Contextual Methods and the Future of CBT

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Contextual Methods and the Future of CBT
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The Opportunity of Upheaval
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Contextual Behavioral Science Strategy

• From a clear philosophy of science, and with a
• General-process account that addresses cognition,
• Construct transdiagnostic processes, and
• Organize them into a useful clinical model, with
• Components that derive from the model, and
• Substantial breadth of application, and
• Successful mediators and moderators linked to
  those process extended by a
• Dissemination and training strategy, and the
• Construction of a development community

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Contextual Behavioral Science

• Philosophy Functional contextualism
• General process account Behavioral principles
  and Relational Frame Theory nested within an
  overall evolutionary science perspective
• Transdiagnostic processes Experiential
  avoidance, cognitive fusion, flexible attention
  to now, perspective taking sense of self, values,
  committed action
• Clinical model Psychological flexibility model

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Contextual Behavioral Science

• Functional Contextualism
• Behavioral principles and RFT within EvoS
• EA, fusion, now, self, values, action
• Psychological flexibility model
• Components
• Breadth of application,
• Mediators and moderators,
• Dissemination and training strategy,
• Construction of a development community

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Components
Acceptance Defusion Contact with Present Self-as-Context Combinations of Four Mindfulness Components Values Other Combination
Campbell-Sills et al., 2006 Marcks Woods, 2005 Cioffi Holloway, 1993 Williams, 2007 Arch Craske, 2006 Cohen et al., 2000 Gutiérrez et al., 2004
Eifert Heffner, 2003 Marcks Woods, 2007 Kingston et al., 2007 Broderick, 2005 Cohen et al., 2006 McMullen et al., 2008
Levitt et al., 2004 Masuda et al., 2004 Leventhal et al., 1989 Burns, 2006 Creswell et al., 2005 Paez-Blarrina et al., 2008
Low et al., 2008 Masuda et al., in press Logan et al., 1995 Feldner et al., 2003 Crocker et al., 2008
Roche et al., 2007 Michael Burns, 2004 Hayes et al., 1999 Harris et al., 2005
Vowles et al., 2007 Haythornthwaite et al., 2001 Fein et al., 1997
Keogh et al., 2005 2006 Paez-Blarrina et al., 2007
Masedo Esteve, 2007 Spencer et al., 2001
Takahashi et al., 2002
Forman et al., 2007
Kehoe et al., 2007
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Pain Tolerance McMullen et al., 2008
Instructions, Metaphor, Exercise
Acceptance and Defusion
Instructions Only
Instructions, Metaphor, Exercise
Distraction
Instructions Only
No Instructions
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8
6
4
2
Shocks to Continue Task
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Impact of ACT Components on Persistence and
Willingness
Persistence and Willingness
g .48
Active Comparison (n692)
Inactive Comparison (n440)
g .69
Subjective Distress During Task
g .13
Active Comparison (n693)
Inactive Comparison (n564)
g .37
Subjective Distress While Recovering From Task
g .47
Active Comparison (n423)
Inactive Comparison (n145)
g .38
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Breadth of Application

• RCTs
• Depression 3
• Stress 4
• Psychosis 2
• Anxiety 1
• Pain 4
• Burnout 1
• Trich 1
• Substance 2 abuse
• DD/DD 1

• RCTs
• OCD 1
• Epilepsy 2
• Diabetes 1
• Weight 3
• Prejudice 2
• Learning 2
• Cancer 2
• Smoking 3
• BPD 2
• Fitness 1

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Large effect size
Follow up Change Outcomes Post Mediators (3
studies no follow-up 3 no post)
Proportion Mediated
0
.25
.50
.75
1.0
Study Problem Comparison Mediator 
Tapper, 2009 Weight Diet PF/EA
Woods, 2006 Trichotillomania Wait list PF/EA
Gaudiano, 2009 Psychosis Enhanced TAU Defusion
Bond, 2000 Work stress Wait list PF/EA
Wicksell, 2009 Pain MDT medication Defusion
Wicksell, 2008 Pain TAU PF/EA
Lazzaroni, 2009 Work stress Wait list PF/EA
Zettle, 1986 Depression CT Defusion
Hayes, 2004 Stigma Psychoeducation Defusion
Lappalainen, 2007 Outpatient misc CBT PF/EA
Lillis, 2009 Weight Wait list PF/EA
Lillis, 2007 Ethnic prejudice Education PF/EA
Gifford, under review Smoking Medications PF/EA
Lundgren, 2008 Epilepsy Supportive treatment PF/EA
Gregg, 2007 Diabetes Education PF/EA/Self-Manage
Varra, 2008 Resistance to ESTs Psychoeducation PF/EA/Defusion
Zettle, in press Depression CT Defusion
Gratz, 2006 BPD TAU PF/EA
Testing with bootstrapped cross product All
below p .1 All but 3, p lt .05
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The CBT Future? My Guess

• Down syndromes, brute force empiricism, EBP
  based only on packages.
• Up EB processes, EB procedures, functional
  analysis, transdiagnostic models. Why? More
  progressive and more functional.
• I believe general functional contextual
  perspectives will compete with more structural,
  special process, or mentalistic accounts
• and I expect more of

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Contextual CBT (Third Wave)

• Is grounded in an empirical, principle-focused
  approach, that is particularly sensitive to the
  context and functions of psychological phenomena
  more so than their validity or form, and thus
  tends to emphasize contextual and experiential
  change strategies in addition to more direct and
  didactic ones

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Contextual CBT

• Seeks the construction of broad, flexible and
  effective repertoires over an eliminative
  approach to syndromes, symptoms, or narrowly
  defined problems
• Emphasizes the relevance of these issues for
  clinicians as well as clients

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Contextual CBT

• Reformulates and synthesizes what is already
  known in behavioral and cognitive therapy, rather
  than rebelling against it and
• Carries the behavioral and cognitive therapy
  tradition forward into deeper or more complex
  questions, issues, and domains that were
  previously addressed primarily by other, less
  empirical traditions.

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Context Over Content

• unlike CBT, there is little emphasis in MBCT on
  changing the content of thoughts rather, the
  emphasis is on changing awareness of and
  relationship to thoughts. (2004, p. 54).
• Behavioral activation interventions address the
  function of negative or ruminative thinking, in
  contrast to CTs emphasis on thought content,
  through attention-to-experience interventions
  (Dimidjian et al., 2006, p. 668).

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Context Over Content

• MCT does not advocate challenging of negative
  automatic thoughts or traditional schemas.
  (Wells, 2008, p. 651) while CBT is concerned
  with testing the validity of thoughts () MCT is
  primarily concerned with modifying the way in
  which thoughts are experienced (p. 652).

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A Content Focus is Not Buying Us Much
Pre to Post Decreases in BDI
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Simplified Psychological Flexibility Model
Aware
Present Moment
Perspective taking
Psychological Flexibility
Committed Action
Defusion
Active
Open
Values
Acceptance
(modified from Harris, 2009)
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Is This Becoming a Consensus Contextual CBT
Model?
Aware
Psychological Flexibility
Active
Open
(modified from Harris, 2009)
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The Triflex as a Consensus Contextual CBT Model?
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The Big Tribal Umbrella
C
B
T
Metacognitive Therapy
Motivational Interviewing
Many others
Functional Analytic Psychotherapy
Mindfulness Based Cognitive Therapy
Exposure with response prevention
Behavioral Activation
Appraisal work
Becks Cognitive Therapy
Dialectical Behavior Therapy
Barlows Unified Protocol
Schema Therapy
Acceptance and Commitment Therapy
Rational Emotive Behavior Therapy
Mindfulness Based Stress Reduction
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With Shared Targets
C
B
T
Emotion
Cognition
Social Functioning
Spirituality
Sense of Self
Overt Behavior
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But Varied Foundations
C
B
T
Neo-Behavioral
Information Processing
Hypothetico-Deductive
Social Learning
Behavior Analytic
Inductive
Relational Frame Theory
Contextual Behavioral Science
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And Philosophies
C
B
T
Functional Contextualism
Elemental Realism
Organicism
Constructivism
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And Distinct Features, e.g.
A
C
T
Relational Frame Theory
Functional Contextualism
Inductive
Behavior Analytic
Contextual Behavioral Science
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CBT