What promotes acceptance in Acceptance and Commitment Therapy?

I normally give studies of internet-delivered therapy a wide berth but this one had a potentially-informative design examining a therapy close to my heart which I haven’t covered yet in these blogs: Acceptance and Commitment Therapy (ACT)…so, I’m getting over myself.

This study by Mike Levin and colleagues (2020) is perhaps the largest scale attempt to “dismantle” ACT; that is, to test whether particular components are necessary to produce whatever benefits ACT as a package provides. They randomly assigned 181 college students showing clinically significant distress to one of 4 conditions: 1) Wait List Control; or 12 online modules of either: 2) Full ACT; 3) an intervention focusing only on acceptance and defusion skills (“Open”); or 4) an intervention focusing only on values clarification and committed action skills (“Engaged”). The so-called “Aware” skills of attending flexibly to the present moment from a defused, self-as-observer perspective were presumed to be necessary to, and present across, all three intervention conditions. The study compared the effect of each condition on two outcome measures (distress and positive mental health) and six process measures (two psychological inflexibility measures, two committed action measures, a fusion measure and a mindfulness measure).

Now, in case you’re thinking “just students”, it’s worth mentioning that the mental health of university student populations is actually pretty bad. For example, Usher and Curran (2019) found that 25% of a sample of 2326 Australian university students had been diagnosed with a mental health disorder by a professional, whereas general community prevalence is estimated at 20%. Stallman (2010) found that 19% of university students had K10 scores of 30 – 50 (high levels of psychological distress); in contrast, the 2017 National Health Survey of the Australian general population found only 4% had scores > 30. In the United States, average distress ratings of college students have increased linearly from 2010 -2019 (Centre for College Mental Health, 2019). So, the results of this study are likely to be relevant to most clients that are willing and able to receive their mental health intervention via their internet-equipped device.

So, what did they find? All interventions improved distress relative to wait list, with no significant differences between interventions on average amount of distress reduction. However, reliable change rates – which count the number of individuals who make enough change to be clearly greater than test-retest reliability error – showed that the Full ACT and Engaged conditions achieved greater proportions of individuals making significant reductions in distress (40% and 46% respectively), than the Open and Wait list control conditions (27% and 17%). A similar pattern was evident with the positive mental health measure: The Full ACT and Engaged conditions achieved significant medium effect sized improvements, but Open did not significantly improve relative to Wait List. These findings alone are incredibly interesting for anyone whose practice is informed by ACT. They tend to suggest that a focus on acceptance and defusion without helping clients ensure these practices are applied in their pursuit of enacting values isn’t particularly helpful. The lack of difference between Engaged and Full ACT suggests that the behavioural activation component of ACT may provide most of the therapeutic value.

But wait, there’s more.

All ACT conditions (Full, Open, Engaged) improved the process measure scores over time compared to wait list, except that Open produced no greater reductions in psychological inflexibility or increases in acceptance than wait-list. This suggests that the strategies in Open for increasing acceptance are not sufficiently powerful when divorced from efforts to increase valued activity. That’s not really surprising to an ACT fan; ACT has always promoted the mutually facilitative effects of increasing acceptance and committed action together.

Finally, ACT did not seem entirely reducible to behavioural activation. Full ACT achieved greater reductions in cognitive fusion than the other conditions and greater increases in acceptance than the Engaged condition.

 

Take home: Clinical Implications

  • Values clarification and committed action activities are sufficient to produce reductions in distress and increases in positive mental health

  • Defusion is optimised by delivering all ACT components (acceptance and defusion combined with values clarification and committed action)

  • Acceptance interventions without application to pursuing valued activities is not a powerful intervention (at least within a 12-module internet-delivered format)

    • Clinicians are advised to consider their client’s likely attendance pattern and adjust their treatment plan to ensure coverage of all ACT components in the likely time available, which is especially important when working with difficult-to-retain populations.

Go to https://www.sciencedirect.com/science/article/pii/S0005796720300085 for the original article.

 

References

Levin, M. E., Krafft, J., Hicks, E. T., Pierce, B., & Twohig, M. P. (2020). A randomized dismantling trial of the open and engaged components of acceptance and commitment therapy in an online intervention for distressed college students. Behaviour Research and Therapy, 126, 103557. doi:https://doi.org/10.1016/j.brat.2020.103557

Stallman, H. M. (2010). Psychological distress in university students: A comparison with general population data. Australian Psychologist, 45(4), 249-257. doi:10.1080/00050067.2010.482109

Usher, W., & Curran, C. (2017). Predicting Australia’s university students’ mental health status. Health Promotion International, 34(2), 312-322. doi:10.1093/heapro/dax091

Matthew Smout