Acceptance and commitment therapy (ACT) - Giornale Italiano di ...

G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol
http://gimle.fsm.it
This model is useful in conceptualizing patients with
chronic diseases and working with them to build psychological
flexibility. One of the crucial aspects is that ACT
challenges the patient’s avoidance and control agenda on
private experiences, confronting the person with his or
her past experience (e.g. Did your control attempts work
in the past and brought you towards the things you
value?), helping the patient experiencing how to accept
and embrace private experiences in the service of chosen
values. Learning mindfulness and defusion behaviors
might offer a realistic alternative to experiential avoidance.
Those might offer these patients different contexts
in which these stressful and painful internal experiences
related to their illness is looked at, rather than looked
from (e.g. past and narrow definitions of the self the patient
is very attached to and that now are at risk because
of the limitations due to the disease). Those “now” contexts
may foster the capability to see thinking and feeling
as ongoing processes, both useful and fallible tools, rather
than unquestionable representations of reality. This is
done without any attempt of reducing or changing the
form and the content of those inner events but by undermining
their role as reasons for action or inaction. This is
particularly important for these patients, who have to deal
with chronic and physical symptoms. By using experiential
exercises and metaphors, informed by the six core
processes of psychological flexibility, the therapist works
to help the client to clarify personally chosen values (e.g.
social interactions, family, work, etc.) that have been neglected
for a long time because of illness-related problems
and are re-discovered as dignified context for commitment
actions (e.g. exposure to physically and psychologically
painful activities, such as physiotherapy, life
styles modification, etc.).
ACT with physical chronic diseases: an overview of the current
empirical evidence and assessment tools
ACT-based protocols, interventions, and assessment
tools have been investigated with different chronic diseases.
We summarize below the main outcomes and assessment
tools. In table I a summary of the controlled
comparison trials with ACT in patients affected by physical
chronic diseases is reported.
ACT oriented assessment tools for chronic diseases
The Acceptance and Action Questionnaire - II (AAQ-
II) (23), is a 10-item self-report measure of psychological
flexibility, conceptualized as a continuum from acceptance
to experiential avoidance, with questions assessing
the ability to stay in contact with emotions without behaving
in order to get rid of them; there is also an AAQ-II
Italian version (24). The AAQ (nine-item version) (25) has
been used also in medical rehabilitation settings with patients
with spinal cord dysfunction, stroke, amputation, or
orthopedic surgery, and data support that it is a reliable
and valid measure also in medical populations and that
avoidance plays an important role in rehabilitation outcomes
(26). So far, different versions of this questionnaire
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are available for assessing psychological flexibility and
acceptance-experiential avoidance process related to
many different health conditions, specifically:
• Acceptance and Actions Diabetes Questionnaire
(AADQ) (27), an 11-item Likert-type self-report scale
(Cronbach’s α = .94), which measures acceptance of
diabetes-related thoughts and feelings and the degree
to which they interfere with valued action.
• Diabetes Acceptance and Action Scale (DAAS) (28), a
42-item Likert-type self-report scale that is used to indicate
levels of psychological flexibility in youth with
type 1 diabetes. The authors are still in the process of
collecting psychometric data.
• Acceptance and Action Epilepsy Questionnaire
(AAEpQ) (29), an 8-item Likert-type self-report scale
for epilepsy related problems (Cronbach’s α = .65-.76;
these alpha values are considered acceptable for a
scale in early use, particularly one with few items).
• Chronic Pain Acceptance Questionnaire (CPAQ) (30),
a 20-item Likert-type self-report scale, which has two
subscales that assess activity engagement (11items) and
pain willingness (9 reversed-key items). The subscales
and total scale are internally consistent (Cronbach’s α
= .78-.82) and reliably predict patient functioning. The
questionnaire is also validated in Italian language (31).
• Acceptance and Action Questionnaire for Weight-Related
Difficulties (AAQW) (32), a 22 items Likert-type
self-report scale, designed to measure acceptance of
weight-related feelings, defusion from weight related
thoughts, and the degree to which thoughts and feelings
interfere with valued action. The mean score for
the sample was 88.9 (sd = 19.8, range 49 to 124) and
the internal consistency is good (Cronbach’s α = .88).
• Psychological Inflexibility in Pain Scale (PIPS) (33): a
12-item Likert-type self-report instrument to assess psychological
inflexibility in people with chronic pain.
Analyses support the reliability and validity of a two factors
solution: the avoidance subscale (8 items) measuring
the tendency to engage in behaviors that lead to avoid
pain and related distress, and the cognitive fusion subscale
(4 items) assessing the experience of thoughts as if
they were true. The questionnaire demonstrates good internal
consistencies (Cronbach’s α = .87 for the total
scale, .89 and .66 for the two subscales respectively).
ACT and diabetes
Diabetes is a chronic illness entailing a high risk of
disability and death, when life styles are not adjusted and
the adherence to medical treatments is low or not regular.
Interventions aimed to manage diabetes-related distress
may help people in dealing with its emotional challenges
and to improve self-management skills.
Gregg et al (27) randomly assigned 81 type-II diabetes
patients to a 7 hours education group (n = 38, following a
patient education manual; 34) and to a group where education
(same as above but in an abbreviated 4 hours form)
was associated with a mindfulness and acceptance training
on difficult thoughts and feelings about diabetes, an exploration
of personal values related to diabetes, and a
focus on the ability to act in a valued direction while con-