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The Efficacy of Focused Acceptance and Commitment Therapy in VA Primary Care
The Efficacy of Focused Acceptance and Commitment Therapy in VA Primary Care
Matthew Jakupcak
VA Puget Sound Health Care System, Seattle, Washington, and University of Washington
Focused Acceptance & Commitment Therapy (FACT) is a brief intervention based on traditional
Acceptance and Commitment Therapy (ACT). Although there is a growing body of research on the
efficacy of ACT for a variety of populations and disorders, there is little research to date on the use of
FACT in group settings. This project is 1 of the first of its kind, as it examines data on psychological
flexibility, health and mental health status, and symptom reduction from a 4-week FACT group.
Participants in this study were 51 patients who attended this group as part of routine clinical care in a VA
integrated primary care and mental health setting. They completed pre- and posttreatment measures of
well-being, depression, anxiety, stress, psychological flexibility, and perceptions of physical and mental
health functioning. Pre- to posttreatment analyses of variance demonstrated large effects for quality of
life, F(1, 51) ⫽ 21.29, p ⬍ .001, 2 ⫽ 0.30, moderate effects for depressive symptoms, F(1, 51) ⫽ 11.47,
p ⬍ .001, 2 ⫽ 0.08, and perceptions of mental health functioning (MCS scale), F(1, 51) ⫽ 9.67, p ⫽
.003, 2 ⫽ 0.11, and small effects for perceptions of perceived stress, F(1, 51) ⫽ 4.08, p ⫽ .04, 2 ⫽
0.03, and physical health functioning (PCS scale), F(1, 51) ⫽ 6.60, p ⫽ .01, 2 ⫽ 0.08. There was a
statistical trend for reductions in anxiety, F(1, 51) ⫽ 3.29, p ⫽ .07, 2 ⫽ 0.01, and a nonsignificant effect
for psychological flexibility, F(1, 51) ⫽ 2.05, p ⫽ .16, 2 ⫽ 0.04. These data provide initial support for
the implementation of a group-based FACT protocol within a VA primary care setting and help to lay
a foundation for further, more controlled studies on Group FACT in future research.
Integrating behavioral health interventions into primary care leads behavioral health services (Melchert, 2015). This underutilization is
to better patient outcomes, reduces provider burden, lowers health attributable, in part, to a dearth of behavioral interventions that fit into
care costs, and mitigates stigma associated with mental health services the existing primary care setting.
(Kathol, deGruy, & Rollman, 2014). Despite these clear benefits, Primary care is characterized by a high volume of patients who
patients and providers in the United States underutilize integrated present with a wide variety of physical and psychosocial com-
Editor’s Note. This article is part of a special issue on Public Mental Jennifer C. Plumb-Vilardaga, Mental Health Service, VA Puget Sound
Health Innovations. Health Care System; Jordan T. Bonow, VA Sierra Nevada Health Care
System, Reno, Nevada; Matthew Jakupcak, Mental Health Service, VA
Puget Sound Health Care System and Department of Psychiatry and
Natalie G. Glover, Mental Health Service, VA Puget Sound Health Care Behavioral Sciences, University of Washington.
System, Seattle, Washington; Patrick D. Sylvers, Mental Health Service, We thank Stacey Cherup-Leslie, Michael Earley, Alison Ilem, Laura McIn-
VA Puget Sound Health Care System and Department of Psychiatry and tire, and Erin Tansill for their assistance in facilitating the Life Paths group
Behavioral Sciences, University of Washington; Erika M. Shearer and within primary care mental health integration at VA Puget Sound.
Mary-Catherine Kane, Mental Health Service, VA Puget Sound Health Correspondence concerning this article should be addressed to Natalie
Care System; Peter C. Clasen, Department of Psychiatry and Behavioral G. Glover, VA Puget Sound: American Lake Division, 9600 Veterans
Sciences, Stanford University School of Medicine; Amee J. Epler and Drive SW, Tacoma, WA 98493. E-mail: [email protected]
156
ACCEPTANCE AND COMMITMENT THERAPY IN PRIMARY CARE 157
plaints. To address the needs of this population, behavioral inter- 3. Patients will demonstrate statistically significant gains in
ventions in this setting must maximize impact through brief, patient-reported psychological flexibility, a theoretical
group-based, trans-diagnostic treatments: in other words, interven- target for ACT-based therapies.
tions that rapidly provide services to a high volume of patients
with a wide variety of presenting concerns. These interventions
Method
must also adopt a stepped-care perspective: Brief treatments will
not resolve all concerns for all patients, however they help all
patients to become acclimated to services, to develop treatment Participants
goals, and to acquire resources for pursuing additional care, if
necessary. Participants included 51 patients who attended the FACT group
Focused Acceptance and Commitment Therapy (Strosahl, Rob- as part of routine clinical care in a VA integrated primary care and
inson, & Gustavsson, 2012), or FACT, represents a promising mental health setting. Patients in this setting typically present with
evidence-based behavioral intervention that meets the needs of the mild to moderate mental health concerns and are either referred to
primary care setting. FACT is an abridged version of Acceptance treatment within the integrated primary care setting or referred to
and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, specialty mental health for more intensive, traditional mental
1999, 2011), a trans-diagnostic approach to psychotherapy that health treatment options. Within the integrated primary care set-
views psychological rigidity as a ubiquitous phenomenon under- ting, treatment options include brief, 1- to 4-session psychoeduca-
lying psychopathology and behavioral problems. Using experien- tional classes (e.g., pain, stress, depression, chronic medical con-
tial exercises, mindfulness practice, and values clarification, ACT ditions, sleep, anger, etc.) and group therapy; brief, 2- to 6-session
promotes psychological flexibility (i.e., a measure of acceptance) individual therapy; initiation of medication by primary care pro-
and overall health. ACT has yielded positive outcomes for numer- viders with telephone follow-up by mental health RNs; or a com-
ous conditions (see Hayes, Luoma, Bond, Masuda, & Lillis, 2006, bination of these services. Participants were referred by integrated
primary care mental health clinical staff who recommended the
for a recent meta-analysis), including mental health and chronic
FACT group based on patients’ presenting problems, treatment
medical conditions. FACT distills the core methods of ACT into a
goals, and interests. Participant mean age was 53.23 years (SD ⫽
protocol that is delivered in two to four sessions, compared with
12.81), 86.27% (n ⫽ 44) were men and 13.7% (n ⫽ 7) were
the typical 12-week ACT paradigm, while providing similar out-
women, and 64% (n ⫽ 32) identified as Caucasian, 28% (n ⫽ 14)
comes for patients (Strosahl, Hayes, Bergan, & Romano, 1998)
African American, 2% (n ⫽ 1) Asian American, and 6% (n ⫽ 3)
and there is growing evidence that brief ACT interventions are
Native American. Diagnoses of participants included both Unspec-
effective when delivered in the group therapy milieu (Butryn,
ified Depressive and Anxiety disorders, Major Depressive Disor-
Forman, Hoffman, Shaw, & Juarascio, 2011; Goodwin, Forman,
der, Adjustment Disorders, and Posttraumatic Stress Disorder with
Herbert, Butryn, & Ledley, 2012; Kohtala, Lappalainen, Savonen,
group sizes ranging from two to 12 patients.
Timo, & Tolvanen, 2015). For these reasons, FACT represents a
useful behavioral intervention for the primary care setting.
Despite these advantages, we are not aware of research demon- Protocol
strating effectiveness of FACT in primary care, particularly in a
Veteran population. Such data are critical to supporting the imple- The FACT group in this protocol consisted of four 90-min,
mentation and dissemination of promising behavioral interventions weekly group sessions: Finding Leverage, Promoting Awareness,
(like FACT) into integrated primary care settings. This project is Promoting Openness, and Promoting Engagement. The protocol
one of the first of its kind, as it examines outcomes related to was developed by seven of our nine authors. The sessions were
changes in core ACT mechanisms (e.g., psychological flexibility), structured based on strategies described in Strosahl, Robinson, and
health and mental health status, and symptom reduction (e.g., Gustavsson (2012), and included elements of both experiential
depression and anxiety) from a 4-week FACT group facilitated in ACT exercises and group discussion. The initial session, Finding
an integrated VA primary care setting. This research was imple- Leverage, involved informed consent, introduced values-based
mented as a quality improvement (QI) project1 within an estab- living, introduced mindfulness, and introduced the ACT concept of
lished, integrated primary care behavioral health program. creative hopelessness (that is, identified the concept of a life
without pain as hopeless). The second session, Promoting Aware-
ness, focused on values clarification and identifying experiential
Hypotheses avoidance as a barrier to psychological flexibility. The third ses-
sion, Promoting Openness, focused on cognitive defusion exer-
We made the following predictions for outcomes associated cises. Cognitive defusion is defined as a process by which an
with participation in a primary care– based FACT group: individual comes to acknowledge his or her thoughts as thoughts,
1. Patients will demonstrate statistically and clinically sig-
nificant improvements in patient-reported quality of life, 1
Traditional outcome research in the primary care setting leverages
as well as their perceptions of their physical and mental randomized, clinical trial (RCT) designs; however, the results of these
health functioning. studies may not always generalize to “real-world” settings because of their
high level of control, frequent exclusion of patients with comorbid condi-
tions, inflexibility with respect to a highly adaptive setting, costliness, and
2. Patients will demonstrate statistically and clinically sig- randomization of patients (Peek, Cohen, & deGruy, 2014). Among alter-
nificant reductions in patient-reported depression, anxi- natives to RCTs are quality improvement (QI) projects, which are ideally
ety, and stress. both theory-driven and generalizable (Neuhauser & Diaz, 2007).
158 GLOVER ET AL.
used measure of mindfulness and self-compassion that may also Research and Therapy, 48, 555–560. http://dx.doi.org/10.1016/j.brat
prove very useful in ACT and FACT research, specifically in terms .2010.02.002
of capturing progress related to psychological flexibility. Gloster, A. T., Rhoades, H. M., Novy, D., Klotsche, J., Senior, A., Kunik,
Current findings should be considered within the context of a M., . . . Stanley, M. A. (2008). Psychometric properties of the Depres-
number of limitations. First, this study did not include a control sion Anxiety and Stress Scale-21 in older primary care patients. Journal
of Affective Disorders, 110, 248 –259. http://dx.doi.org/10.1016/j.jad
group and randomization, therefore it is not possible to determine
.2008.01.023
whether FACT participation caused changes in the measured out-
Goodwin, C. L., Forman, E. M., Herbert, J. D., Butryn, M. L., & Ledley,
comes. Nevertheless, this study offers critical preliminary data
G. S. (2012). A pilot study examining the initial effectiveness of a brief
(with respect to both clinical outcomes and feasibility) to support acceptance-based behavior therapy for modifying diet and physical
more rigorous effectiveness trials. Second, though ACT is known activity among cardiac patients. Behavior Modification, 36, 199 –217.
for its transdiagnostic efficacy (Strosahl et al., 2012), it may have http://dx.doi.org/10.1177/0145445511427770
proven useful to track participants’ diagnoses, to explore whether Hayes, S. C. J., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006).
they moderated the reported outcomes. Third, the study did not Acceptance and commitment therapy: Model, processes and outcomes.
attempt to assess the process of change. Research examining more Behaviour Research and Therapy, 44, 1–25. http://dx.doi.org/10.1016/j
traditional ACT protocols has revealed evidence to support that .brat.2005.06.006
ACT works through generally recognized processes of change Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and
(e.g., cognitive defusion, use of acceptance strategies, and willing- commitment therapy: An experiential approach to behavior change.
ness to engage in value-driven behavior regardless of unpleasant New York, NY: Guilford Press.
thoughts and emotions; Ruiz, 2012); however, the process of Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and
change may differ with respect to a more time-limited FACT Commitment Therapy: The process and practice of mindful change (2nd
ed.). New York, NY: Guilford Press.
protocol in a group setting. Future work is critical to examine this
Heun, R., Burkart, M., Maier, W., & Bech, P. (1999). Internal and external
hypothesis. Finally, as mentioned earlier, the use of follow-up
validity of the WHO Well-Being Scale in the elderly general population.
data/long-term monitoring would have been useful in demonstrat-
Acta Psychiatrica Scandinavica, 99, 171–178. http://dx.doi.org/10.1111/
ing sustainment, if any, of short-term clinical improvements j.1600-0447.1999.tb00973.x
gained following participation in the FACT group. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical
Despite these limitations, the current study provides preliminary approach to defining meaningful change in psychotherapy research.
evidence for the efficacy of a FACT group protocol in a VA Journal of Consulting and Clinical Psychology, 59, 12–19. http://dx.doi
primary care setting. Moreover, the brief, group-based, and trans- .org/10.1037/0022-006X.59.1.12
diagnostic nature of the intervention employed in this study rep- Jenkinson, C., Layte, R., Jenkinson, D., Lawrence, K., Petersen, S., Paice,
resents an ideal fit for the needs of modern primary care. For these C., & Stradling, J. (1997). A shorter form health survey: Can the SF-12
reasons, FACT represents a promising intervention that can ad- replicate results from the SF-36 in longitudinal studies? Journal of
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