A systematic review of the use of Acceptance and Commitment Therapy (ACT) in chronic disease and long-term conditions

The relationship between acceptance, fatigue, and subjective cognitive impairment in hematologic cancer survivors

Background/Objective: Cancer and its treatment can have a detrimental impact on psychological well-being. Acceptance as the basis of acceptance and commitment therapy (ACT) has shown beneficial effects on depression and anxiety. However, its relationship to fatigue and cognitive impairment has not been investigated. A protective effect of acceptance may open up a new target for psychological intervention. Method: A cross-sectional postal survey was undertaken. 922 hematological cancer survivors (≥ 2.5 years post diagnosis) were recruited through two regional cancer registries in Germany. Acceptance (AAQ-II), fatigue (BFI) and subjective cognitive impairment (AFI) were assessed. Results: Higher levels of acceptance were negatively associated with fatigue and subjective cognitive impairment (R² = .34 and R² = .26, respectively). The relationship between fatigue and fatigue-related impairment of daily life was weaker for survivors with high acceptance. Conclusions: Acceptance is strongly associated with fatigue and subjective cognitive impairment. ACT may be useful to reduce symptoms of fatigue and subjective cognitive impairment in cancer survivors.

The Intentional Non-Adherence Scale (INAS): Initial development and validation

OBJECTIVE

Adherence continues to be a major challenge in healthcare but there is still limited understanding of all the factors which can influence adherence behaviour. The present study was designed to identify a range of factors associated with intentional non-adherence and to see if they could be formed into a psychometrically sound scale.

METHODS

Patients in three different clinical groups (Hypertension (N = 175); Oncology (N = 115); Gout (N = 196)) were given the new scale together with an adherence self-report and/or biomarker measure. Other, more established measures of factors known to be associated with adherence (BMQ, PAM, BIPQ), were also completed by patients for comparative and validation purposes. Exploratory Factor Analysis (EFA) was conducted to examine the factor structure of the new scale, and other statistical analyses were used for testing the psychometric properties of the new scale.

RESULTS

EFA revealed two factors, which were labelled "Resisting illness" and "Testing treatment". Both scales were found to have good psychometric properties and explained unique variance in adherence in all three clinical groups.

CONCLUSION

This new scale shows promise in describing and explaining some relatively novel factors underlying treatment non-adherence. Further work in different patient groups and clinical contexts is needed to confirm the factor structure and predictive value of these scales.

Preventing suicidal behavior in patients with multiple sclerosis: a scoping review

INTRODUCTION

Suicidal behavior is a relatively rare occurrence among patients with multiple sclerosis (MS). Nonetheless, it is important to identify and be aware of the constituting risk factors to prevent suicidal behavior among vulnerable patients. Areas covered: This scoped review will shortly outline well-known biological and psychosocial risk factors for suicidal behavior among MS patients and suggest preventive initiatives. The preventive strategies should include a close monitoring of MS pharmacotherapy to prevent progression, and awareness and early identification of psychosocial risk factors across a variety of heathcare and social instances the patient may encounter during their life with the disease. The staff in these instances should be educated in detecting the MS patients at increased risk and refer them to relevant healthcare instances, including the general practitioner, neurologists, psychiatrist, etc. In addition, referral to social instances to support educational, vocational, and home environment to the state of the disease is of utmost importance. Expert commentary: Enhancing quality of life for as long as possible by these means may be held to reduce the risk for psychosocial problems and hence suicidal behavior.

Acceptance and Commitment Therapy for Muscle Disease (ACTMus): protocol for a two-arm randomised controlled trial of a brief guided self-help ACT programme for improving quality of life in people with muscle diseases

INTRODUCTION

In adults, muscle disease (MD) is often a chronic long-term condition with no definitive cure. It causes wasting and weakness of the muscles resulting in a progressive decline in mobility, alongside other symptoms, and is typically associated with reduced quality of life (QoL). Previous research suggests that a psychological intervention, and in particular Acceptance and Commitment Therapy (ACT), may help improve QoL in MD. ACT is a newer type of cognitive behavioural treatment that aims to improve QoL by virtue of improvement in a process called psychological flexibility. The primary aim of this randomised controlled trial (RCT) is to evaluate the efficacy of a guided self-help ACT programme for improving QoL in people with MD. Main secondary outcomes are mood, symptom impact, work and social adjustment and function at 9-week follow-up.

METHODS AND ANALYSIS

Acceptance and Commitment Therapy for Muscle Disease is an assessor-blind, multicentre, two-armed, parallel-group RCT to assess the efficacy of ACT plus standard medical care (SMC) compared with SMC alone. Individuals with a diagnosis of one of four specific MDs, with a duration of at least 6 months and with mild to moderate anxiety or depression (Hospital Anxiety and Depression Scale score ≥8) will be recruited from UK-based MD clinics and MD patient support organisations. Participants will be randomised to either ACT plus SMC or SMC alone by an independent randomisation service. Participants will be followed up at 3, 6 and 9 weeks. Analysis will be intention to treat, conducted by the trial statistician who will be blinded to treatment allocation.

ETHICS AND DISSEMINATION

The study has received full ethical approval. Study results will be disseminated via peer-reviewed publications, conference presentations and journal articles. Data obtained from the trial will enable clinicians and health service providers to make informed decisions regarding the efficacy of ACT for improving QoL for patients with MD.

TRIAL REGISTRATION NUMBER

NCT02810028.

PROTOCOL VERSION

V.11 (4 April 2017).

Unfolding the values of work - therapists´ experience of addressing the return to work process in occupational rehabilitation based on Acceptance and Commitment Therapy

Background

Facilitating return to work can be challenging due to the complexity of work disability. Few studies have examined rehabilitation programs based on Acceptance and Commitment Therapy that intend to support return to work, and none have investigated therapists’ experience with providing such programs. The aim of this study was therefore to explore therapists’ experience of addressing the return to work process in an inpatient occupational rehabilitation program based on Acceptance and Commitment Therapy.

Methods

This was a qualitative interview study supported by participant observation. Therapists were interviewed regarding their experiences with addressing return to work in an inpatient occupational rehabilitation program based on Acceptance and Commitment Therapy. In addition, the rehabilitation program was investigated through participant observation. The interviews were analysed according to Interpretative Phenomenological Analysis and informed by an analysis of field notes from the participant observation.

Results

Acceptance and Commitment Therapy was experienced as a meaningful approach to facilitate return to work, as it allowed therapists to address all relevant aspects of the individual participant’s life that might influence work participation. The therapists’ twofold goal was to support participants in building both a meaningful life and sustainable work participation. To do so, they attempted to instil long-term and interrelated processes concerning ownership, causes of sick leave, relation to expectations, the values of work, and the scope of agency.

Conclusion

Unfolding values connected to work participation might reconcile the tension between work and family life by integrating work with other areas of life. Providing work participation with personal meaning also seems especially commensurable with a context where economy presents a poor incentive for return to work. Therapists should, however, be attentive to the need to secure the prominence of return to work by relating participants’ chosen themes explicitly to their return to work process. Therapists should also be aware of the dilemma that may arise when they attempt to refrain from providing advice while simultaneously encouraging actions they consider appropriate to facilitate sustainable work participation. In addition, having an individual-oriented approach to occupational rehabilitation may obscure the extent to which return to work is a multi-stakeholder process.

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

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 workshop for Italian psychologists working with people with MS.

Methods

Data were collected via online questionnaires from 34 psychologists before the workshop, after the workshop, 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 workshop evaluation questionnaire and an ACT knowledge examination were administered after the workshop.

Results

Most participants (94%) acknowledged the potential beneficial effects of the workshop on their work. Almost all participants reported their intention to apply ACT clinically. More than 90% of participants indicated that the workshop was efficacious. All participants scored higher than 75% on the examination. Mindfulness increased from after the workshop 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.

Adapting and validating a measure of diabetes-specific self-compassion

AIMS

Self-compassion (SC), or treating oneself with kindness when dealing with personal challenges, has not been rigorously examined in people with T1D. SC has been shown to buffer against negative emotions and to be linked to improved health outcomes, but diabetes-specific SC has not been studied. This study aimed to adapt the Self-Compassion Scale and validate it for a diabetes-specific population.

METHODS

We developed and validated a diabetes-specific version of the Self-Compassion Scale (Neff, 2003) in a sample of adults with T1D (N=542; 65% female; 97% non-Hispanic White; M age 41, SD=15.7; M A1c=7.3, SD=1; 72% insulin pump users; 50% continuous glucose monitoring [CGM] users). Confirmatory factor analyses (CFA), and reliability and construct validity analyses were conducted. Validity measures included diabetes distress, diabetes empowerment, diabetes numeracy, and A1c.

RESULTS

A two-factor bi-factor structure showed best fit, providing support for use of the adapted scale (SCS-D) as a unitary construct. The 19-item unidimensional SCS-D demonstrated excellent internal consistency (ɑ=0.94; range of item-total correlations: 0.52-0.71) and construct validity. As hypothesized, higher SCS-D was associated with less distress, greater empowerment, and lower A1c, and was not associated with numeracy.

CONCLUSIONS

The SCS-D is a reliable and valid measure of diabetes-specific self-compassion in adults with T1D.

'It's nothing you could ever prepare anyone for': the experiences of young people and their families following parental stroke

AIMS

This study sought to explore the experiences of young people (aged 8-16) and their families following parental acquired brain injury (ABI), with the aim of developing an understanding of the ways in which members of a family make sense of events post-injury, and to consider the implications of different perspectives on adjustment and coping.

DESIGN

The study applied a qualitative approach using a thematic analysis methodology.

PROCEDURE

Individual semi-structured interviews were conducted with 10 individuals from three families affected by parental stroke.

RESULTS

Findings suggested that post-injury, families experienced a period of uncertainty in which they were required to renegotiate their roles and adjust to the loss associated with parental stroke. Additionally, the psychosocial wellbeing of young people was negatively affected, whilst protective and coping strategies were recognised.

CONCLUSIONS

The research offers an insight into the processes that may contribute to patterns of interpersonal relating that could negatively impact on adjustment. Provision of adequate information, psychological and practical support during recovery may therefore be crucial elements of supporting young people and their families in adjusting to the challenges posed by stroke.

A 4-Day Mindfulness-Based Cognitive Behavioral Intervention Program for CFS/ME. An Open Study, With 1-Year Follow-Up

Background: Chronic Fatigue Syndrome/Myalgic Encephalopathy (CFS/ME) is an incapacitating illness in which single treatment interventions seem to have variable effects. Based on an earlier study we have conducted a new study with a concentrated intervention program. The aims of this study were to: (1) explore the clinical course for patients with CFS/ME who participated in a treatment program delivered during four consecutive days, and (2) evaluate their satisfaction with this program. Methods: 305 patients diagnosed with CFS/ME (Oxford criteria), recruited from a clinical population referred to a specialist outpatient clinic, participated in an open uncontrolled study of the clinical course through 1 year. The study group participated in a 4-day group intervention program, comprised by education, cognitive group therapy sessions, mindfulness sessions, physical activity and writing sessions, within a context of cognitive behavioral therapy, mindfulness, acceptance and commitment model. Assessments were done by self-reports prior to the first consultation, 1 week before and 1 week after the intervention program, and at 3 months and 1 year after the intervention. SPSS 23 and R 3.3 were used for statistical analyses. The associations between case definitions and the outcome measures (Chalder Fatigue Scale (FS), Short Form 36 (SF-36) physical functioning scale) were assessed by a linear mixed effects model (LME). Results: Results showed statistically significant clinical changes for 80% of the patients after the intervention, changes being sustained through 1 year after the program. For both Fatigue Scale (FS) and the SF-36 there were statistically significant effects of time from baseline to all time points with a statistically significant drop in scores, applying the linear mixed effects model. A subgroup fulfilling the inclusion criteria from the PACE study (Chalder Fatigue Scale >6/11, SF-36 Physical functioning <65/100) showed clinically significant improvement through 1 year, changes in outcome measures were statistically significant (p < 0.001). None of the patients included in the program dropped out, and a great majority of patients expressed high satisfaction with the content, focus and amount of treatment. Conclusion: Clinical changes observed from pre-treatment to 1 year follow-up could represent effects of the 4-day concentrated intervention program, and should be further explored in a controlled study.

Mindfulness-based interventions for women with breast cancer: an updated systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to systematically update the evidence for mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) in women with breast cancer.

MATERIAL AND METHODS

In October 2016, PubMed, Scopus, and Central were searched for randomized controlled trials on MBSR/MBCT in breast cancer patients. The primary outcome was health-related quality of life. Secondary outcomes were fatigue, sleep stress, depression, anxiety, and safety. For each outcome, standardized mean differences (SMD/Hedges' g) and 95% confidence intervals (CI) were calculated. Risk of bias was assessed by the Cochrane risk of bias tool.

RESULTS

The Literature search identified 14 articles on 10 studies that included 1709 participants. The overall risk of bias was unclear, except for risk of low attrition bias and low other bias. Compared to usual care, significant post-intervention effects of MBSR/MBCT were found for health-related quality of life (SMD = .21; 95%CI = [.04-.39]), fatigue (SMD = -.28; 95%CI = [-.43 to -.14]), sleep (SMD = -.23; 95%CI = [-.40 to -.05]), stress (SMD = -.33; 95%CI = [-.61 to -.05]), anxiety (SMD = -.28; 95%CI = [-.39 to -.16]), and depression (SMD = -.34; 95%CI = [-.46 to -.21]). Up to 6 months after baseline effects were significant for: anxiety (SMD = -.28; 95%CI = [-.47 to -.09]) and depression (SMD = -.26; 95%CI = [-.47 to -.04]); and significant for anxiety (SMD = -.21; 95%CI = [-.40 to -.03]) up to 12 months after baseline. Compared to other active interventions, significant effects were only found post-intervention and only for anxiety (SMD = -.45; 95%CI = [-.71 to -.18]) and depression (SMD = -.39; 95%CI = [-.65 to -.14]). However, average effects were all below the threshold of minimal clinically important differences. Effects were robust against potential methodological bias. Adverse events were insufficiently reported.

CONCLUSIONS

This meta-analysis revealed evidence for the short-term effectiveness and safety of mindfulness-based interventions in women with breast cancer. However, their clinical relevance remains unclear. Further research is needed.

Acceptance and commitment therapy (ACT) for clinically distressed health care workers: Waitlist-controlled evaluation of an ACT workshop in a routine practice setting

OBJECTIVES

To examine the effects of a 1-day acceptance and commitment therapy (ACT) workshop on the mental health of clinically distressed health care employees, and to explore ACT's processes of change in a routine practice setting.

DESIGN

A quasi-controlled design, with participants block allocated to an ACT intervention or waiting list control group based on self-referral date.

METHODS

Participants were 35 health care workers who had self-referred for the ACT workshop via a clinical support service for staff. Measures were completed by ACT and control group participants at pre-intervention and 3 months post-intervention. Participants allocated to the waitlist condition went on to receive the ACT intervention and were also assessed 3 months later.

RESULTS

At 3 months post-intervention, participants in the ACT group reported a significantly lower level of psychological distress compared to the control group (d = 1.41). Across the 3-month evaluation period, clinically significant change was exhibited by 50% of ACT participants, compared to 0% in the control group. When the control group received the same ACT intervention, 69% went on to exhibit clinically significant change. The ACT intervention also resulted in significant improvements in psychological flexibility, defusion, and mindfulness skills, but did not significantly reduce the frequency of negative cognitions. Bootstrapped mediation analyses indicated that the reduction in distress in the ACT condition was primarily associated with an increase in mindfulness skills, especially observing and non-reactivity.

CONCLUSIONS

These findings provide preliminary support for providing brief ACT interventions as part of routine clinical support services for distressed workers.

PRACTITIONER POINTS

A 1-day ACT workshop delivered in the context of a routine staff support service was effective for reducing psychological distress among health care workers. The brief nature of this group intervention means it may be particularly suitable for staff support and primary care mental health service settings. The findings indicate that the beneficial effects of an ACT workshop on distressed employees' mental health were linked to improvements in specific mindfulness skills. Study limitations include non-random allocation of participants to the ACT and control groups, and measurement of mediators and outcome at the same time point (3 months post-intervention).

Oral manifestations, dental management, and a rare homozygous mutation of the PRDM12 gene in a boy with hereditary sensory and autonomic neuropathy type VIII: a case report and review of the literature

BACKGROUND

Hereditary sensory and autonomic neuropathy type VIII is a rare autosomal recessive inherited disorder. Chen et al. recently identified the causative gene and characterized biallelic mutations in the PR domain-containing protein 12 gene, which plays a role in the development of pain-sensing nerve cells. Our patient's family was included in Chen and colleagues' study. We performed a literature review of the PubMed library (January 1985 to December 2016) on hereditary sensory and autonomic neuropathy type I to VIII genetic disorders and their orofacial manifestations. This case report is the first to describe the oral manifestations, and their treatment, of the recently discovered hereditary sensory and autonomic neuropathy type VIII in the medical and dental literature.

CASE PRESENTATION

We report on the oral manifestations and dental management of an 8-month-old white boy with hereditary sensory and autonomic neuropathy-VIII over a period of 16 years. Our patient was homozygous for a mutation of PR domain-containing protein 12 gene and was characterized by insensitivity to pain and thermal stimuli, self-mutilation behavior, reduced sweat and tear production, absence of corneal reflexes, and multiple skin and bone infections. Oral manifestations included premature loss of teeth, associated with dental traumata and self-mutilation, severe soft tissue injuries, dental caries and submucosal abscesses, hypomineralization of primary teeth, and mandibular osteomyelitis.

CONCLUSIONS

The lack of scientific knowledge on hereditary sensory and autonomic neuropathy due to the rarity of the disease often results in a delay in diagnosis, which is of substantial importance for the prevention of many complications and symptoms. Interdisciplinary work of specialized medical and dental teams and development of a standardized treatment protocols are essential for the management of the disease. There are many knowledge gaps concerning the management of patients with hereditary sensory and autonomic neuropathy-VIII, therefore more research on an international basis is needed.

A pilot case series of a brief acceptance and commitment therapy (ACT)-based guided self-help intervention for improving quality of life and mood in muscle disorders

This study aimed to demonstrate proof of concept and acceptability of a brief acceptance and commitment therapy (ACT)-based guided self-help intervention for improving quality of life (QoL) and mood for people with muscle disorders (MD). A case-series with an AB design was used to assess changes in primary (QoL) and secondary (depression and anxiety) outcome variables across the period of study. Change in the psychological process targeted by ACT – psychological flexibility – was also investigated, to allow insight into possible treatment mechanisms. Post-intervention, participants also completed a brief free-text evaluation. Relative to pre-intervention scores, four (of seven) participants showed varying degrees of improvement in all primary and secondary outcome variables and were thus considered responders. However, consistent concomitant improvements in psychological flexibility were not apparent. Participants reported a mostly positive experience of the intervention; all appeared to complete the intervention, and no adverse events were reported. Nonetheless, there was evidence that those with compromised concentration or who report good initial QoL and low levels of distress may derive less benefit. Although several methodological weaknesses limit the strength of our conclusions, this ACT-based guided self-help intervention shows encouraging utility for improving QoL and mood in MD.

Using Acceptance and Commitment Therapy to Improve Outcomes in Functional Movement Disorders: A Case Study

Although there are many theories of functional movement disorders (FMD), the causes and prognosis remain unclear, and there are no treatments with high-quality empirical support. Acceptance and commitment therapy (ACT) is an acceptance-based behavior therapy which, via altering a process called psychological flexibility, aims to support behaviors that are consistent with a person’s overarching values—even in difficult, uncertain, or immutable contexts. It may, therefore, have pragmatic benefits in the context of FMD. We outline the theoretical basis for ACT and detail a case study of a brief (six session) intervention for increasing personally meaningful activity with FMD. The participant was in her early 20s and had been diagnosed with functional propriospinal myoclonus. ACT techniques including relational framing, defusion, and mindfulness exercises were used to increase psychological flexibility, with the goal of enabling effective functioning within the difficult context created by FMD. Following treatment, the participant showed a reliable change/clinical recovery in psychological flexibility (Acceptance and Action Questionnaire II [AAQ-II]), FMD symptom interference (Work and Social Adjustment Scale [WSAS]; primary outcome), and mood (Clinical Outcomes in Routine Evaluation 10-item scale [CORE-10]; secondary outcome). This case study demonstrates an approach that focuses first on improving functioning with FMD, as opposed to eliminating or controlling symptoms.

An 18-month study of the effects of IBD symptomatology and emotion regulation on depressed mood

PURPOSE

Depressive symptomatology in IBD patients is known to predict disease activity, which, in turn, can increase depressive symptoms in perpetuating a cycle between depression and IBD symptomatology. The mechanisms that contribute to the relationship between disease activity and depressive symptoms are not clearly investigated yet. Since emotion regulation has been considered particularly relevant to define the impact of adverse experiences on different outcomes, the current study aimed to examine the longitudinal influence of two maladaptive emotion regulation processes, cognitive fusion and brooding, on the association between disease activity and depressed mood.

METHODS

This study was conducted over an 18-month period, using a sample of 116 IBD patients that completed self-report validated measures in three different waves. Correlation analyses and cross-lagged panel models were performed.

RESULTS

The main result from this study discovered that the experience of IBD symptomatology at baseline, although positively linked to the manifestation of depressed mood 18 months later (r = 0.25; p < 0.01), does not directly predict depressive symptoms. This relationship is rather indirect, as it is explained by the engagement in cognitive fusion (p = 0.028) and brooding (p = 0.017). These maladaptive emotion regulation processes, that were revealed to be consistent over time, link IBD symptoms with subsequent depressed mood.

CONCLUSIONS

These findings indicate that clinicians should be aware of the emotion regulation processes patients tend to use to handle difficult experiences. The inclusion of psychological assessments and interventions in the healthcare of IBD patients should be seriously considered. Further implications are discussed.

Revisión sistemática sobre la eficacia de la Terapia de Aceptación y Compromiso (ACT) en el tratamiento psicológico de pacientes con cáncer

Introducción: Aunque se han publicado muchos estudios que han intentado demostrar la eficacia de diferentes tratamientos psicológicos en pacientes con cáncer; hasta la fecha no se ha revisado la evidencia disponible sobre la eficacia de la Terapia de Aceptación y Compromiso (ACT) en estos pacientes. Objetivo: se pretende analizar sistemáticamente la evidencia empírica sobre la ACT en el tratamiento psicológico de los enfermos con cáncer. Método: se ha realizado una búsqueda en las bases de datos PubMed, Science Direct, Medline, Psychology and Behavioral Sciences Collection, Journal of Contextual Psychology y Cochrane Biblioteca. Resultados: De los 108 artículos encontrados, se han seleccionado para la revisión un total de 8, que seguían un diseño experimental o cuasiexperimental en pacientes adultos diagnosticados de cáncer tratados con ACT. Conclusiones: Los resultados, aunque heterogéneos, sugieren mejorías a medio – largo plazo en las variables de ansiedad, depresión, aceptación, calidad de vida, distrés y flexibilidad psicológica. Además, la ACT ha resultado ser más eficaz que otras terapias psicológicas. De este modo, a pesar de las limitaciones encontradas en este estudio, se han obtenido resultados prometedores para futuras revisiones y/ o metaanálisis.