Evaluating ACT Workshops: Changes in Knowledge and Clinical Practice Eric Morris, Joe Oliver, Rachel Richards, Alessandra Iervolino & Janet Wingrove

ACT Workshops Following the 2006 ACT World Con in London we thought it would be a good idea to introduce more of our colleagues to the approach Following the 2006 ACT World Con in London we thought it would be a good idea to introduce more of our colleagues to the approach So we led 3 one-day Introductory ACT workshops, and attempted to evaluate them! So we led 3 one-day Introductory ACT workshops, and attempted to evaluate them! Aim of training was to increase interest and knowledge in ACT, situating it as part of the broader family of behavioural and cognitive psychotherapies. Aim of training was to increase interest and knowledge in ACT, situating it as part of the broader family of behavioural and cognitive psychotherapies.

Context (where we work) a mental health Trust that employs over 300 psychologists a mental health Trust that employs over 300 psychologists Largest mental health Trust in the UK, and supports research and innovation, linked with the Institute of Psychiatry and King’s College Largest mental health Trust in the UK, and supports research and innovation, linked with the Institute of Psychiatry and King’s College a number of specialties: adult, child, older adult, learning disability, forensic services a number of specialties: adult, child, older adult, learning disability, forensic services the majority of psychologists are CBT trained, using a formulation-based approach (rather than manualised treatments) the majority of psychologists are CBT trained, using a formulation-based approach (rather than manualised treatments)

Context 2 We arranged for ACT workshops to psychologists working with adults in 3 directorates We arranged for ACT workshops to psychologists working with adults in 3 directorates Interest was high, with the workshops having attendance from the majority of psychologists in these directorates. Interest was high, with the workshops having attendance from the majority of psychologists in these directorates. Workshops were designed to be a mixture of theory, experiential exercises and discussion of the state of the evidence for ACT. Workshops were designed to be a mixture of theory, experiential exercises and discussion of the state of the evidence for ACT.

Context 3 We were interested to see how ACT would be received by our colleagues, and hopefully turn some more people on to it as an approach. We were interested to see how ACT would be received by our colleagues, and hopefully turn some more people on to it as an approach. As psychologists in the UK tend to be trained in a broader form of CBT, it was going to be interesting to see whether people could integrate ACT into their idea of what CBT is, and use some of the techniques and functional analytic thinking in their practice. As psychologists in the UK tend to be trained in a broader form of CBT, it was going to be interesting to see whether people could integrate ACT into their idea of what CBT is, and use some of the techniques and functional analytic thinking in their practice. We sent participants a copy of Russ Harris' paper “Embracing your Demons: an introduction to Acceptance and Commitment Therapy” prior to the workshop. We sent participants a copy of Russ Harris' paper “Embracing your Demons: an introduction to Acceptance and Commitment Therapy” prior to the workshop.

Content of training Based on our aims, training sought to: Based on our aims, training sought to: Engage audience Engage audience Offer some theoretical background Offer some theoretical background Balance theory with experiential exercises (give examples of exercises used) Balance theory with experiential exercises (give examples of exercises used) Review outcome data Review outcome data Suggest the ACT model as an “interesting alternative”. Avoid direct challenges Suggest the ACT model as an “interesting alternative”. Avoid direct challenges Consider how audience could pragmatically use ACT in their current practice Consider how audience could pragmatically use ACT in their current practice

Some experiential exercises used Leaves on a Stream Leaves on a Stream Lifetime Achievement Award (Attend your own funeral) Lifetime Achievement Award (Attend your own funeral) Milk, Milk, Milk Milk, Milk, Milk Wearing a label Wearing a label Taking Your Mind for a Walk Taking Your Mind for a Walk Eyes On Eyes On

Evaluation and Feedback Knowledge - AKQ (ACT Knowledge Questionnaire; Luoma, 2007), & Discriminating CBT/ACT Knowledge - AKQ (ACT Knowledge Questionnaire; Luoma, 2007), & Discriminating CBT/ACT Interest/Intentions to learn more ACT (visual analogue) Interest/Intentions to learn more ACT (visual analogue) Evaluation of Experiential Exercises Evaluation of Experiential Exercises Qualitative Feedback Qualitative Feedback

Results

Participants Feedback collected from 38 participants pre and post, and 24 followed up after 12 months Feedback collected from 38 participants pre and post, and 24 followed up after 12 months A minority of participants were pre-qualification psychologists (trainees or assistants; N = 3 pre/post, N = 0 f/u) A minority of participants were pre-qualification psychologists (trainees or assistants; N = 3 pre/post, N = 0 f/u) Therapeutic orientation: Therapeutic orientation: CBT or CBT + other 92% CBT or CBT + other 92% 8 participants had previously attended ACT workshops 8 participants had previously attended ACT workshops

Effect on ACT Knowledge Paired t-test (N=32) demonstrated a main effect of time on the number of correct responses to the AKQ. Paired t-test (N=32) demonstrated a main effect of time on the number of correct responses to the AKQ. There were more correct answers post-workshop (mean = 8.9, SD 2.7, range 3-14) compared with pre-workshop (mean = 7.1, SD 2.8, range 2-14). There were more correct answers post-workshop (mean = 8.9, SD 2.7, range 3-14) compared with pre-workshop (mean = 7.1, SD 2.8, range 2-14). E.g., Q10 Which of the following is not an ACT-consistent explanation of “psychopathology”? E.g., Q10 Which of the following is not an ACT-consistent explanation of “psychopathology”? emotional avoidance. emotional avoidance. ineffective thinking and behavior patterns. ineffective thinking and behavior patterns. cognitive fusion. cognitive fusion. lack of committed action. lack of committed action.

Discriminating ACT from CBT Discriminating important components of each approach (criterion-related) Discriminating important components of each approach (criterion-related) Participants scored significantly better at identifying important ACT components post-workshop Participants scored significantly better at identifying important ACT components post-workshop Specific effect, with no changes in identifying CBT components Specific effect, with no changes in identifying CBT components Use of Metaphor in ACT- Important? Pre 66% Post 84% Use of Metaphor in ACT- Important? Pre 66% Post 84% Identifying cognitive errors in ACT – Important? Pre 66% Post 34% Identifying cognitive errors in ACT – Important? Pre 66% Post 34%

Discriminating ACT from CBT Inspection of data showed greatest improvement in following items on ACT questionnaire: Realising not important: Realising not important: Identifying cognitive errors Identifying cognitive errors Using written thought records Using written thought records Challenging negative thoughts and beliefs Challenging negative thoughts and beliefs Working with dysfunctional assumptions Working with dysfunctional assumptions Realising important: Realising important: Use of metaphors Use of metaphors Reflect bias in assuming everything important to start with but then being able to be selective and understand what not important after the workshop. Reflect bias in assuming everything important to start with but then being able to be selective and understand what not important after the workshop.

Satisfaction with Experiential Exercises Relationship between expectations regarding disclosure and coercion Relationship between expectations regarding disclosure and coercion People who anticipated difficulty sharing reported post-workshop that it was difficult to share (r =.55, p <.01) People who anticipated difficulty sharing reported post-workshop that it was difficult to share (r =.55, p <.01) Found the exercises coercive? Found the exercises coercive? In general most people didn’t (mean = 1.6, SD 1.9, range 0 – 7.4) In general most people didn’t (mean = 1.6, SD 1.9, range 0 – 7.4) However, People who reported difficulty sharing tended to feel more pressured/coerced to disclose experiences (r =.49, p <.01) However, People who reported difficulty sharing tended to feel more pressured/coerced to disclose experiences (r =.49, p <.01)

Intention to learn more ACT Likely to Read more 94% Likely to Use ACT 89% Likely to do Further Training 89%

12 month feedback Influence on clinical work Influence on clinical work 83% said yes, with 90% saying with 3 or more clients 83% said yes, with 90% saying with 3 or more clients 63% said it influenced their supervision practice 63% said it influenced their supervision practice Planning to use ACT in the future: 92% Planning to use ACT in the future: 92% How? How? Integrated with another treatment approach: 46% Integrated with another treatment approach: 46% Recommend workshop to colleagues? 96% Recommend workshop to colleagues? 96%

Conclusions How to assess effectiveness in ACT training: knowledge, behaviour change? How to assess effectiveness in ACT training: knowledge, behaviour change? Most clinicians may integrate ACT into their practice… rather than have a “Damascene conversion” Most clinicians may integrate ACT into their practice… rather than have a “Damascene conversion” Acceptability of experiential exercises: Acceptability of experiential exercises: use informed consent, however even with this a minority of therapists will anticipate and experience exercises as aversive, and perceive the use of them as coercive use informed consent, however even with this a minority of therapists will anticipate and experience exercises as aversive, and perceive the use of them as coercive

Discussion Assessing the impact of ACT training is best done across several domains: Assessing the impact of ACT training is best done across several domains: Improvements in knowledge Improvements in knowledge Satisfaction with content and perceived usefulness Satisfaction with content and perceived usefulness Changes in behaviour Changes in behaviour Doing training in an ACT-consistent fashion: Doing training in an ACT-consistent fashion: Not dogmatic but pragmatic Not dogmatic but pragmatic Building on clinicians’ repertoires, expanding practice Building on clinicians’ repertoires, expanding practice Being willing for some people to “not get it”, and not like it Being willing for some people to “not get it”, and not like it An introduction to ACT doesn’t have to be a 2 day highly experiential workshop, to get people enthused about the model An introduction to ACT doesn’t have to be a 2 day highly experiential workshop, to get people enthused about the model

Discussion Points Future training – alteration to content? Future training – alteration to content? Issue of coercion re experiential exercises Issue of coercion re experiential exercises Future of evaluation of ACT training Future of evaluation of ACT training

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