Evaluating ACT Workshops: Changes in Knowledge and Clinical Practice

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

2. 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 • 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.

3. Context (where we work) • 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 • 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)

4. Context 2 • 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. • Workshops were designed to be a mixture of theory, experiential exercises and discussion of the state of the evidence for ACT.

5. 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. • 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.

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

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

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

9. Results

10. Participants • 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) • Therapeutic orientation: • CBT or CBT + other 92% • 8 participants had previously attended ACT workshops

11. Effect on ACT Knowledge • 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). • E.g., Q10 Which of the following is not an ACT-consistent explanation of “psychopathology”? • emotional avoidance. • ineffective thinking and behavior patterns. • cognitive fusion. • lack of committed action.

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

13. Discriminating ACT from CBT Inspection of data showed greatest improvement in following items on ACT questionnaire: • Realising not important: • Identifying cognitive errors • Using written thought records • Challenging negative thoughts and beliefs • Working with dysfunctional assumptions • Realising important: • 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.

14. Satisfaction with Experiential Exercises • 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) • Found the exercises coercive? • 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)

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

16. 12 month feedback • Influence on clinical work • 83% said yes, with 90% saying with 3 or more clients • 63% said it influenced their supervision practice • Planning to use ACT in the future: 92% • How? • Integrated with another treatment approach: 46% • Recommend workshop to colleagues? 96%

17. Conclusions • How to assess effectiveness in ACT training: knowledge, behaviour change? • Most clinicians may integrate ACT into their practice… rather than have a “Damascene conversion” • 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

18. Discussion • Assessing the impact of ACT training is best done across several domains: • Improvements in knowledge • Satisfaction with content and perceived usefulness • Changes in behaviour • Doing training in an ACT-consistent fashion: • Not dogmatic but pragmatic • Building on clinicians’ repertoires, expanding practice • 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

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

20. Contact:Eric.Morris@kcl.ac.ukJoseph.Oliver@slam.nhs.uk