Evaluating ACT Workshops: Evaluating ACT Workshops: Changes in Knowledge and Changes in Knowledge and Clinical PracticeClinical Practice

Eric Morris, Joe Oliver, Rachel Richards, Eric Morris, Joe Oliver, Rachel Richards,

Alessandra Iervolino & Janet WingroveAlessandra Iervolino & Janet Wingrove

ACT WorkshopsACT Workshops Following the 2006 ACT World Con in Following the 2006 ACT World Con in

London we thought it would be a good London we thought it would be a good idea to introduce more of our colleagues idea to introduce more of our colleagues to the approachto the approach

So we led 3 one-day Introductory ACT So we led 3 one-day Introductory ACT workshops, and attempted to evaluate workshops, and attempted to evaluate them! them!

Aim of training was to Aim of training was to increase interest increase interest and knowledgeand knowledge in ACT, situating it as in ACT, situating it as part of the broader family of behavioural part of the broader family of behavioural and cognitive psychotherapies. and cognitive psychotherapies.

Context (where we work)Context (where we work) a mental health Trust that employs over 300 a mental health Trust that employs over 300

psychologistspsychologists Largest mental health Trust in the UK, and Largest mental health Trust in the UK, and

supports research and innovation, linked supports research and innovation, linked with the Institute of Psychiatry and King’s with the Institute of Psychiatry and King’s CollegeCollege

a number of specialties: adult, child, older a number of specialties: adult, child, older adult, learning disability, forensic servicesadult, learning disability, forensic services

the majority of psychologists are CBT the majority of psychologists are CBT trained, using a formulation-based approach trained, using a formulation-based approach (rather than manualised treatments)(rather than manualised treatments)

Context 2 Context 2 We arranged for ACT workshops We arranged for ACT workshops

to psychologists working with to psychologists working with adults in 3 directoratesadults in 3 directorates

Interest was high, with the Interest was high, with the workshops having attendance workshops having attendance from the majority of psychologists from the majority of psychologists in these directorates. in these directorates.

Workshops were designed to be a Workshops were designed to be a mixture of theory, experiential mixture of theory, experiential exercises and discussion of the exercises and discussion of the state of the evidence for ACT. state of the evidence for ACT.

Context 3 Context 3 We were interested to see how ACT would We were interested to see how ACT would

be received by our colleagues, and hopefully be received by our colleagues, and hopefully turn some more people on to it as an turn some more people on to it as an approach. approach.

As psychologists in the UK tend to be As psychologists in the UK tend to be trained in a broader form of CBT, it was trained in a broader form of CBT, it was going to be interesting to see whether going to be interesting to see whether people could integrate ACT into their idea of people could integrate ACT into their idea of what CBT is, and use some of the techniques what CBT is, and use some of the techniques and functional analytic thinking in their and functional analytic thinking in their practice. practice.

We sent participants a copy of Russ Harris' We sent participants a copy of Russ Harris' paper “Embracing your Demons: an paper “Embracing your Demons: an introduction to Acceptance and Commitment introduction to Acceptance and Commitment Therapy” prior to the workshop. Therapy” prior to the workshop.

Content of trainingContent of training Based on our aims, training sought to:Based on our aims, training sought to:

Engage audienceEngage audience Offer some theoretical backgroundOffer some theoretical background Balance theory with experiential Balance theory with experiential

exercises (give examples of exercises exercises (give examples of exercises used)used)

Review outcome dataReview outcome data Suggest the ACT model as an “interesting Suggest the ACT model as an “interesting

alternative”. Avoid direct challengesalternative”. Avoid direct challenges Consider how audience could Consider how audience could

pragmatically use ACT in their current pragmatically use ACT in their current practicepractice

Some experiential Some experiential exercises usedexercises used

Leaves on a StreamLeaves on a Stream Lifetime Achievement Award (Attend Lifetime Achievement Award (Attend

your own funeral)your own funeral) Milk, Milk, Milk Milk, Milk, Milk Wearing a labelWearing a label Taking Your Mind for a WalkTaking Your Mind for a Walk Eyes OnEyes On

Evaluation and FeedbackEvaluation and Feedback

Knowledge - AKQ (ACT Knowledge Knowledge - AKQ (ACT Knowledge Questionnaire; Luoma, 2007), & Questionnaire; Luoma, 2007), & Discriminating CBT/ACTDiscriminating CBT/ACT

Interest/Intentions to learn more Interest/Intentions to learn more ACT (visual analogue)ACT (visual analogue)

Evaluation of Experiential Exercises Evaluation of Experiential Exercises Qualitative FeedbackQualitative Feedback

ResultsResults

ParticipantsParticipants

Feedback collected from 38 Feedback collected from 38 participants pre and post, and 24 participants pre and post, and 24 followed up after 12 monthsfollowed up after 12 months

A minority of participants were pre-A minority of participants were pre-qualification psychologists (trainees or qualification psychologists (trainees or assistants; N = 3 pre/post, N = 0 f/u)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 8 participants had previously attended ACT workshopsACT workshops

Effect on ACT KnowledgeEffect on ACT Knowledge Paired t-test (N=32) demonstrated a main effect Paired t-test (N=32) demonstrated a main effect

of time on the number of correct responses to of time on the number of correct responses to the AKQ. the AKQ.

There were more correct answers post-workshop There were more correct answers post-workshop (mean = 8.9, SD 2.7, range 3-14) compared with (mean = 8.9, SD 2.7, range 3-14) compared with pre-workshop (mean = 7.1, SD 2.8, range 2-14). pre-workshop (mean = 7.1, SD 2.8, range 2-14).

E.g., Q10 Which of the following is not an ACT-E.g., Q10 Which of the following is not an ACT-consistent explanation of “psychopathology”? 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 Discriminating ACT from CBTCBT

Discriminating important components of each Discriminating important components of each approach (criterion-related)approach (criterion-related)

Participants scored significantly better at Participants scored significantly better at identifying important ACT components post-identifying important ACT components post-workshopworkshop Specific effect, with no changes in identifying CBT Specific effect, with no changes in identifying CBT

componentscomponents Use of Metaphor in ACT- Important? Pre 66% Use of Metaphor in ACT- Important? Pre 66%

Post 84%Post 84% Identifying cognitive errors in ACT – Important? Identifying cognitive errors in ACT – Important?

Pre 66% Post 34%Pre 66% Post 34%

Discriminating ACT from Discriminating ACT from CBTCBT

Inspection of data showed greatest Inspection of data showed greatest improvement in following items on ACT improvement in following items on ACT questionnaire:questionnaire:

Realising not important:Realising not important: Identifying cognitive errorsIdentifying cognitive errors Using written thought recordsUsing written thought records Challenging negative thoughts and beliefsChallenging negative thoughts and beliefs Working with dysfunctional assumptionsWorking with dysfunctional assumptions

Realising important:Realising important: Use of metaphorsUse of metaphors

Reflect bias in assuming everything important Reflect bias in assuming everything important to start with but then being able to be to start with but then being able to be selective and understand what not important selective and understand what not important after the workshop.after the workshop.

Satisfaction with Experiential Satisfaction with Experiential ExercisesExercises

Relationship between expectations Relationship between expectations regarding disclosure and coercionregarding disclosure and coercion People who People who anticipatedanticipated difficulty difficulty

sharing reported post-workshop that it sharing reported post-workshop that it was difficult to share (r = .55, p <.01)was difficult to share (r = .55, p <.01)

Found the exercises coercive?Found the exercises coercive? In general most people didn’t (mean = In general most people didn’t (mean =

1.6, SD 1.9, range 0 – 7.4)1.6, SD 1.9, range 0 – 7.4) However, People who reported difficulty However, People who reported difficulty

sharing tended to feel more sharing tended to feel more pressured/coerced to disclose pressured/coerced to disclose experiences (r = .49, p <.01)experiences (r = .49, p <.01)

Intention to learn more Intention to learn more ACTACT

Likely to Read more 94% Likely to Read more 94%

Likely to Use ACT 89%Likely to Use ACT 89%

Likely to do Further Likely to do Further Training 89%Training 89%

12 month feedback12 month feedback Influence on clinical workInfluence on clinical work

83% said yes, with 90% saying with 3 or 83% said yes, with 90% saying with 3 or more clientsmore clients

63% said it influenced their supervision 63% said it influenced their supervision practicepractice

Planning to use ACT in the future: 92%Planning to use ACT in the future: 92% How? How?

Integrated with another treatment Integrated with another treatment approach: 46%approach: 46%

Recommend workshop to colleagues? Recommend workshop to colleagues? 96%96%

ConclusionsConclusions How to assess effectiveness in ACT How to assess effectiveness in ACT

training: knowledge, behaviour training: knowledge, behaviour change? change?

Most clinicians may Most clinicians may integrateintegrate ACT into ACT into their practice… rather than have a their practice… rather than have a “Damascene conversion”“Damascene conversion”

Acceptability of experiential exercises: Acceptability of experiential exercises: use informed consent, however even with use informed consent, however even with

this a minority of therapists will this a minority of therapists will anticipate and experience exercises as anticipate and experience exercises as aversive, and perceive the use of them as aversive, and perceive the use of them as coercivecoercive

DiscussionDiscussion Assessing the impact of ACT training is best Assessing the impact of ACT training is best

done across several domains:done across several domains: Improvements in knowledge Improvements in knowledge Satisfaction with content and perceived Satisfaction with content and perceived

usefulnessusefulness Changes in behaviour Changes in behaviour

Doing training in an ACT-consistent fashion:Doing training in an ACT-consistent fashion: Not dogmatic but pragmaticNot dogmatic but pragmatic Building on clinicians’ repertoires, expanding Building on clinicians’ repertoires, expanding

practicepractice Being willing for some people to “not get it”, and Being willing for some people to “not get it”, and

not like itnot like it An introduction to ACT doesn’t have to be a An introduction to ACT doesn’t have to be a

2 day highly experiential workshop, to get 2 day highly experiential workshop, to get people enthused about the modelpeople enthused about the model

Discussion PointsDiscussion Points

Future training – alteration to Future training – alteration to content?content?

Issue of coercion re experiential Issue of coercion re experiential exercisesexercises

Future of evaluation of ACT trainingFuture of evaluation of ACT training

Contact:Contact:

Eric.Morris@kcl.ac.ukEric.Morris@kcl.ac.uk

Joseph.Oliver@slam.nhsJoseph.Oliver@slam.nhs.uk.uk