set of skills from an initial set (Zettle, 2007). In terms of timing, defusion is promoted throughout, but generally results are more visible as time goes on from the initial learning as new skills are developed (Zettle, 2007).
Mechanism 2 – Values:
In ACT, values are defined as “verbally construed global life consequences” (Hayes, Strosahl & Wilson, 1999, p. 206). “ACT aims to help someone choose life directions in various domains e.g. family, career and helps people to move in the direction of those values whilst committed action involves engaging in behaviours in line with one’s values” (Hayes et al. 2006). Similarly to defusion, values help by reducing experiential avoidance. Values, and how they are applied in the context of ACT is a specific factor. Values are thought to work by assisting patients with subsequent goal setting and achievement. Furthermore, values can reveal what experiences led to depression (Zettle, 2007). The effects of this can be seen in the reduction of “pursuit of value-incongruent goals, failure to attain value-congruent goals, and failure to pursue value-congruent goals” (Zettle, 2007, p.115). Values are usually determined through introspection and modified through goal-setting (Zettle, 2007). The determination of values is arguably most important at the beginning of treatment since it determines the treatment plan, however the ways in which they change throughout treatment are still of great importance regardless of timing (Zettle, 2007).
A study in 2011 was performed on ACT to bring results from a previous study up to modern scientific standards in terms of limitations (Zettle, Rains, & Hayes; Zettle & Rains, 1989). The article was selected because a part of bringing the study up to modern scientific standards included testing of processes of change through a mediation analysis. The final participant sample for the study consisted of 37 women experiencing moderate to severe depression. 12 were assigned to a control condition, 13 to cognitive therapy (CT), and 12 to ACT (Zettle et al., 2011). Levels of depression were measured using scores on the Beck Depression Inventory (BDI) and the therapeutic process was measured using the Automatic Thoughts Questionnaire (ATQ + ATQ-B) and the Dysfunctional Attitude Scale (DAS) (Zettle et al., 2011).
Once initial results had been determined, a formal mediation analysis was performed using the ATQ-B to measure cognitive defusion, the ATQ to measure the level of occurrence of depressogenic thoughts, and the DAS to measure dysfunctional attitudes occurring at a higher level of cognitive organization (Zettle et al., 2011). The study sample was clinical and as previously mentioned, the design was a mediation analysis. The primary moderator for the study sample was scores on the BDI. The impact that each mechanism had as a mediator was measured by the changes in pre vs post-treatment scores they caused on the BDI (Zettle et al., 2011). The study found that the ATQ-B, and by extension defusion, mediated differences in depression outcome.
The first limitation to the study was that “the differences in outcome on the BDI were significant at post treatment” (p.278) for ATQ-B (Zettle et al., 2011). Although this means that ideal criteria for mediation analysis was not met, since reversed BDI did not mediate the ATQ-B, it seems unlikely that the results were responsible for process differences (Zettle et al., 2011). A second limitation to the study was that there may have been better mediators to measure that were simply unknown at the time and have yet to be taken from cognitive therapy (Zettle et al., 2011).
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
- Bramwell, K., & Richardson, T. (2017). Improvements in depression and mental health after acceptance and commitment therapy are related to changes in defusion and values-based action. Journal of Contemporary Psychotherapy, doi:http://dx.doi.org/10.1007/s10879-017-9367-6
- Hacker, T., Stone, P., & MacBeth, A. (2016). Acceptance and commitment therapy—Do we know enough? cumulative and sequential meta-analyses of randomized controlled trials. Journal of Affective Disorders, 190, 551-565. doi:http://dx.doi.org/10.1016/j.jad.2015.10.053
- Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(1), 1-25. doi:http://dx.doi.org/10.1016/j.brat.2005.06.006
- Hayes, S. C., Masuda, A., Bissett, R., Luoma, J., & Guerrero, L. F. (2004). DBT, FAP and ACT: How empirically oriented are the new behavior therapy technologies? Behavior Therapy, 35(1), 35-54. doi:http://dx.doi.org/10.1016/S0005-7894(04)80003-0
- Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change, Guilford Press, New York, NY. Retrieved from http://myaccess.library.utoronto.ca/login?url=https://search.proquest.com/docview/619405442?accountid=14771
- Hofmann, S. G., Sawyer, A. T., & Fang, A. (2010). The empirical status of the “new wave” of cognitive behavioral therapy. Psychiatric Clinics of North America, 33(3), 701-710. doi:http://dx.doi.org/10.1016/j.psc.2010.04.006
- Zettle, R. D. (2007). ACT for depression: A clinician’s guide to using acceptance and commitment therapy in treating depression. New Harbinger Publications, Oakland, CA. Retrieved from http://myaccess.library.utoronto.ca/login?url=https://search.proquest.com/docview/621935122?accountid=14771
- Zettle, R. D., & Rains, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45(3), 436-445. doi: http://dx.doi.org/10.1002/1097-4679(198905)45:3<436::AID-JCLP2270450314>3.0.CO;2-L
- 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(3), 265-283. doi:http://dx.doi.org/10.1177/0145445511398344
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