Acceptance and Commitment Therapy (ACT) for …

1 CONTROLLED TRIALS FORUMA cceptance and CommitmentTherapy (ACT) for PsychologicalAdjustment after Traumatic BrainInjury: Reporting the Protocol for aRandomised Controlled TrialDiane L. Whiting,1,2 Grahame K. Simpson,1,3 Hamish J. McLeod,4 Frank P. Deane,2andJoseph Ciarrochi51 Liverpool Brain Injury Rehabilitation Unit, Liverpool Hospital, Sydney, Australia2 School of Psychology, University of Wollongong, Australia3 Rehabilitation Studies Unit, University of Sydney, Australia4 Institute of Health and Wellbeing, University of Glasgow, Scotland, UK5 School of Social Sciences and Psychology, University of Western Sydney, AustraliaFollowing a severe traumatic brain injury (TBI) there is a complex presentationof psychological symptoms which may impact on recovery. Validated treatmentsaddressing these symptoms for this group of people are limited. This article reportson the protocol for a single-centre, two-armed, Phase II Randomised Control Trial(RCT) to address the adjustment process following a severe TBI.

2 Participants willbe recruited from Liverpool Brain Injury Rehabilitation Unit and randomly allocatedto one of two groups, Acceptance and Commitment Therapy (ACT) or an activecontrol (Befriending). The active treatment group utilises the six core processes ofACT with the intention of increasing participation and psychological flexibility andreducing psychological distress. A number of primary and secondary outcomemeasures, administered at assessment, post-treatment and 1-month follow-up,will be used to assess clinical outcomes. The publication of the protocol beforethe trial results are available addresses fidelity criterion (intervention design) forRCTs. This ensures transparency in the RCT and that it meets the guidelinesaccording to the CONSORT statement. The protocol has also been registered onthe Australian New Zealand Clinical Trials Registry : Acceptance and Commitment Therapy , traumatic brain injury, psychological distress, randomisedcontrolled trial, participationDistress Following Traumatic BrainInjuryThe impact of traumatic brain injury (TBI) oftenresults in a complex presentation of psychologicalsymptoms and associated distress.

3 These symp-toms can encompass anxiety, depression, anger,grief and traumatic stress. The resulting psycho-logical distress can be linked to the traumatic eventAddress for correspondence: Diane Whiting, Senior Clinical Psychologist, Brain Injury Rehabilitation Unit, LiverpoolHospital. Locked Bag 7103, Liverpool BC NSW 1871, Australia. E-mail: the injury, to loss of functioning or a com-bination of both these factors. It has been pro-posed that chronic inflammatory processes in thebrain may be an underlying mechanism that con-tributes to the development of depression and stressresponses and inhibits the process of repair (Hoff-man & Harrison, 2009). Furthermore, the ability tocope with these symptoms is often complicated bythe cognitive changes brought about by the brainBRAIN 376c The Authors 2013 doi: AND Commitment Therapy FOR PSYCHOLOGICAL ADJUSTMENT AFTER TBIinjury, by psychosocial factors and by premorbidcoping styles (Ponsford, Sloan, & Snow, 1995).

4 High levels of psychological distress after aTBI have been well documented. A recent sys-tematic review concluded that there was a 33%prevalence rate of depression from 1 year and laterpost-injury (Guillamondegui et al., 2011). Hib-bard, Uysal, Kepler, Bogdany and Silver (1998)found that rates for anxiety symptoms reported inthe literature ranged between 18 and 60%. Not onlyare psychological symptoms evident, but there canalso be disruption in the way people perceive theirsense of self (Myles, 2004). People with a TBI mayno longer have a stable sense of who they are and tend to view the self more negatively after aTBI (Carroll & Coetzer, 2011). These psychologi-cal symptoms can also co-present with behaviouralproblems, such as verbal and physical aggression(Baguley, Cooper, & Felmingham, 2006; Rao et al.,2009).All of these factors contribute to a complexadjustment process which influences the person sability to (1) engage in many aspects of theirrehabilitation, and (2) become involved in mean-ingful activities (Fleming et al.)

5 , 2011). Lowerlevels of depression have been associated withincreased participation in social and recreationalactivities after a brain injury (Brown, Gordon, &Spielman, 2003). Therefore, timely interventionfor these adjustment difficulties may lead to im-proved participation in rehabilitation and engage-ment in their life, such that clients become betterable to accept their changes and move on with Treatments forEmotional/Behavioural Adjustmentafter TBIE arly psychological interventions in the treat-ment of TBI predominantly drew upon learning/behaviour theory and these approaches continue toplay an important role, particularly in the man-agement of challenging behaviours (Schlund &Pace, 1999; Wood & Alderman, 2011). The suit-ability of cognitive approaches ( , cognitive be-havioural Therapy , motivational interviewing andproblem-solving Therapy ) has also been investi-gated, particularly for the treatment of psycholog-ical distress.

6 Cognitive behaviour Therapy (CBT)has been considered particularly applicable forthose with a TBI because of the structured na-ture of the treatment and the ability to adapt thetherapy to individual requirements (Khan-Bourne& Brown, 2003). These adaptations can includethe use of written notes during sessions, undertak-ing one task at a time, using repetition to ensurenew concepts are learned and breaking down tasksinto smaller parts (Hibbard, Rendon, Charatz, &Kothera, 2005).Programmes using CBT have proven to beeffective in treating a range of post-TBI psy-chological problems, including anger (Medd &Tate, 2000), anxiety (Hsieh et al., 2012a), cop-ing skills (Anson & Ponsford, 2006), hopelessness(Simpson, Tate, Whiting, & Cotter, 2011) and so-cial anxiety (Hodgson, McDonald, Tate, & Gertler,2005). Despite these promising developments, thenumber of high-quality studies employing ran-domised controlled designs (RCTs) to evaluatepsychological treatments for people with severeTBI is sparse.

7 Systematic reviews have identifiedno cognitive interventions rated as Class 1 for de-pression (Fann, Hart, & Schomer, 2009) or anx-iety (Soo & Tate, 2009). The one Class 1 studyidentified by Soo and Tate (2009) involved an in-tervention for Acute Stress Disorder among peoplewith mild TBI (Bryant, Moulds, Guthrie, & Nixon,2003). A subsequent RCT for the treatment of anx-iety has just been published (Hsieh et al., 2012b)and holds the promise of being rated highly forits robust methodology. Only one RCT has beenidentified for the treatment of anger (Medd & Tate,2000), and rated as Class 1 in one review (Ylvisakeret al., 2007), but Class 2 due to the small samplesize in a second review (Cattelani, Zettin, & Zoc-colotti, 2010). Overall, there are only a handfulof robust psychological treatment studies of post-TBI adjustment that can be relied upon to guidedecisions about the best approach to this signif-icant problem.

8 There is an urgent need for morehigh-quality studies in this seeking to expand this limited evidence base,there are also reasons to question whether adaptedforms of CBT represent the best treatment ap-proach. One potential limitation of CBT for post-TBI adjustment is its emphasis on thought chal-lenging (Kinney, 2001). Cognitive impairmentsand related problems with self-awareness maymake the challenging of unhelpful thought pro-cesses very difficult for people with TBI (Shereret al., 1998). Similarly, problems with divided at-tention may reduce the capacity to simultaneouslyhold thoughts in mind while seeking alternative ormore helpful ways of thinking (Blanchet, Paradis-Giroux, P epin, & Mckerral, 2009). The cognitiveinflexibility often seen after a TBI may also reducethe capacity to shift to more helpful or adaptivethinking patterns (Heled, Hoofien, Margalit, Na-tovich, & Agranov, 2012). Given these concerns,newer forms of cognitive Therapy may also play asignificant role in treating the problems of adjust-ment to L.

9 WHITING ET and Commitment Therapy (ACT) Acceptance and Commitment Therapy (ACT) isone of the third-wave of behavioural therapies,with a focus on changing one s relationship withinternal experiences (thoughts, feelings, memoriesand physical sensations) rather than on directlychanging the content of these experiences. The keypremise of ACT is to teach people to be able tohave internal experiences, in a mindful and non-judgmental way, and still engage in effective ac-tion. The ACT model is comprised of six core pro-cesses which form a hexaflex, indicating that allcomponents are presumed to be interlinked (Hayes,Strosahl, & Wilson, 2003). The therapist can electto work on any of the components of the model atany stage of the Therapy process, or these compo-nents can be combined and presented at the sametime. In this respect, use of the hexaflex compo-nents is not seen as six core processes that configure the hex-aflex and guide the process of developing psycho-logical flexibility include: cognitive defusion, ac-ceptance, contact with the present moment, self ascontext, values and committed action (Hayes et al.)

10 ,2003). Cognitive defusion is the process of creat-ing some distance or separation from distressingthoughts, emotions or experiences. Acceptance isthe opening up and making room for these inter-nal experiences so there is no longer an ongoingstruggle. Contact with the present moment is be-ing in the here and now, consciously connectingwith is happening in that moment. Self as context,or the observing self, seeks to demonstrate that acomponent of us is always the same, regardlessof what is changing with regard to our feelings orexperiences. Values are what guide our behaviourand are unique and personally relevant to each in-dividual. They assist in setting goals, which is thecommitted action component of the of ACT in Chronic HealthConditionsPrior research using ACT with other chronic healthconditions suggests that it may be promising foruse with people who have a TBI. The research intoACT and chronic pain has been the most exten-sive.