Designing and Delivering ACT Interven2ons for Individuals with Medical Condi2ons:

Transcription

1 ACBS Symposium World Con 12 Designing and Delivering ACT Interven2ons for Individuals with Medical Condi2ons: Transdiagnos2c principles and key change processes

2 Megan Oser, PhD Vanessa Alvarez, MA Gabe Gruner, LICSW

3 Introduc*on Transdiagnos2c psychological vulnerability factors play a role in a variety of clinical presenta2ons and health problems Heterogeneous (i.e., comorbidi2es) and treatment- refractory pa2ent popula2ons abound in real world clinical prac2ce ACT to treat a heterogeneous and treatment- resistant (relapse, chronicity, mul2ple aqempts at fixing problem) group of pa2ents with medical and psychiatric condi2ons - Theore2cal (transdiagnos2c psychological flexibility) - Empirical (e.g. ACT for heterogeneous group of treatment- resistant pa2ents (Clarke et al., 2012; 2014), and chronic pain group study (McCracken, Sato, & Taylor, 2013)

4 Study Aims To examine the poten2al u2lity of an ACT group treatment for outpa2ents with chronic medical and psychiatric condi2ons in an open trial pilot study To examine whether par2cular transdiagnos2c psychological vulnerability factors improved during ACT group

5 Objec2ves Characterize our sample at baseline Examine differences between completers and non- completers Examine changes in process measures from pre- to post interven2on Describe adapta2ons/modifica2ons made to ACT group for this par2cular pa2ent popula2on

6 ACT Group Session Outline 8-12 weekly group sessions; minutes each Format Mindfulness exercise 6 core components: didac2c and experien2al Prac2ce/behavioral experiments (e.g. behavioral commitment)

7 Procedures 4 cohorts of pa2ents Assessed at baseline at end of treatment/ group and at booster groups

8 Measures Acceptance and Ac2on Ques2onnaire- II (AAQ- II): 7 item version Anxiety Sensi2vity Index (ASI) Distress Tolerance Scale (DTS) PHQ- 4: 4- item anxiety and depression screener

9 Sample at Baseline 24 pa2ents recruited from academic hospital outpa2ent psychiatry clinic; all pa2ents currently receiving psychiatric services Inclusion Criteria: medical and psychiatric condi2on 63% female; M age = 54 years; 71% Caucasian 58% graduated from college or postgraduate school; 1 pt 8 th grade or less; 1 pt only some high school 75% were unemployed and/or on disability; 46% on Medicaid 83% mood disorder; 42% anxiety disorder, 13% substance use 83% prescribed an2depressant; 75% benzodiazepine; 21% mood stabilizer; 17% opioid 25% married; 33% single Most frequently men2oned medical diagnosis was fibromyalgia

10 Sample: Medical Condi2ons Crohn s Disease TBI resul2ng in seizures Hydrocephalus with mul2ple shunt surgeries Hepa22s C Diabetes with renal failure, on dialysis, and re2nopathy Mul2ple sclerosis Systemic infec2on- prolonged ICU stay- and resul2ng in PTSD HIV Spinal muscular atrophy End stage renal failure- Alport s disease; conges2ve heart failure, and intracranial bleeds requiring surgical interven2on Fibromyalgia

11 Adapta2ons of ACT for Chronic Medical Condi2ons Focus on physical pain, body sensa2ons, physical changes (mindfulness and acceptance) Self- as- context: role changes and limita2ons Adherence to difficult medical regimens and social func2oning (values, commiqed ac2on) Make accommoda2ons for wheelchairs and assis2ve devices Modify take your mind for a walk Legi2mately miss sessions due to illness, medical complica2ons, hospitaliza2ons, etc.

12 Baseline: Experien2al Avoidance AAQ- II group AAQ- II comparison 1 AAQ- II comparison 2 AAQ- II comparison 3

13 Baseline: Anxiety Sensi2vity ASI group ASI comparison 1 ASI comparison 2

14 Baseline: Distress Tolerance DTS group DTS comparison 1 DTS comparison 2

15 Baseline: GAD and Depression Screener 83% screen posi2ve for depression (PHQ- 2) 79% posi2ve for anxiety (PHQ- 2)

16 Results: Completers v. Non- Completers Treatment completers missing no more than 3 sessions ( 70% group session aqendance) Avg 61% of total group sessions; 58% missed no more than 3 sessions (roughly 30%) No difference on demographic and descrip2ve variables

17 Contrast of Completers and Non- Completers: AAQ- II p = Completers (n = 14) Non- completers (n = 10) AAQ- II

18 Contrast of Completers and Non- Completers: ASI p = completers (n =10) non- completers (n = 8) ASI

19 Contrast of Completers and Non- Completers: DTS 3.00 p = completers (n = 14) 1.00 non- completers (n = 10) DTS

20 Contrast of Pre- Treatment and Post- Treatment (n =13) Pre- treatment Post- treatment M SD M SD p value Effect Size AAQ-II ASI DTS

21 Experien2al Avoidance pre post

22 Anxiety Sensi2vity Index pre post

23 Distress Tolerance pre post

24 Depression/GAD screen results Screening posi2ve for depression remained the same pre (69%) to post- treatment (69%). Likewise, screen posi2ve for anxiety remained same pre (77%) to post- treatment (77%). For GAD and depression screen: 3 pa2ents no longer posi2ve screen from pre- post 3 pa2ents who did not screen posi2ve at pre screened posi2ve at post 7 pa2ents remained the same from pre- post

25 Discussion Preliminary support for an ACT group interven2on adapted for individuals with chronic medical and psychiatric condi2ons. Improvements were observed on all measures; however, ACT only significantly improved perceived tolerance of distress Values based ac2ons require ability to tolerate distress/uncertainty Tolerance of affec2ve distress in context of medical condi2ons may promote behavior consistent with health- related values (e.g., adherence to medical and behavioral treatment recommenda2ons). Incuba2on period for capturing improvements exists; improvements may not be realized un2l > 6 months post- treatment (Gifford et al., 2004; Hayes et al., 2004).

26 Limita2ons Small sample size; underpowered Rela2vely high aqri2on No follow- up Incuba2on period for capturing improvements

27 Future Direc2ons Include longer follow- up periods to determine whether desired outcomes are maintained over 2me Explore medical record data to obtain objec2ve proxy measures of change in management of medical condi2ons. Temporal hypothesis of distress tolerance changing first then larger construct of experien2al avoidance Need values measure and perhaps behavioral measures

28 References Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., OrcuQ, H. K.,... & ZeQle, R. D. (2011). Preliminary psychometric proper2es of the Acceptance and Ac2on Ques2onnaire II: A revised measure of psychological inflexibility and experien2al avoidance. Behavior Therapy, 42(4), Clarke, S., Kingston, J., James, K., Bolderston, H., & Remington, B. (2014). Acceptance and commitment therapy group for treatment- resistant Par2cipants: A randomised controlled trial. Journal of Contextual Behavioral Science. Clarke, S., Kingston, J., Wilson, K. G., Bolderston, H., & Remington, B. (2012). Acceptance and Commitment Therapy for a heterogeneous group of treatment- resistant clients: A treatment development study. Cogni:ve and Behavioral Prac:ce, 19(4), Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and commitment therapy and the treatment of persons at risk for long- term disability resul2ng from stress and pain symptoms: A preliminary randomized trial. Behavior Therapy, 35, Gifford, E. V., Kohlenberg, B. S., Hayes, S. C., Antonuccio, D. O., Piasecki, M. M., Rasmussen- Hall, M. L., & Palm, K. M. (2004). Acceptance- based treatment for smoking cessa2on. Behavior Therapy, 35, Hayes, S. C., BisseQ, R., Roget, N., Padilla, M., Kohlenberg, B., Fisher, G., & Niccolls, R. (2004). The impact of acceptance and commitment training and mul2cultural training on the s2gma2zing avtudes and professional burnout of substance abuse counselors. Behavior Therapy, 4,

29 References Kroenke, K., Spitzer, R. L., Williams, J. B., & Löwe, B. (2009). An ultra- brief screening scale for anxiety and depression: the PHQ 4. Psychosoma:cs, 50(6), McCracken, L. M., Sato, A., & Taylor, G. J. (2013). A trial of a brief group- based form of acceptance and commitment therapy (ACT) for chronic pain in general prac2ce: pilot outcome and process results. The Journal of Pain, 14(11), Reiss, S., Peterson, R. A., Gursky, D. M., & McNally, R. J. (1986). Anxiety sensi2vity, anxiety frequency and the predic2on of fearfulness. Behaviour research and therapy, 24(1), 1-8. Simons, J. S., & Gaher, R. M. (2005). The Distress Tolerance Scale: Development and valida2on of a self- report measure. Mo:va:on and Emo:on, 29(2), Twohig, M. P., Hayes, S. C., Plumb, J. C., PruiQ, L. D., Collins, A. B., HazleQ- Stevens, H., & Woidneck, M. R. (2010). A randomized clinical trial of acceptance and commitment therapy versus progressive relaxa2on training for obsessive- compulsive disorder. Journal Of Consul:ng And Clinical Psychology, 78(5), Wicksell, R. K., Kemani, M. M., Jensen, K. K., Kosek, E. E., Kadetoff, D. D., Sorjonen, K. K., &... Olsson, G. L. (2013). Acceptance and commitment therapy for fibromyalgia: A randomized controlled trial. European Journal Of Pain, 17(4),