Evaluation of Acceptance and Commitment Therapy Training for Psychologists Working with People with Multiple Sclerosis

Transcription

1 SHORT REPORT Evaluation of Acceptance and Commitment Therapy Training for Psychologists Working with People with Multiple Sclerosis Kenneth I. Pakenham, PhD; Theresa Scott, PhD; Michele Messmer Uccelli, MA, MSCS Background: Acceptance and commitment therapy (ACT) is the most widely used and researched recent variant of cognitive behavioral therapy and has been shown to increase quality of life in people with chronic illnesses, including multiple sclerosis (MS). However, few MS health practitioners are trained in ACT. This study evaluated a 2-day ACT training for Italian psychologists working with people with MS. Methods: Data were collected via online questionnaires from 34 psychologists before the, after the, and at 6-month follow-up. Two sets of variables were measured at each assessment: primary outcomes (well-being, negative affect, positive affect, and job satisfaction) and ACT processes (values, mindfulness, psychological flexibility, and cognitive defusion). A separate online evaluation questionnaire and an ACT knowledge examination were administered after the. Results: Most participants (94%) acknowledged the potential beneficial effects of the on their work. Almost all participants reported their intention to apply ACT clinically. More than 90% of participants indicated that the was efficacious. All participants scored higher than 75% on the examination. Mindfulness increased from after the to follow-up; however, there were no statistically significant changes in other variables. Correlations suggested beneficial associations between the ACT processes and the primary outcomes. Conclusions: Results suggest that ACT training is personally and professionally helpful for psychologists in the MS field. Int J MS Care. 2018;20: Acceptance and commitment therapy (ACT)1 is the most widely used and researched recent variant of the well-established cognitive behavioral therapy. ACT is based on mindfulness and acceptance processes and on relational frame theory. 1,2 ACT targets experiential avoidance, which refers to intentional efforts to avoid private events experienced as aversive. 2 ACT aims to increase psychological flexibility, which involves behaving consistently with one s chosen From the School of Psychology, University of Queensland, Brisbane, Australia (KIP, TS); and Italian Multiple Sclerosis Society, Genoa, Italy (MMU). Correspondence: Michele Messmer Uccelli, MA, MSCS, Italian Multiple Sclerosis Society, Via Operai 40, Genoa, Italy 16149; michele.messmer@aism.it. DOI: / Consortium of Multiple Sclerosis Centers. values even in the presence of intrusive internal experiences (eg, unwanted thoughts and feelings). 1 ACT uses six interrelated processes to cultivate psychological flexibility: 1) acceptance openness to experience; 2) cognitive defusion observing thoughts rather than taking them literally; 3) present moment awareness (mindfulness) open and responsive awareness of the present; 4) self-as-context flexible self-awareness and perspective taking; 5) values freely chosen, personally meaningful life directions; and 6) committed action values-guided effective action. 1 Consistent with the ACT framework, these processes are related to better mental and physical health. 2 Regarding multiple sclerosis (MS), greater acceptance and mindfulness are related to better adjustment in patients and their caregivers. 3,4 44

2 ACT Training for Psychologists Working in MS ACT interventions can enhance quality of life and physical health and can decrease anxiety and depression in people with various chronic illnesses, including MS. 5-8 ACT incorporates mindfulness, which can improve quality of life and mental health in people with MS. 9 Importantly, ACT is a transdiagnostic treatment model that can provide relief for multiple life difficulties rather than for a particular disorder. ACT training can also improve well-being, self-care, and psychological flexibility in health practitioners. 10,11 These ACT training benefits are particularly relevant to psychologists given that they are at risk for burnout and that self-care and psychological flexibility can protect against burnout. 12 ACT training typically involves experiential exercises whereby trainees experience each of the ACT processes and acquire the skills for enhancing these in their own lives, which, in turn, positions them for teaching these processes to clients. 12,13 Owing to ACT being relatively new, few health professionals serving people with MS are trained in it. The purpose of this study was to evaluate an ACT training for psychologists who work with people with MS in Italy. It was expected that participants attending the ACT training would show improvements after the in personal outcomes (well-being, positive and negative affect, and job satisfaction) and in the ACT processes (mindfulness, psychological flexibility, cognitive fusion, and values). Consistent with the ACT framework, it was predicted that higher levels of mindfulness, psychological flexibility, and values and less cognitive fusion would be associated with better personal outcomes (higher well-being, positive affect, and job satisfaction and lower negative affect). Methods Overview Data were collected at three time points: before the, after the, and at 6-month follow-up. The study received ethical approval from the Regional Ethics Committee, Liguria, Italy (PR240REG2015). Participants were informed about the study at registration, and informed consent was obtained from all the participants. Measures An online questionnaire obtained demographic information and contained measures of the primary outcomes and ACT processes. All the primary outcomes and ACT processes were measured at the three time points, demographic information was obtained before the, a separate online evaluation questionnaire was administered after the, and a paper examination was completed immediately after the. Well-established, psychometrically sound, Italian-validated measures of the primary outcomes and ACT processes were used as follows. Primary Outcomes The primary outcomes were well-being (Mental Health Continuum Short Form), 14 positive and negative affect (Positive and Negative Affect Schedule), 15 and job satisfaction (a single item, I am satisfied with my current job, rated on a 5-point scale from 1 = totally disagree to 5 = totally agree). 16 ACT Processes The ACT processes were psychological flexibility (Acceptance and Action Questionnaire II), 17 mindfulness (Mindful Attention Awareness Scale), 18 and values (Valued Living Questionnaire) 19 ; the inverse of the ACT process of cognitive defusion was measured by the Cognitive Fusion Questionnaire. 20 Workshop Evaluation Questionnaire Forced-choice questions asked about previous experience using ACT, intentions to use ACT, and satisfaction. An open-ended question elicited suggestions regarding changes. ACT Knowledge Examination A paper examination with 42 multiple-choice questions was administered at the end of the. ACT Workshop The 2-day was offered in response to requests from psychologists collected from the Italian MS Society s annual professional development survey and was delivered by one author (K.I.P.) on July 7 and 8, 2015, in Genoa, Italy. The was a modified version of a university ACT training course for trainee clinical psychologists developed and evaluated by the same author. 21 The was delivered in English and translated into Italian by two translators with experience in medical and related fields. Topics included an introduction to ACT, illustrative ACT-based interventions for people with MS, and the six ACT processes. The concluded with a demonstration role-play with a participant playing the role of a client with MS. Experiential exercises and self-practice of the ACT processes were emphasized. Resources included 45

3 Pakenham et al. Correlations Between ACT Processes and Primary Outcomes Correlations between the ACT processes and the primary outcomes are summarized in Table 2. As predicted, higher psychological flexibility, mindfulness, and values and less cognitive fusion were significantly associated with greater well-being and positive affect and lower negative affect across most time points. Greater mindfulness and less cognitive fusion were significantly related to better job satisfaction at follow-up. Although some ACT processes were either unrelated or only weakly related to the primary outcomes before the, most ACT variables were statistically significantly associated with the primary outcomes at follow-up. Most correlations between the ACT processes and well-being and negative and positive affect were statistically significant, with the mean correlation coefficient for each outcome being moderately high and the ACT processes sharing 22% to 31% of the variance in these outcomes; correlarole-plays, discussion, and audio-visuals. The application of ACT strategies in an MS clinical context was highlighted. Results Participant Characteristics Participants were 34 psychologists (31 women and three men) working with clients with MS and their families who are part of a program promoted by the Italian MS Society that provides professional development activity in MS. All but one participant completed the study assessments. The mean (SD) age of participants was (8.29) years (range, years). The mean (SD) number of years of professional work experience was (7.03) years (range, 3-30 years). All the participants had at least 1 year of experience working with people with MS; 60%, 5 years experience; and 37.5%, at least 7 years experience. All but two participants indicated that their main psychology specialization was some form of psychotherapy; two participants indicated developmental and education and neuropsychology. No participant indicated ACT as their primary psychotherapy approach. Most participants (69.4%) reported no previous experience with ACT. Most participants (77.8%) reported that they did not use ACT in their work. Workshop Evaluation Most participants reported that the educational impact of the was optimal (50.0%) or good (41.7%), with 8.3% indicating sufficient. Most participants indicated that the impact of the on their MS work was optimal (41.2%) or good (52.9%), with 2.9% indicating sufficient and only one person indicating very little. The overall efficacy of the training was rated as optimal by 69.4% and as good by 27.8%, with one person indicating sufficient. Most participants (94.1%) reported that they would apply ACT in their MS work. Only eight participants provided suggestions for modifying the. Three clear themes emerged from their responses: timing (more time for practical work, viewing of videos, breaks, and discussion), structure (using small groups, a range of presenters, and translators who have ACT knowledge), and content changes (more MS case examples). ACT Knowledge Examination The mean (SD) examination score was (1.69) of 42 (range, 34-42). All the participants achieved well above the minimum required (75%) by the regulatory body to receive continuing education credits. Changes in Primary Outcomes and ACT Processes Wilcoxon signed rank tests of significance examined changes in the primary outcomes and ACT processes over time (Table 1). None of the primary outcomes changed statistically significantly over the three assessments. Of the ACT processes, only mindfulness changed statistically significantly. As expected, mindfulness increased significantly from after the (mean, 4.12) to follow-up (mean, 4.27) (z score = 1.99, P <.05). Table 1. Changes in primary outcomes and ACT processes over time in the 34 participants Variable 6-mo follow-up Primary outcomes Well-being 3.07 (0.80) 3.14 (0.86) 3.09 (0.83) Job satisfaction 4.09 (0.62) 3.91 (0.79) 3.85 (0.78) Positive affect (3.53) (3.61) (3.68) Negative affect 6.21 (1.43) 6.27 (1.91) 7.12 (3.00) ACT processes Psychological (7.10) (6.41) (6.92) flexibility Mindfulness 4.19 (0.84) 4.12 (0.76) 4.27 (0.75) Values (10.40) (10.86) (12.14) Cognitive fusion (8.78) (8.07) (8.07) Note: Data are given as mean (SD). Abbreviation: ACT, acceptance and commitment therapy. 46

4 Table 2. Correlations between primary outcomes and ACT processes ACT process ACT Training for Psychologists Working in MS Well-being Job satisfaction Positive affect Negative affect Psychological 0.46 a 0.64 a 0.64 a b 0.56 a 0.65 a 0.72 a 0.52 a 0.65 a flexibility Mindfulness 0.50 a 0.52 a 0.52 a b 0.45 a 0.58 a 0.61 a 0.67 a 0.49 a 0.60 a Values 0.63 a 0.57 a 0.55 a b a a Cognitive fusion a 0.51 a b a 0.58 a 0.79 a a a Mean coefficient Variance explained, % c Abbreviation: ACT, acceptance and commitment therapy. a P <.01. b P <.05. c Mean correlation coefficient squared. tion coefficients increased at follow-up and were greater than 0.30, with two coefficients reaching statistical significance. Discussion Most participants rated the positively and acknowledged the beneficial effects that the was likely to have on their work. All the participants reported their intention to apply ACT clinically, and most indicated that the was efficacious. All the participants demonstrated adequate mastery of content given that they achieved well above the minimum examination score required by the regulatory body to receive continuing education credits. The increases in mindfulness suggest personal training benefits. Mindfulness actually increased after the to follow-up, rather than from before to after the, probably because of greater opportunities to practice mindfulness skills during the longer follow-up interval. The trend toward stronger beneficial associations between the personal outcomes and the ACT processes after the point to the potential for other training benefits that should be explored in future research. These findings are noteworthy given that the ACT processes are associated with greater well-being and self-care in health practitioners and that greater mindfulness is associated with better personal and client outcomes in health professionals. 12 Several methodological limitations may explain the lack of statistically significant change in primary outcomes and ACT processes. First, the small sample size limited power to detect statistically significant change; prevention research typically requires large samples to detect change. Second, given that the sample consisted of psychologists, the lack of statistically significant changes may have been due to baseline ceiling effects; however, only job satisfaction and values evidenced ceiling effects. Third, the brevity of the is likely to have limited the acquisition of ACT strategies, given data suggesting that longer ACT training s are more effective. 13,21 Other limitations include the inability to match examination scores and evaluation data with the primary outcome and ACT process data, thereby limiting explorative analyses on issues such as whether those who had previous ACT knowledge improved more than those without such knowledge. Finally, participants were not asked at the 6-month follow-up whether they had used ACT in their MS work. The potential benefits of the were further supported by numerous written anecdotal reports from participants. The also prompted one participant to be awarded a funded fellowship to obtain training in an ACT-based resilience intervention for people PRACTICE POINTS Acceptance and commitment therapy (ACT) is a new variant of cognitive behavioral therapy and is associated with quality-of-life benefits for people with MS. Preliminary evaluative data on an ACT training for psychologists shows promising professional and personal benefits. Training health practitioners in ACT is likely to increase possibilities for developing new innovative psychological strategies for people with MS. 47

5 Pakenham et al. with MS and to translate it into Italian. 5,22 Although few participants suggested changes to the, several timing, structural, and content changes may improve training outcomes. These preliminary yet promising findings have warranted the development of future ACT training evaluation projects for MS psychologists in Italy. Training health practitioners in ACT is likely to encourage the development of innovative contemporary psychological interventions for people with MS, as has occurred in other chronic illness areas. 8 o Financial Disclosures: The authors have no conflicts of interest to disclose. Funding/Support: The Italian Multiple Sclerosis Research Foundation (FISM) provided financial support. References 1. Hayes SC, Strosahl K, Wilson KG. Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. 2nd ed. New York, NY: Guilford Press; Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44: Pakenham KI, Fleming M. Relations between acceptance of multiple sclerosis and positive and negative adjustments. Psychol Health. 2011;26: Pakenham KI, Samios C. Couples coping with multiple sclerosis: a dyadic perspective on the roles of mindfulness and acceptance. J Behav Med. 2013;36: Pakenham KI, Ryan A, Mawdsley M, Brown F. Evaluation of an ACT resilience training program (READY) for people with MS or diabetes. Paper presented at: Association for Contextual Behavioral Science 12th World Conference, Minneapolis, MN, June 18-22, Sheppard SC, Forsyth JP, Hickling EJ, Bianchi J. A novel application of acceptance and commitment therapy for psychosocial problems associated with multiple sclerosis. Int J MS Care. 2010;12: Nordin L, Rorsman I. Cognitive behavioural therapy in multiple sclerosis: a randomised controlled pilot study of acceptance and commitment therapy. J Rehabil Med. 2012;44: Graham CD, Gouick J, Krahe C, Gillanders D. A systematic review of the use of Acceptance and Commitment Therapy (ACT) in chronic disease and long-term conditions. Clin Psychol Rev. 2016;46: Simpson R, Booth J, Lawrence M, Byrne S, Mair F, Mercer S. Mindfulness based interventions in multiple sclerosis: a systematic review. BMC Neurol. 2014;14: Pakenham KI. Training in acceptance and commitment therapy fosters self-care in clinical psychology trainees. Clin Psychol. 2017;21: Richards R, Oliver JE, Morris E, Aherne K, Iervolino AC, Wingrove J. Acceptance and commitment therapy training for clinicians: an evaluation. Cogn Behav Therapist. 2011;4: Pakenham KI, Stafford-Brown J. Stress in clinical psychology trainees: current research status and future directions. Aust Psychol. 2012;47: Luoma JB, Plumb Vilardaga J. Improving therapist psychological flexibility while training acceptance and commitment therapy: a pilot study. Cogn Behav Ther. 2013;42: Lamers S, Westerhof GJ, Bohlmeijer ET, ten Klooster PM, Keyes CL. Evaluating the psychometric properties of the mental health continuumshort form (MHC-SF). J Clin Psychol. 2011;67: Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol. 1988;54: Wanous JP, Reichers AE, Hudy MJ. Overall job satisfaction: how good are single item measures? J Appl Psychol. 1997;82: Bond FW, Hayes SC, Baer RA, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther. 2011;42: Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological wellbeing. J Pers Soc Psychol. 2003;84: Wilson KG, Sandoz EK, Kitchens J, Roberts ME. The valued living questionnaire: defining and measuring valued action within a behavioral framework. Psychol Rec. 2010;60: Gillanders DT, Bolderston H, Bond FW. The development and initial validation of the Cognitive Fusion Questionnaire. Behav Ther. 2014;45: Pakenham KI. Effects of acceptance and commitment therapy (ACT) training on clinical psychology trainee stress, therapist skills and attributes, and ACT processes. Clin Psychol Psychother. 2015;22: Burton NW, Pakenham KI, Brown WJ. Feasibility and effectiveness of psychosocial resilience training: a pilot study of the READY program. Psychol Health Med. 2010;15: