ACT therapists help war survivors in Sierra Leone

Sierra Leone, a small country on the Western coast of Africa is in recovery after a brutally violent and lengthy civil war, and therapists are lending help with Acceptance and Commitment Therapy (ACT). One Association for Contextual Behavioral Science (ACBS) member, Beate Ebert from Germany, and her friends have founded a non-profit organization "commit and act e.V.", with the intention to bring therapy training, especially ACT, to conflict or post-conflict areas, starting in Sierra Leone. As a result of that, Leonean therapists have attended several ACBS World Conferences to learn ACT. ACBS has established the Developing Nations Training Fund to support these efforts, has declared therapeutic support of developing countries as one of its main goals in the future.

Several ACBS members, such as JoAnne Dahl, D. J. Moran and Ross White have taken on a more personal involvement -- visiting Sierra Leone together with Beate to give ACT trainings.  Beate was gracious enough to answer some questions about her recent experiences with ACT in Sierra Leone.

Doug: The people of Sierra Leone have been through so much. How are they coping?

Beate: It is a complicated situation. When I visited Sierra Leone for the first time in 2010 , I  met Aminata – in the picture below. She lives in one of the amputee-camps, the rebels cut her arm in the war when she was 12; she is around 30 now, has 3 children and she cooks palm oil on the fire to sell it.  Like human beings often do, people in Sierra Leone try to forget all the cruel events, for example they pray to forget - and these people in the amputee camps are very much left alone with no support by the government, and not much possibility to earn their own living, only supported by inhabitants of the close village who do not have much for their own families.

Survivors of the conflict must find ways to cope.

Aminata is one of the victims we hope to support through the therapists we train in the workshops. This year, Hannah Bockarie, many of you met her at the World Conference in Parma, organized an ACT training with 35  local counselors in Bo, the second biggest city in the country. So, Ross White, Jennifer Nardozzi and I traveled around and did a few workshops this year.

Doug: What was your experience like with these workshops?

Beate: This was my third visit to Sierra Leone, and my experience is that we are building a solid basis here. People are awake, and very quick in adapting the ACT approach to their therapy skills. I never experienced such gratefulness before. It worked really well. These participants hardly wanted to take the breaks, even though we have this hot and moist climate. They are not only eager to learn, but so quick in understanding and adapting what we give to them. We had social workers in the workshop who work with street kids, and they adapted the life line exercise to teach their boys the difference between the "easy way", this is going to the street, avoiding the father who beats them or avoiding school problems, and the "best way", the valued way, this could be asking for professional support for their families. 

Therapists practice the ACT life line exercise.

Doug: Those therapists sound really talented and motivated.

Beate: There is a lot of experience there, some of them with 10-15 years as counsellors. Their willingness to support each other, and their experience of community is immense. Therapists shared, how hard it is sometimes, to end their workday. One woman said, “ all these girls who have been raped are coming to see me, they are stigmatized, their families don’t want them any more, so I take them to the police, outside my working hours, I give them money for food, even if I have no money myself.”

Doug: Does it seem like ACT has something to offer?

Beate: At the end of the workshop, many came personally to shake our hands and thank us for the blessing we bring with our method. We met some people who we had trained previously, and you can see how valuable ACT is for them. People reported that they used ACT successfully in their daily practice and  that they share the tools they got with their colleagues. They used ACT for taking care of themselves as caregivers and this was so needed. They do an incredible amount of work and there are hardly any capacities for their support, like supervision. 

Participants are proud of what they have learned.

Doug: It sounds like some really good work is happening there. What’s next?

Beate: It was so fulfilling to be there, and to see how local therapists are building up what we started. This is our goal, that people like Hannah take it on, that they train their people in the future and we can go to other places. Hannah showed me a proposal she wrote for opening an ACT center with an experienced colleague who participated in last years and this years training. We also have requests from other parts of the country, Makeni for example, where the rate of domestic violence and sexual violence against women is the highest in the country. 

Doug: Anything else you would like ACBS members to know?

Beate: I could go on and on, this project is so close to my heart. It´s such a gift for me, to be connected to my friends and colleagues in Sierra Leone and to learn from them about community, friendliness and caring. If you want to consider coming as a trainer, please visit our SIG Meeting at the ACBS World Conference in Washington, D.C. or contact me.

Thank you for taking the time to read this. Thank you for supporting this with your contribution to ACBS and the fund. Thanks for being this visionary community, empowering so many people around the world.

Left to right: Beate Ebert, Hannah Bockarie, Ross White

Article by ACBS Staff Member Douglas M. Long

New meta-analysis highlights CBS laboratory research

The utility and importance of laboratory studies within Contextual Behavioral Science (CBS) has recently been highlighted in a new paper by Levin, Hildebrandt, Lillis, and Hayes. The psychological flexibility model – which underlies Acceptance and Commitment Therapy -- was evaluated in this meta-analysis of 66 laboratory studies. This unique meta-analysis evaluates components and processes such as acceptance, defusion, present moment, values, mixed mindfulness components, and more. Significant positive effects were found. In this interview, author Michael Levin answers a few questions, and provides recommendations for future research. 

Doug: How does this paper fit into the big picture of CBS?
Michael: There is a large and growing number of lab-based component studies relevant to ACT and this is the first meta-analysis we know of that has reviewed this literature within the framework of the psychological flexibility model.

Doug: What is unique and special about this meta-analysis?

Michael: In addition to providing an overall summary of the effect sizes for each component, there are enough varied studies now that we could  explore important theoretical questions such as whether they impact outcomes in ways consistent with our theory and whether there are differences between rationale-alone vs. more experiential interventions.This paper also gave us a chance to discuss the CBS approach and outline how lab-based studies can fit within theory/treatment development and testing.

Doug: What were some challenges that you faced?

Michael: Early into the meta-analysis we realized that, due to different approaches taken by authors and the varied audiences they were speaking to, the interventions were not necessarily labeled in a way that consistently reflected the psychological flexibility model. Many were labeled as "acceptance" or "mindfulness", the meaning of which varied somewhat across articles. However, we were able to reliably code these interventions ourselves for the meta-analysis and found a number of studies testing each component in isolation as well as combined. 

Doug: What sorts of component studies do you hope to see in the future?

Michael: We didn't find any lab-based studies testing self-as-context alone and there is a clear need for research in this area. Also, more careful comparisons are needed to examine the impact of combining specific components (i.e., acceptance vs. acceptance + values). We also recommend generally not using rationale-alone manipulations, unless there is a specific theoretical question, given our finding that such interventions are fairly inert. As we begin to build upon and expand our research questions with lab-based studies a broader range of behavioral measures (i.e., implicit measures, behavioral flexibility, delayed discounting) and measures with more applied relevance to the participant are needed.

Article by ACBS Staff Member Douglas M. Long

Young ACBS researcher wins grant for ACT with OCD

Michael Twohig, Assistant Professor at Utah State University, and his colleague Jon Abramowitz have recently been awarded $50,000 from the International OCD Foundation. The grant was awarded for their proposal to investigate the combination of Acceptance and Commitment Therapy (ACT) and Exposure and Response Prevention (ERP) for the treatment of Obsessive Compulsive Disorder (OCD).

Taking a break from some writing over the winter holiday season, Michael agreed to an interview with ACBS. In it, he explains his new study, and shares some useful insights from his experiences as a young psychologist. 

DOUG: Thanks for taking the time to answer some questions, Mike. First, tell us, what do you hope to find in your new study? 

MIKE: Jon Abramowitz and I want to see whether conducting exposures from and ACT model increases acceptability and engagement in the exposures compared to those conducted from a more traditional fear reduction model. Of course I would be pleased if we had positive findings. Exposure exercises are useful, when done in the right way, but they are very hard for some people to do. If casting the exercises from and ACT model helps people do them more often and more fully, we would likely see better outcomes with a larger sample. Still, it is research and we will just have to see how things turn out. Like, my old mentor Alan Baron used to say, "the rats don't lie." 

DOUG: What do you think ACT can add to ERP?

MIKE: I think ACT offers a different procedures from which to do exposures. The exposures are about fostering willingness and the sessions involve doing what we can to foster that. It has a unique process of change. ACT tries to foster psychological flexibility--which is not the main goal when exposure is done from other models. Also, ACT seeks a different main outcome: increased functioning. I see these three things as the big differences from exposures done from a fear reduction model. 

  

DOUG: What inspires you? What is it that you find meaningful about your work?

MIKE: All and all, my overarching value in this work is to help our clients receive the best psychological treatments possible. This has been my focus since my undergraduate days in Milwaukee. This shows up in many ways in my lab, from running outcome studies to training students. 

It is great to be making a difference. There is an odd pressure with having people listen to what I say, but I am also pleased that I get to push the field around a little. Sometimes I do miss being a grad student and having all criticisms aimed at my advisor.

I try and make sure my work does some good for our clients. Sometimes it is easy to see--as in an outcome study--but other times the good comes years later--as in a review paper that organizes research. I think keeping my focus on doing work that matters has been really useful to me. It has also made my work seem meaningful and I don't really tire of it.

DOUG: What difficulties have you faced in pursuit of a psychology career? 

MIKE: That is a tough question. It is a long road and it feels like it never ends. I only got licensed 2 years ago and I am currently going up for tenure, so it feels like the evaluation part of grad school never ends. I will admit, the pay is better now. 

DOUG: Is there anything you wish you had known before you started on this path?

MIKE: You will never, ever, be caught up. I learned that towards the end of grad school and have slept better ever since. 

DOUG: Looking ahead at the years to come, what sort of impact do you hope your lab will have? 

MIKE: I think besides putting great students out in the world, we will help find a way for behavioral and ACBS values to be integrated into the field of psychology. 

DOUG: What other research topics do you hope to explore?

MIKE: My lab is getting into translational work with basic behavior analysts. We have rat and pigeon researchers on all our thesis and dissertation committees.

DOUG: Any final thoughts?

MIKE: It is a little freaky if I am really at a point I get interviewed. But if I am really here I want to thank a few of my mentors: Drs. Woods, Friman, Hayes, and Whittal. All I really do as a mentor is repeat things you four said to me. Thanks!    

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Interview by Douglas M. Long

University of Nevada, Reno

ACBS Staff Writer

ACT has "strong research support" for chronic pain says Society of Clinical Psychology

The Society of Clinical Psychology (APA’s Division 12) has recently listed ACT as having “strong research support” for the treatment of chronic pain. ACT’s new status reflects the number and quality of randomized control trials for this problem area. The key studies cited there in support of ACT reflect enormous efforts from several research teams. Congratulations to all those who lent a hand! 

ACBS member-at-large Rikard Wicksell, is one such researcher. Rikard K. Wicksell, Ph.D., is a licensed clinical psychologist, and a clinical researcher at the Behavioral Medicine Pain Treatment Service, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, in Stockholm, Sweden. Since 2001, he has, in collaboration with colleagues, developed a treatment approach based on ACT for children, adolescents, and adults with chronic pain. Rikard sat down for an extensive interview – offering advice to young researchers and chronic pain clients, and sharing his hopes for ACBS.

DOUG: The Society of Clinical Psychology recently rated ACT has having strong research support for chronic pain. Given all your work with this population, this must be really nice to see. What are your thoughts?

RIKARD: I’m pleased to see that an independent organization has concluded that the empirical support is rather solid. And, we shouldn’t be worried that ACT “just made the cut”. Several RCT’s with promising preliminary findings will be published within a year or so that will likely provide further support. We are now working on a systematic review on ACT and pain that will include treatment evaluations, lab-studies, cross-sectional, and longitudinal data – perhaps 90 studies in total. For members not aware of the research on ACT and chronic pain, I want to point out the great contributions by Lance McCracken and Kevin Vowles.

From a clinical perspective I am still a bit worried that some people may think of ACT as a method (“just another”) for helping people to reduce pain and distress rather than a fundamentally different approach to human suffering. I’m concerned that core aspects of the model are not fully getting across to regular clinicians working with pain patients. The shift in perspective from symptom alleviation to vital living (in the presence of treatment resistant pain and distress) is difficult, to say the least, for patients as well as for clinicians.

DOUG: How did you become interested in the treatment of chronic pain?

RIKARD: The behavioral medicine field has fascinated me for a long time. During my final year in school, I conducted a behavioral intervention with an adolescent suffering from a severe form of myoclonic epilepsy. With a relatively brief intervention, his functioning improved substantially. His ability to stand up increased from a few seconds to several minutes. When I got in touch with Gunnar L Olsson, a pediatric anesthesiologist interested in developing a CBT-oriented approach for chronic pain, I found this to be an irresistible challenge with enormous potential.

In a sense, I guess I could say that I’m not really interested in chronic pain per se. I am interested in the individual and his/her suffering. Chronic pain just represents one of several areas where people, and clinicians, appear to be involved in a commonly unsuccessful struggle for cure and relief, possibly with a paradoxical increase in disability as the result of this process.

DOUG: What is it like working with this population?

RIKARD: The vast majority of our patients are rather ordinary individuals, easy to relate to. One may think that working with chronic treatment resistant pain is frustrating and emotionally challenging. A more traditional approach focused on symptom management probably is. In contrast, an ACT-oriented approach focuses on variables we can influence (behaviors) and is orientated towards something inherently positive (valued living). As a result, although we are sometimes disappointed and frustrated, a positive and optimistic spirit normally characterizes the collaborations with patients.

DOUG: If you were to offer advice to someone dealing with chronic pain, what would you say?

RIKARD: I don’t find it strange or inadequate to try to minimize the pain experience. I am sure this would intuitively be my primary focus, if I were in their shoes. I would point out though two related yet different problems: the presence of pain and the absence of a vital life. I would ask the person: What has the quest for pain relief cost? What has been reduced or left out of life in the service of living a life with as little pain as possible? And, what would you be willing to pay (in terms of pain and distress) to be able to do the things you value the most? I then would suggest taking a deep breath and start to dream about what life could be like, if pain reduction was no longer allowed to guide actions.

When asked about particularly relevant parts of the treatment program our patients commonly emphasize the values work and the creative hopelessness process. When working through this part of the treatment program, we explicitly state that therapy is not about making someone move in this or that direction. Rather, it is an opportunity to collaboratively explore the available options. The decision about where to head in life is, then, up to the patient.

DOUG: What are some of the challenges which you and your colleagues have faced in conducting your research? Any advice for new researchers?

RIKARD: This is a complicated and complex process with lots of struggles and frustration along the road. So, my first advice is to identify the value in it, and make sure that some reinforcing aspects are present throughout the process.

I think less extensive studies with a relatively simple design have some clear advantages. You can, for example, make changes based on previous studies, and thereby correct the things you were unpleased with. Also, relevant data can be analyzed and presented more quickly.

Getting input – especially from more senior researchers -- is essential. Kelly Wilson once passed along some words of advice that I try to hold on to: “if you only have one good idea, guard it with your life.” Although the academic world sometimes appears to be highly competitive, research is fundamentally about sharing and collaborating.

DOUG: What do you value about ACBS? What is your hope for the organization? Where would you like to see it go?

RIKARD: The quote about sharing good ideas leads back to the invaluable openness and collaborative spirit within ACBS. Especially, I value the wonderful combination of a scientific orientation and a friendly, supportive atmosphere.

The future of both ACBS and contextual behavioral science is about research. Unfortunately, it is not always obvious what the relevant research questions are or how they may be explored. Possibly the organization can play an even more active role when it comes to initiating and coordinating research activities -- especially with studies that may be difficult to conduct but are potentially groundbreaking. As commonly said in ACBS; it takes a village. If we can find a way to optimize the research activities that occur within the organization, that village may accomplish even more and better research in the future. Interdisciplinary research networks, and a “most wanted” list of research hypothesis are a couple of ideas.

There are many clinicians and researchers around the world capable of accomplishing great things but who lack a supportive environment. For all of us, but particularly for them, I think ACBS makes a critical difference. These are exciting times, and as a community we are in a position to make real difference. I appreciate being part of this work and look forward to see what we can accomplish together.

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Interview by Douglas M. Long
University of Nevada, Reno
ACBS Staff Writer