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

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 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 

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 workshop for psychologists who work with people with MS in Italy. It was expected that participants attending the ACT training workshop would show improvements after the workshop 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).

Data were collected at three time points: before the workshop, after the workshop, 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 workshop registration, and informed consent was obtained from all the participants.

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 workshop, a separate online workshop evaluation questionnaire was administered after the workshop, and a paper examination was completed immediately after the workshop. Well-established, psychometrically sound, Italian-validated measures of the primary outcomes and ACT processes were used as follows.

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 

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 

Forced-choice questions asked about previous experience using ACT, intentions to use ACT, and workshop satisfaction. An open-ended question elicited suggestions regarding workshop changes.

A paper examination with 42 multiple-choice questions was administered at the end of the workshop.

The 2-day workshop 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 workshop was a modified version of a university ACT training course for trainee clinical psychologists developed and evaluated by the same author.21 The workshop 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 workshop 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 role-plays, discussion, and audio-visuals. The application of ACT strategies in an MS clinical context was highlighted.

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 41.82 (8.29) years (range, 30–60 years). The mean (SD) number of years of professional work experience was 12.50 (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.

Most participants reported that the educational impact of the workshop was “optimal” (50.0%) or “good” (41.7%), with 8.3% indicating “sufficient.” Most participants indicated that the impact of the workshop 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 workshop. 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).

The mean (SD) examination score was 39.06 (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.

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 workshop (mean, 4.12) to follow-up (mean, 4.27) (z score = −1.99, P < .05).

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 workshop, 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; correlation coefficients increased at follow-up and were greater than 0.30, with two coefficients reaching statistical significance.

Most participants rated the workshop positively and acknowledged the beneficial effects that the workshop was likely to have on their work. All the participants reported their intention to apply ACT clinically, and most indicated that the workshop was efficacious. All the participants demonstrated adequate mastery of workshop 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 workshop to follow-up, rather than from before to after the workshop, 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 workshop 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 workshop is likely to have limited the acquisition of ACT strategies, given data suggesting that longer ACT training workshops are more effective.13,21 Other limitations include the inability to match examination scores and workshop 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 workshop were further supported by numerous written anecdotal reports from participants. The workshop also prompted one participant to be awarded a funded fellowship to obtain training in an ACT-based resilience intervention for people with MS and to translate it into Italian.5,22 Although few participants suggested changes to the workshop, 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 

The authors have no conflicts of interest to disclose.

The Italian Multiple Sclerosis Research Foundation (FISM) provided financial support.