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ACT for Psychological Flexibility, Mindfulness, and Depression

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By John M. de Castro, Ph.D.

 

“Mindfulness is a valuable practice for improving the cognitive symptoms of depression, such as distorted thinking and distractibility. It helps individuals recognize these more subtle symptoms, realize that thoughts are not facts and refocus their attention to the present.” – Margarita Tartakovsky

 

Mindfulness training in general has been shown to be effective for treating depression. Acceptance and Commitment Therapy (ACT) is a mindfulness based psychotherapy technique that is based upon Cognitive Behavioral Therapy (CBT) and has also been shown to be effective for depression. ACT focuses on the individual’s thoughts, feelings, and behavior and how they interact to impact their psychological and physical well-being. It then works to change thinking to alter the interaction and produce greater life satisfaction. ACT employs mindfulness practices to increase awareness and develop an attitude of acceptance and compassion in the presence of painful thoughts and feelings. Additionally, ACT helps people strengthen aspects of cognition such as in committing to valued living. ACT teaches individuals to “just notice”, accept and embrace private experiences and focus on behavioral responses that produce more desirable outcomes.

 

As impressive as the effectiveness of many mindfulness based therapies are for depression, they require the supervision of a trained therapist working either with a single individual or in small groups. With the magnitude of the problem of depression, these therapies can only touch a small fraction of depression suffers. Recently the internet has been used to provide therapy to a wide audience. It allows for therapies to be made available to a much larger number of patients over a much larger geographical area. Indeed, ACT provided over the internet has been shown to be effective for depression. It is not known, however, which psychological processes are affected by ACT that work to relieve depression and what participant characteristics are predictive of responsiveness to ACT for depression.

 

In today’s Research News article “How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms.” See:

https://www.facebook.com/ContemplativeStudiesCenter/photos/a.628903887133541.1073741828.627681673922429/1260365230654067/?type=3&theater

or below or view the full text of the study at:

http://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-016-0841-6

Pots and colleagues investigated potential mediators of ACT therapy for depression delivered over the internet. They randomly assigned patients diagnosed with mild to moderate depression to either receive Acceptance and Commitment Therapy (ACT), an expressive writing treatment, or a wait-list control condition. ACT was delivered over the internet in nine modules that could be completed by participants over nine to twelve weeks. The expressive writing condition was delivered similarly over the internet over the same time frame and involved the participants writing about their recent emotional experiences. The wait-list control participants received no treatments until 6-months later. Measures were taken of depression, mindfulness, psychological flexibility, anxiety, positive mental health and demographic variables prior to and after treatment and 6 and 12 months later.

 

They found, as previously reported, that ACT produced significant improvements in depressive symptoms that were maintained 6 and 12 months later. ACT produced a large improvement in psychological flexibility and the mindfulness facet of non-reactivity to internal events that were found to mediate the effect on depression. In other words, ACT reduced depression by improving non-reactivity and psychological flexibility.

 

Pots and colleagues state that “The central therapeutic mechanism in ACT is psychological flexibility, which is the ability to act in accordance with intrinsically motivating values or goals while being in contact with the present moment.” Hence, the results indicate that ACT was successful in producing its desired effect and this increase in the alignment of actions with values is a strong determinant of the reduction in depression. This is thought to be an important aspect of emotion regulation that is so important for allowing emotions to be experienced but not allowing them to produce maladaptive responses. This is also facilitated by not being particularly reactive to these emotions. Hence ACT appears to improve depression by improving the coherence and alignment of beliefs and values with the individual’s actions and emotions.

 

So, improve psychological flexibility, mindfulness, and depression with Acceptance and Commitment Therapy (ACT).

 

“It may be wise to not undertake the entire program while in the midst of an episode of clinical depression. Current evidence suggests that it may be prudent to wait until you have gotten the necessary help in climbing out of the depths and are able to approach this new work of working with your thoughts and feelings, with your mind and spirit unburdened by the crushing weight of acute depression.” – Jon Kabat-Zinn, Mark Williams, John Teasdale, and Zindel Segal

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are also available on Google+ https://plus.google.com/106784388191201299496/posts

 

Study Summary

Pots WT, Trompetter HR, Schreurs KM, Bohlmeijer ET. How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms. BMC Psychiatry. 2016 May 23;16:158. doi: 10.1186/s12888-016-0841-6.

 

Abstract

BACKGROUND: Acceptance and Commitment Therapy (ACT) has been demonstrated to be effective in reducing depressive symptoms. However, little is known how and for whom therapeutic change occurs, specifically in web-based interventions. This study focuses on the mediators, moderators and predictors of change during a web-based ACT intervention.

METHODS: Data from 236 adults from the general population with mild to moderate depressive symptoms, randomized to either web-based ACT (n = 82) or one of two control conditions (web-based Expressive Writing (EW; n = 67) and a waiting list (n = 87)), were analysed. Single and multiple mediation analyses, and exploratory linear regression analyses were performed using PROCESS and linear regression analyses, to examine mediators, moderators and predictors on pre- to post- and follow-up treatment change of depressive symptoms.

RESULTS: The treatment effect of ACT versus the waiting list was mediated by psychological flexibility and two mindfulness facets. The treatment effect of ACT versus EW was not significantly mediated. The moderator analyses demonstrated that the effects of web-based ACT did not vary according to baseline patient characteristics when compared to both control groups. However, higher baseline depressive symptoms and positive mental health and lower baseline anxiety were identified as predictors of outcome across all conditions. Similar results are found for follow-up.

CONCLUSIONS: The findings of this study corroborate the evidence that psychological flexibility and mindfulness are distinct process mechanisms that mediate the effects of web-based ACT intervention. The results indicate that there are no restrictions to the allocation of web-based ACT intervention and that web-based ACT can work for different subpopulations.

http://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-016-0841-6

 

Increase Mindfulness with a Brief On-line Training

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By John M. de Castro, Ph.D.

 

“The best way to capture moments is to pay attention. This is how we cultivate mindfulness. Mindfulness means being awake. It means knowing what you are doing.” ~Jon Kabat-Zinn

 

Over the last several decades, research and anecdotal experiences have accumulated an impressive evidential case that the development of mindfulness has positive benefits for the individual’s mental, physical, and spiritual life. Mindfulness appears to be beneficial both for healthy people and for people suffering from a myriad of illnesses. It appears to be beneficial across ages, from children to the elderly. And it appears to be beneficial across genders, personalities, race, and ethnicity. The breadth and depth of benefits is unprecedented. There is no other treatment or practice that has been shown to come anyway near the range of mindfulness’ positive benefits. With impacts so great it is important to know how to optimize the development of mindfulness.

 

“Mindfulness is defined as the “awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally” (John Kabat-Zinn). This is the goal of mindfulness training. There are, however, a vast array of techniques for the development of mindfulness. They include a variety of forms of meditation, yoga, mindful movements, contemplative prayer, and combinations of practices. Some are recommended to be practiced for years while others are employed for only a few weeks. Regardless of the technique, they all appear to develop and increase mindfulness. It is unclear what technique may be best and what components are essential. There does appear, however, to be one central component; the practice of awareness of the present moment.

 

Many mindfulness practices require experienced and/or accredited instructors. This in turn requires traveling to a facility, attending sometimes lengthy classes for many weeks, and involves expense. In today’s busy world many people find that this commitment of time and resources is difficult if not impossible. So, it is important to develop simple, convenient, and efficient means to develop mindfulness. The internet holds great promise. Instruction can be delivered inexpensively and conveniently to large numbers of people spread across wide geographic areas. Mindfulness training has been successfully conducted over the internet with positive benefit. So, on-line mindfulness training appears to be a viable method for developing mindfulness.

 

The issue then becomes how much training is needed. In today’s Research News article “A Moment of Mindfulness: Computer-Mediated Mindfulness Practice Increases State Mindfulness.” See:

https://www.facebook.com/ContemplativeStudiesCenter/photos/a.628903887133541.1073741828.627681673922429/1237611539596103/?type=3&theater

or below or view the full text of the study at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4841572/

Mahmood and colleagues examine if a very brief (5-min) instruction in mindfulness delivered on-line is sufficient to develop at least some improvement in mindfulness. They randomly assigned on-line participants to either a 5-minute body scan meditation condition or a control condition in which the participants were asked to simply sit in silence for 5-minutes. Participants levels of mindfulness were measured before and after the 5-minute training.

 

They found that the mindfulness condition produced significant increases in mindfulness while the control condition did not. Hence, a very brief body scan mindfulness training is capable of increasing mindfulness. It should be noted, however, that the effects were relatively small and there was no testing for how long the effects may last. It remains for future research to determine the amount of on-line practice needed to produce large and lasting increases in mindfulness. But, the fact that a brief mindfulness training can be delivered over the internet and have positive benefits is an encouraging step toward the development of a convenient and inexpensive means to deliver this beneficial training.

 

Regardless, it is clear that mindfulness can be increased with a brief on-line training

 

 

“Mindfulness is simply being aware of what is happening right now without wishing it were different; enjoying the pleasant without holding on when it changes (which it will); being with the unpleasant without fearing it will always be this way (which it won’t).” ~James Baraz

 

CMCS – Center for Mindfulness and Contemplative Studies

 

This and other Contemplative Studies posts are available on Google+ https://plus.google.com/106784388191201299496/posts

 

Study Summary

Mahmood, L., Hopthrow, T., & Randsley de Moura, G. (2016). A Moment of Mindfulness: Computer-Mediated Mindfulness Practice Increases State Mindfulness. PLoS ONE, 11(4), e0153923. http://doi.org/10.1371/journal.pone.0153923

 

Abstract

Three studies investigated the use of a 5-minute, computer-mediated mindfulness practice in increasing levels of state mindfulness. In Study 1, 54 high school students completed the computer-mediated mindfulness practice in a lab setting and Toronto Mindfulness Scale (TMS) scores were measured before and after the practice. In Study 2 (N = 90) and Study 3 (N = 61), the mindfulness practice was tested with an entirely online sample to test the delivery of the 5-minute mindfulness practice via the internet. In Study 2 and 3, we found a significant increase in TMS scores in the mindful condition, but not in the control condition. These findings highlight the impact of a brief, mindfulness practice for single-session, computer-mediated use to increase mindfulness as a state.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4841572/

 

Log-on for Less Anxiety with Mindfulness

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“Needless anxiety and stress cannot burden us if the thoughts don’t enter our mind. And fortunately, we are only capable of focusing on one thing at a time. When you’re aware of only what you’re working on and the sensations of your body, conscious worry is not possible.” – Jordan Bates

 

Anxiety disorders are the most common mental illness in the United States, affecting 40 million adults, or 18% of the population. (Source: National Institute of Mental Health). Generalized Anxiety Disorder (GAD) affects about 3.1% of the U.S. population. GAD involves excessive worry about everyday problems. People with GAD may excessively worry about and anticipate problems with their finances, health, employment, and relationships. They typically have difficulty calming their concerns, even though they realize that their anxiety is more intense than the situation warrants. Physically, GAD sufferers will often show excessive fatigue, irritability, muscle tension or muscle aches, trembling, feeling twitchy, being easily startled, trouble sleeping, sweating, nausea, diarrhea or irritable bowel syndrome, and headaches.

 

Anxiety disorders are not only a torment for the victims but they also place tremendous pressure on the health care system. People with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders. Anxiety disorders are treatable but only about a third of the sufferers get treatment. The most common treatment for GAD is drugs. Anxiolytic drugs are some of the most prescribed drugs in the U.S. Psychotherapy is another common form of treatment with Cognitive Behavioral Therapy particularly effective. Mindfulness practices are known to reduce anxiety (see http://contemplative-studies.org/wp/index.php/2015/11/02/be-open-or-focused-in-meditation-to-reduce-anxiety/,  http://contemplative-studies.org/wp/index.php/2015/07/17/the-mindfulness-cure-for-social-anxiety/, http://contemplative-studies.org/wp/index.php/2015/07/17/stop-worrying/), and appear to do so by altering brain activity (see http://contemplative-studies.org/wp/index.php/2015/08/13/get-the-brain-to-reduce-anxiety-with-meditation/).

 

The problems with these treatments is that drugs can have very troublesome side effects and psychotherapy can be expensive and time consuming. Therapy also demands that there be a qualified professional in the immediate area and the patient has the time and transportation available to attend therapy sessions. So, there is a need for cost-effective, convenient, and safe alternative treatments.

 

One way to lower costs and make therapy available for patients over wide geographical areas is to deliver therapy over the internet. In today’s Research News article “Internet-delivered acceptance-based behaviour therapy for generalized anxiety disorder: A randomized controlled trial”

https://www.facebook.com/ContemplativeStudiesCenter/photos/a.628903887133541.1073741828.627681673922429/1159827387374519/?type=3&theater

Dahlin and colleagues developed a form of mindfulness based Acceptance and Commitment Therapy (ACT) for delivery by a therapist over the internet. They recruited participants with GAD over the internet and assigned them randomly to either receive therapy for 9-weeks or to a waiting list control condition. They found significant improvement in Generalized Anxiety Disorder (GAD) and depression for the therapy group with large to moderate effect sizes. These improvements were still present 34-weeks later.

 

These are exciting results. Anxiety disorders are so prevalent and so infrequently treated that it’s important to demonstrate that a safe and effective therapy can be inexpensively delivered over the internet. This opens the door to widespread access to safe, convenient, effective, and inexpensive treatment. Future trials should employ a more active control condition and open up treatment to a wider array of GAD sufferers.

 

Mindfulness practices have a number of effects that appear to be helpful with anxiety disorders. They have been shown to improve emotion regulation. This allows the individual to experience the anxiety but react to it in a constructive way and thereby preventing an upward spiraling of anxiety as the patient becomes more anxious of becoming more anxious. Mindfulness practices also appear to blunt physiological and psychological reactions to stress. Since, high levels of anxiety are stressful, mindfulness practices may reduce the reactions to this stress, making the anxiety more bearable. Finally, anxiety involves worries about the future. By focusing the individual on the present, mindfulness practices interrupt worries about the future.

 

Regardless of the explanation, it is clear that mindfulness based Acceptance and Commitment Therapy (ACT) is effective for Generalized Anxiety Disorder (GAD) even when delivered over the internet.

 

So log-on for less anxiety with mindfulness.

 

“I confessed to him that I saw breathing exercises as an attempt to distract. He said, “Yes. It’s a tool. Mindfulness is all in the subtleties.” Then he paused and told me, “Instead, when thoughts and feelings come, you simply say to them ‘Hello. I see you. Welcome.’”” – Lucy Roleff


CMCS – Center for Mindfulness and Contemplative Studies

 

Reduce Depression with Cyber-Mindfulness  

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MBCT Depression Internet Beck2

 

“Our emotional reactions depend on the story we tell ourselves, the running commentary in the mind that interprets the data we receive through our senses.” ― Mark Williams,

 

Depression is widespread and debilitating. It is the most common mental illness affecting about 4% of the population worldwide. There are a number of treatments for depression the most common of which is antidepressant medication. But the drugs do not always work and can become ineffective over time. They can also have troublesome side effects. So, there is a need to discover safe and effective alternative treatments.

 

Mindfulness training has been shown to be an effective treatment for depression (see http://contemplative-studies.org/wp/index.php/category/research-news/depression/). Cognitive Behavioral Therapy (CBT) has been shown to be effective for depression by altering the ways people think about and process events that occur in their lives. Mindfulness Based Cognitive Behavioral Therapy (MBCT) adds mindfulness training to CBT. It was designed specifically to treat depression and has been shown to be effective even with people who do not respond to antidepressant medications (see http://contemplative-studies.org/wp/index.php/2015/07/17/dealing-with-major-depression-when-drugs-fail/). MBCT has been so effective that the British Medical Service considers it a treatment of choice for depression.

 

MBCT can be delivered either individually or in groups. But, it requires that a highly trained therapist lead the process and it can be delivered to only a limited number of people at a time. Hence, it is relatively expensive to deliver. Also, it requires the patients to come to a practitioner’s facility on a regular basis over 8 to 12 weeks. This can be inconvenient for many and impossible for others. In addition, depressed individuals lack energy and motivation and many simply can’t find the strength to attend regular sessions. So, there is a need to develop better ways to deliver therapy. The internet provides a mechanism that could potentially overcome many of these drawbacks to face-to-face delivery of MBCT. It’s low cost and widely available and can be accessed when the patient feels up to it.

 

In today’s Research News article “PS2-43: Internet Delivered Mindfulness-based Cognitive Therapy for Reducing Residual Depressive Symptoms: An Open Trial and Quasi-experimental Comparison to Propensity Matched Controls”

https://www.facebook.com/ContemplativeStudiesCenter/photos/a.628903887133541.1073741828.627681673922429/1134263793264212/?type=3&theater

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4453426/

Beck and colleagues developed and tested an 8-session MBCT program delivered over the internet to recurrently depressed patients. Compared to treatment as usual for depression internet based MBCT produced a clinically significant decrease in depression with large effect size.

 

These are very exciting results. The cyber MBCT program is highly scalable and can be delivered to large numbers of depression sufferers at low cost. Because it’s delivered over the internet, it is convenient and available to patients who live in areas without access to clinics. The program needs to be compared to face-to-face MBCT. But, these results suggest that its effectiveness is comparable. Further research is definitely called for.

 

So, reduce depression with cyber-mindfulness.

 

“Unhappiness itself is not the problem—it is an inherent and unavoidable part of being alive. Rather, it’s the harshly negative views of ourselves that can be switched on by unhappy moods that entangle us. It is these views that transform passing sadness into persistent unhappiness and depression. Once these harsh, negative views of ourselves are activated, not only do they affect our mind, they also have profound effects on our body—and then the body in turn has profound effects on the mind and emotions.”  ― Mark Williams

 

CMCS – Center for Mindfulness and Contemplative Studies