The Impact of ACT Training on Stress and Burnout in Human Services Workers

1. The Impact of ACT Training on Stress and Burnout in Human Services Workers Jo Lloyd BSc MSc (j.lloyd@gold.ac.uk) Professor Frank Bond BA MSc PhD CPsychol

2. CBT and Individual Focussed Stress-Management • Historic relationship between the cognitive behaviour therapies (CBTs) and stress management training (SMT) programmes. • Dates back to relaxation techniques that stemmed from Wolpe’s (1958) systematic desensitization during the 1st wave of behaviour therapy. • SMT movement has wholeheartedly embedded 2nd wave CBT technologies, however research into the relevance of newer psychopathology theories to models of occupational health is in its infancy. • During the past 20 years, these ‘newer’ theories of psychopathology have posited individual characteristics that may be applicable to occupational health.

3. ACT for Stress-Management • Bond & Hayes (2002) adapted the traditional ACT therapeutic approach to fit into a more training-oriented stress management protocol. • It is predicted that by increasing psychological flexibility people will be better able to: • Be mindful of unwanted thoughts (e.g. negative perceptions of clients or themselves), feelings (e.g. anger, frustration), and impulses (e.g. suppression, avoidance). • Identify, prioritise and pursue their values and goals.

4. Stress-Management Format • Brief group-based training intervention (8-12 people) • Run from standardised training protocols • 2+1 method of delivery (9 hours contact time in total) • Format allows participants to carry out homework assignments in order to encourage application of learned coping strategies. • Participants receive feedback on their efforts during following session. • Effective behaviours learnt in less therapeutic time

5. Stress-Management Protocols • Training protocols map directly onto clinical goals of ACT: • Creative hopelessness→ questioning workability of stress coping strategies. • Control is the problem → paradox of trying to “get rid of stress”, polygraph metaphor. • Defusion/acceptance → e.g. costs of low willingness (clean vs. dirty discomfort), leaves on the stream exercise, right vs. wrong, observer exercise. • Values based action → e.g. tombstone eulogy, values clarification (work and personal domains), willingness question (promoting goal-directed action). • Willingness as a values-based action → bubble in the road metaphor, goals, actions and barrier clarification, public commitment to values.

6. ACT/Psychological Flexibility and Employee Wellbeing • Within occupational contexts ACT training has significantly improved: • General mental health and propensity to innovate in a media organisation (Bond & Bunce, 2000) • General mental health largely in high strain individuals working in UK local government (Flaxman & Bond in press) • Psychological flexibility predicts people’s ability to learn new software as well as their mental health and job performance (Bond and Flaxman, 2006) • People with greater psychological flexibility are better able to take advantage of job control opportunities (Bond & Bunce, 2003; Bond & Flaxman 2006; Bond, Flaxman, & Bunce, 2008)

7. ACT for Professional Burnout and Stigma • Psychological effects of working with difficult clients (entanglement with stigmatizing attitudes) is a key feature of professional burnout. • Hayes, Bissett et al, (2004) compared the impact of ACT, multicultural, and educational training on professional burnout and stigmatizing attitudes amongst drug abuse counselors. • ACT significantly reduced stigma at follow-up and burnout at post-intervention and follow-up.In addition, reductions in burnout at follow-up significantly exceeded those attained through multicultural training. • Changes in the ACT condition were mediated by changes in the believability of stigmatizing attitudes.

8. The Human Service Profession • Extending the work of Hayes, Bissett et al (2004) to the human service profession. • Human service workers are often required to spend a considerable proportion of their time in direct involvement with vulnerable people. • Such frequent and emotionally charged interactions can lead to chronic stress and eventually emotional burnout (Maslach, Jackson & Leiter, 1996). • There are a plethora of individual and organisational consequences of stress and emotional burnout.

9. Present Study • Aim: Investigate the impact of ACT training in improving mental health and performance outcomes among human service workers who deal directly with the elderly. • Design: Randomised controlled outcome experiment comparing two training conditions (1) ACT stress management training (n = 43) and (2) a waitlist control group (n = 67). • Participants: 110 customer-facing staff (sampled nationally) • Outcomes measured at four time points: • T1: pre-training • T2: +1 week (3 hours contact time) • T3: +2 months (6 hours contact time) • T4 :+6 months (9 hours contact time)

10. Present Study Contd. • Training marketed as “Work-Life Effectiveness Training” • Outcome measures: • Emotional burnout (MBI-HSS) • Psychological distress (GHQ) • Attitude towards the elderly (Kogan’s OP scale) • Job measures (motivation, satisfaction and turnover) • Absenteeism (no. of absences 6 months prior to training, during training and 6 months follow-up). • Mediator variable: • Psychological flexibility (AAQ-II)

11. Hypotheses • In comparison to a control group, workers who receive ACT training will show significant improvements in mental health and performance outcome measures. • An increase in psychological flexibility will serve as the mechanism by which these changes will occur.

12. Results: Emotional Exhaustion Non significant T1 → T4 (overall) group X time interaction effect. Significant T2 → T3 group X time interaction effect. ACT: η² = .12 Control: Non sig

13. Depersonalisation (MBI_DP) Code_num 1.80 training control 1.70 1.60 Scores 1.50 1.40 1.30 T1 T2 T3 T4 Figure 2. Changes in depersonalisation in each condition Results: Depersonalisation Significant T1 → T4 (overall) group X time interaction effect ACT: η² = .32 Control: Non sig Significant T3 → T4 group X time interaction effect. ACT: η² = .19 Control: Non sig

14. Results: Psychological Distress Significant T1 → T4 (overall) group x time interaction effect ACT: η² = .32 Control: η² = .21 Significant T2 → T3 group X time interaction effect. ACT: η² = .19 Control: η² = .18

15. Psychological flexibility a b ACT Psychological distress c An increase in psychological flexibility partially mediated the decrease in psychological distress in the ACT group. Results: Mediation Analysis • A series of linear multiple regressions were carried out according to a procedure detailed by Baron and Kenny (1986) to determine mediation.

16. Conclusions/Implications • ACT training useful in alleviating two emotional burnout components and psychological distress in human service workers. • Mechanism of change for psychological distress was consistent with the core underlying theory of ACT. • No significant change in performance and attitude outcomes. • Critical reductions in negative psychological outcomes can be isolated as occurring at different time points. • Limitations of longitudinal research • Implications for continued support • Burnout patterns (Hatinen, Kinnunen, Pekkonen & Aro, 2004). • Limitation of the long-term utility of interventions focussing only on modifying the individuals coping strategies, without also targeting the toxins inherent in their work environment.