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Jeanie Stafford-Brown & Kenneth Pakenham School of Psychology The University of Queensland

ACT ON STRESS: The efficacy of ACT for reducing stress and improving the quality of therapy in clinical psychology interns. Jeanie Stafford-Brown & Kenneth Pakenham School of Psychology The University of Queensland Brisbane, Australia. BACKGROUND: Stress in clinical psychology students.

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Jeanie Stafford-Brown & Kenneth Pakenham School of Psychology The University of Queensland

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  1. ACT ON STRESS: The efficacy of ACT for reducing stress and improving the quality of therapy in clinical psychology interns Jeanie Stafford-Brown & Kenneth Pakenham School of Psychology The University of Queensland Brisbane, Australia

  2. BACKGROUND: Stress in clinical psychology students • Elevated levels of stress in mental health professionals • Clinical psychologists 29 - 74% (eg. Cushway et al, 1996; Gilroy et al, 2001; Guy et al, 1989) • Trainee clinical psychologists 75% - (eg. Cushway, 1992) • Excessive stress can negatively impact personal and professional functioning and result in less than optimal standards of care for clients • Dearth of empirical studies on stress in trainee clinical psychologists, and there is no published intervention research • Mindfulness-based interventions have been efficacious in similar populations e.g., med students, student counsellors

  3. STUDY AIM • To evaluate the efficacy of a group ACT stress management intervention for post-graduate clinical psychology interns in: • reducing stress and enhancing adjustment • fostering therapist characteristics associated with better therapy outcomes

  4. HYPOTHESES • Relative to a control group ACT intervention participants would report greater improvements in: • Adjustment outcomes • stress • psychological distress • life satisfaction • Therapist qualities • self-compassion • self-efficacy • therapeutic alliance • ACT process variables • acceptance and action • mindfulness • defusion • valued living • That changes in adjustment outcomes and therapist qualities, would be mediated by changes in some or all of the ACT processes

  5. DESIGN A non-randomised controlled trial with repeated measures

  6. PARTICIPANTS • 56 students from Australian Psychological Society accredited clinical post-graduate training programs at 4 universities in South East Queensland • Inclusion criterion = current enrolment in the internship component of their degree • No exclusion criteria • Characteristics: • Gender: 49 females; 7males • Age: mean = 28.5 years (SD = 8.3; range = 21 to 52) • Relationship status: 70% single • Degree enrolled in: • 57% masters degree • 29% doctorate • 14% PhD • Full-time study = 95% • 86% had completed their undergraduate studies in Queensland

  7. MEASURES • Adjustment Outcomes • Stress Scale for Mental Health Professionals (MHPSS; Cushway & Tyler, 1996) • General Health Questionnaire – 28 (Goldberg, 1981) • Satisfaction With Life Scale (SWLS; Diener et al, 1985) • Therapist Qualities • Working Alliance Inventory-therapist version (WAI-SF; Horvath, 1991) • Self-Compassion Scale (SCS; Neff, 2003) • Counselor Activity Self-Efficacy Scales (CASES; Lent et al, 2003)

  8. MEASURES • ACT Processes • Five Facet Mindfulness Questionnaire (FFMQ; Baer et al, 2006) • Acceptance and Action Questionnaire (AAQ; Hayes et al, 2004) • Valued Living Questionnaire (VLQ; Wilson & Groom, 2002) • White Bear Suppression Inventory (WBSI; Wegner & Zanakos, 1994) • Social Validation of the Intervention • 14 forced choice – for example: • whether personally and professionally useful • whether participation increased their interest in ACT • whether they had improved in the six core ACT processes • whether they would recommend the intervention to other students whether it should be offered each year to new students • 6 open-ended – for example: • challenging aspects of the intervention • would they continue to use ACT strategies/processes personally or professionally • should ACT be included in clinical training

  9. INTERVENTION: Session 1 • Aims to: • build rapport • provide a brief overview of ACT • undermine the effectiveness of experiential avoidance tactics • illustrate that regarding thoughts and emotions, control is the problem, not the solution • present willingness as the alternative to experiential avoidance • introduce mindfulness as a willingness strategy • Strategies: • brief overview of ACT and RFT • identify signs of stress and strategies used to deal with them • explore effectiveness of these strategies in the short- and long-term • The Man-in-the-Hole Metaphor (Hayes et al, 1999) • Chinese Handcuffs Metaphor (Hayes et al, 1999) • The Rule of Private Events (Hayes et al, 1999) • Polygraph Metaphor (Hayes et al, 1999) • The Chocolate Cake Exercise (Hayes et al, 1999) • The Two Scales Metaphor (Hayes et al, 1999) • Quicksand Metaphor (Hayes & Smith, 2005) • mindfulness of breathing exercise (Harris, 2007) • informal mindfulness exercises • indentify “stress buttons” (triggers of stress) (Bond & Hayes, 2002)

  10. INTERVENTION: Session 1 • Between Session Practice: • Notice how cognitive avoidance and cognitive struggle amplifies or helps maintain the stress process, when your “stress buttons” have been pressed (Bond & Hayes, 2002) • Practice mindfulness of breathing from CD once every day • Do one “informal” mindfulness activity daily

  11. INTERVENTION: Session 2 • Aims to: • Broaden repertoire of mindfulness exercises • build willingness/acceptance by defusing language • foster contact with the “observing self” & undermine attachment to conceptualised self • Strategies: • Guided mindfulness • Body Scan (Walser & Westrup, 2007) • Participants instruct facilitator how to walk from chair to door - response to each instruction “how do I do that” (Luoma et al, 2007) • Milk, Milk, Milk Exercise (Hayes et al, 1999) • twinkle, twinkle, little ……. (Hayes & Smith, 2005) • What are the Numbers Exercise (Hayes et al, 1999) • Passengers on the Bus Metaphor (Hayes et al, 1999) • defusion techniques discussed and practiced • Leaves on a Stream Exercise (Hayes & Smith, 2005) • Bad Cup Metaphor (Hayes et al, 1999) • substituting self-referential uses of the word “but” with “and” (Hayes et al, 1999) • Chessboard Metaphor (Hayes et al, 1999) • Observer Exercise (Hayes et al, 1999)

  12. INTERVENTION: Session 2 • Between Session Practice: • Practice “Leaves on a Stream” track 4 on CD (12 mins) and “The Observing Self” track 5 on CD (15 mins) by alternating each day • Experiment daily with other defusion techniques outlined in handout

  13. INTERVENTION: Session 3 • Aims to: • promote willingness of difficult internal events • clarify values as chosen life directions • identify and undermine barriers to values-based action • link willingness & values-based action • Strategies: • Passengers on the Bus Metaphor • Tin Can Monster Exercise (Hayes & Smith, 2005) • Eulogy Exercise (Bond, 2004) • Values Worksheet • Values Assessment Rating Form • The Bubble in the Road Metaphor (Hayes et al, 1999) • Homework: • Practice the Tin Can Monster Exercise from CD daily using the stress buttons identified in session 1 • Continue daily practice of defusion techniques and “informal” mindfulness • Reflect on values

  14. INTERVENTION: Session 4 • Aims to: • identify values as a therapist • identify value-directed goals, and related barriers • highlight the experiential qualities of applied willingness, and the nature of commitment • understand the link between willingness and commitment • introduce the notion of self-compassion, and highlight its relevance to self-care and the ACT therapeutic stance • bring it all together • Strategies: • Guided mindfulness exercise • Identifying Your Values as a Therapist Exercise (Luoma et al., 2007) • The Bubble in the Road Metaphor revisited (Hayes et al, 1999) • Goals Actions & Barriers Form completed (Hayes et al, 1999) • The Joe the Bum Metaphor (Hayes et al, 1999) • The Jump Exercise (Hayes et al, 1999) • Swamp Metaphor (Hayes et al, 1999) • Self-compassion introduced - Loving Kindness Meditation (Harris, 2007) • FEAR and ACT algorithms (Hayes et al, 1999)

  15. CLINICAL TRAINING BACKGROUND

  16. RESULTS: Descriptive Data • Satisfaction with clinical training (5-point response scale - 1 “totally dissatisfied” to 5 “totally satisfied”) • Mean = 3.60 (SD = .80; range 1 - 5) • At Pre-treatment ‘Caseness’ Levels using GHQ (cut-off score of ≥ 5) = 73%

  17. RESULTS: Pre- to Post-Treatment Group Comparisons Adjustment outcomes Relative to the control group the intervention group reported lower: • Stress • Psychological distress (Somatic symptoms) Therapist characteristics & therapeutic alliance Relative to the control group the intervention group reported greater improvements in: • Self-compassion (overidentification) • Self-efficacy (insight skills) • Therapeutic alliance (bond)

  18. RESULTS: Pre- to Post-Treatment Group Comparisons cont. ACT processes Relative to the control group the intervention group reported greater improvements in: • Acceptance and action • Willingness) • Mindfulness • Acting with awareness • Non-judging • Defusion • Valued living

  19. RESULTS: Maintenance of treatment gains • All treatment gains were maintained at the 10-week follow-up

  20. RESULTS: Mediational analyses • Bootstrapped nonparametric multiple mediator tests showed that ACT processes mediated changes in: • psychological distress • somatic symptoms • self-compassion (overidentification subscale) • self-efficacy (insight skills) • therapeutic alliance (bond subscale) • Key ACT mediators: • present moment awareness • self-as-context • defusion • acceptance • values action

  21. Intervention Engagement • minimal attrition • take up of options to join other group or 1:1 session • on time and stayed until the end of each session • high participation in discussions • high participation in experiential exercises • 82 – 97% did some between session practice each week

  22. Satisfaction • personally useful M = 3.9 (1 “not useful” – 5 “very useful”) • professionally useful M = 3.9 (1 “not useful” – 5 “very useful”) • 96% increased interest in ACT • 96% ACT offered as part of training • 78% would recommend the program (22% unsure) • all reported improvement on 1 or more ACT processes • 92% personally use ACT strategies or processes • 85% professionally use ACT strategies or processes

  23. Resilience for every Day Nicola Burton, Ken Pakenham, Wendy Burton

  24. Background • Resilience = effective coping and adaptation in the face of significant life challenges (Tedeschi & Kilmer, 2005) • It is characterized by good mental and physical health, functional capacity, and social competence, despite cumulative and current stressful life events. • Resilience is a dynamic process of adaptation to stressful events that involves an interaction between protective factors & stressors.

  25. Background • Prior research focused on: • children • specific resilience-related intra-personal characteristics • individuals in specific adverse circumstances (eg. chronic physical illness, bereavement, divorce)

  26. Background 5 key resilience protective factors (Southwick, Vythilingam & Charney, 2005) • Positive emotions • Cognitive flexibility • Meaning • Social support • Active coping strategies (eg. problem solving, positive reappraisal, humour, acceptance, exercise) • Each protective factor shown to be related to: • better mental health • lower risk of disease • better health outcomes for those already diagnosed with illness • neurobiological resilience factors (eg. a highly functional dopamine-mediated reward system) (Ryff & Singer, 2003; Southwick et al., 2005)

  27. Background • Resilience training targets protective factors that can be modified, to increase an individual’s hardiness for remaining healthy in the face of cumulative stress. • Few intervention studies have attempted to increase resilience among adults in the general population. • Worksite RCT (prevention): Improvements in resilience, self esteem, locus of control, life purpose, & interpersonal relations (Waite & Richardson, 2004) • Diabetes: negligible improvements relative to care-as-usual group (Bradshaw et al., 2007) • Worksite trial (ill participants): increases in effective coping and decreases in depression (Steensma et al, 2006)

  28. READY (REsilience and Activity every DaY) • CBT and ACT informed intervention • involved 11 x 2 hour group-based sessions over 14 weeks • Session format: • discussion • experiential exercises • skills rehearsal and practice • didactic input • between session practice activities • review of between session practice • Resources: • participant manual • CD • therapist manual

  29. Session 1 Introduction • Welcome, general introductions & housekeeping • What is resilience? • READY model of resilience • Warning signs of low resilience • READY program overview • Introduction to READY workbook and READY personal plan • Review and READY personal plan

  30. Feeling Doing Positive emotions Coping strategies Resilience Cognitive flexibility Social support Thinking Relations Meaning Being

  31. Session 2: Physical Activity • Physical activity & resilience • Physical activity recommendations • Physical activity definitions and domains • Step counting, pedometers and sitting time • Physical activity and goal setting • Physical activity and problem solving

  32. ACT modules • Session 3: Mindfulness • Mindfulness of: eating sultana, environment, breath, body • CD • Session 4: Defusion I • Session 5: Defusion II (including observer self) • Session 6: Acceptance • Session 7 : Review • Session 8: Values

  33. Sessions 9 - 11 • Session 9: Social Support & Connectedness • Session 10: Relaxation & Pleasurable Activities • Session 11: Planning for the Future

  34. Pilot StudyBurton, Pakenham & Brown (2010). Psychology, Health & Medicine, 15, 266-277 • Pre-post single group design • 18 volunteers recruited from administrative staff at University of Queensland • 15 women; 3 men • mean age 36.5 years (SD 8.6) were • 2 drop-outs

  35. Measures: psychosocial • Psychological Well-being (Ryff, 1989) • autonomy • environmental mastery • personal growth • positive relations • purpose in life • self-acceptance • Depression (CES-D; Radloff, 1977) • Stress & Anxiety (DASS-21; Lovibond & Lovibond, 1995) • Positive affect (PANAS-X; Watson & Clark, 1999) • Values (Valued Living Questionnaire, Wilson & Groom, 2002) • Mindfulness (Mindful Attention Awareness Scale, Brown, 2003) • Acceptance & Action Questionnaire II (AAQII; Hayes et al., 2006) • MOS Social Support Survey (Sherbourne & Stewart, 1991)

  36. Measures: physical • Physical activity • Self-reported time spent in physical activity in previous week • total time spent in walking for transport, for exercise or recreation, moderate & vigorous physical activity (summed to provide a measure of activity minutes/week) • Daily steps • for 7 consecutive days recorded by pedometer (used to derive average steps/day) • BMI • Blood pressure (BP_Sys and BP_Dias) • Hematological data involved a fasting blood sample to measure: • blood glucose • total cholesterol • C-Reactive protein (CRP) • cortisol

  37. Results • Data were analyzed using standardized mean differences and paired t-tests. • There was a significant difference between baseline and post intervention scores on measures of: • mastery (p=.001) • positive emotions (p=.002) • personal growth (p=.004) • mindfulness (p=.004) • acceptance (p=.012) • stress (p=.013) • self acceptance (p=.016) • valued living (p=.022) • autonomy (p=.032) • total cholesterol (p=.025)

  38. Engagement • The average proportion of sessions attended = 81% • 3 participants attending all 11 sessions • 37% (n=6) missed 1 or 2 sessions • 44% (n=7) missed 3 or 4 sessions • The most common reasons given for missing sessions were clashes with work meetings and planned recreation leave. • High level of in-session participation

  39. Intervention Satisfaction & Feedback • Satisfaction: the mean rating 4.67 • (5-point scale; 5 excellent & 4 very good) • Personal helpfulness: mean rating 4.44 • (5-point scale; 5 a lot & 4 moderately so) • Workbook: mean rating 3.87 • (4-point scale; 4 very helpful & 3 moderately helpful), • READY Personal Plan:mean rating 3.5 • 75% agreed with weekly frequency • 87% agreed with 2 hour session duration • 56% agreed with overall program length (31% thought it was too short)

  40. RCTBurton, Pakenham & Brown (2009). BMC Public Health 9:427 doi:10.1186/1471-2458-9-427 • Cluster randomized trial • 75 participants allocated to either a waitlist or 1 of 2 intervention conditions: • READY including physical activity module • READY excluding physical activity module • Both intervention conditions received a 10x2.5 hour group resilience training program (READY) over 13 weeks. • Measures as per pilot

  41. Adaptations of READY • Clinical Training: • Group READY program in University Psychology Clinic • Experienced facilitator + 3 trainee clinical psychologists as co-facilitators • Target population: people referred to clinic • Screening • Group sessions + 5 individual sessions with trainee psychologists • Coping with Chronic Illness • Carers

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