Acceptance and Commitment Therapy as an Alternative to Exposure:

A Pilot Study in the Treatment of Veterans Diagnosed with PTSDKatharine C. Sears, Ph.D.1,2; Varvara Mazina, B.A.1,2; Amy Wagner, Ph.D.3; Robyn D. Walser, Ph.D.1

1VA Palo Alto Health Care System National Center for PTSD; 2Stanford University School of Medicine; 3Portland VA Medical Center

BACKGROUND

Acknowledgements: Poster production by the National Center for PTSD Dissemination and Training Division

• There is a need to provide alternative therapies to the evidence-based standards for the treatment of PTSD.

• Drop-out rates and refusal rates for exposure-based therapies, the main empirically-based intervention for PTSD, range from 40-50% (Schnurr et al., 2007; van Minnen, Arntz, & Keijsers, 2002).

•With its emphasis on acceptance and valued living in the present moment, Acceptance and Commitment Threapy (ACT) may be an effective alternative.

• In this ongoing multi-site VA pilot study, ACT was offered to Veterans diagnosed with PTSD who had already declined or dropped out of exposure-based treatment(s).

•Participants were recruited through VA PCT clinics in Livermore, CA, San Jose, CA, and Portland, OR.

•Only Veterans who had previously refused or dropped out of exposure-based treatment (before the 6th session) were eligible to enroll.

•Nine male Veterans (mean age 52.6, 50% Caucasian) completed a 12-week ACT protocol and answered a series of questionnaires at pre-, post-, and 3-month follow up.

Measures

•PTSD Checklist (PCL-C)

•Acceptance and Action Questionnaire (AAQ-2)

•4-Item Values Questionnaire (developed for this study)

•White Bear Suppression Inventory (WBSI)

•Treatment Credibility/Expectancy Questionnaire (CEQ)

•World Health Organization Quality of Life Scale (WHOQOL)

• Aim 1: To determine the effectiveness of ACT to reduce PTSD symptoms

• Aim 2: To investigate how ACT processes (acceptance) area associated with reductions in PTSD symptoms

• Aim 3: To explore whether increased in acceptance is associated with an increased willingness to try exposure-based treatment(s).

• Pilot data indicate that ACT may lead to decreased PTSD symptoms and more values-based living for Veterans with PTSD.

•Veterans had realistic pre-treatment expectancies about ACT, and came to endorse it as a highly credible treatment for PTSD by post-treatment and follow-up.

•Correlation data show an association between changes in acceptance and PTSD symptom severity in this small sample, providing some support for ACT mechanisms of change.

•There is no evidence from this sample that completing a 12-session ACT protocol is associated with enhanced willingness to engaged in exposure-based treatments.

•Acceptance scores showed a familiar trend in ACT research of continuing to improve after treatment ends.

•Many Veterans want psychotherapy but are unwilling or unready to undergo trauma-focused treatment. The majority of Veterans with PTSD who refuse exposure receive treatments of unknown efficacy. ACT may be a viable alternative to exposure-based therapies in VA.

OBJECTIVES

METHODS

RESULTS CONCLUSIONS

LIMITATIONS & FUTURE DIRECTIONS

• This small pilot study is underpowered to draw any firm conclusions. More data is needed to confirm the validity of these findings.

•Future ACT research should include the efficacy of ACT in Veterans with traumatic brain injury (TBI).

•Future research should further investigate barriers to exposure-based treatments, and whether ACT may increase willingness to engage these options.

ReferencesBond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., . . . Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and Action Questionniare - II: A revised measure of psychological flexibility and experiential avoidance. Behavior Therapy, 1-38.

Devilly, G.J. & Borkovec, T.D. (2000). Psychometric properties of the credibility/expectancy questionnaire. Journal of Behavior Therapy and Experimental Psychiatry, 31, 73-86.

Skevington, S. M., Lotfy, M., & O'Connell, K. A. (2004). The World Health Organization's WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Quality of Life Research, 13, 299-310.

Weathers, F. W., Ruscio, A. M., & Keane, T. M. (1999). Psychometric properties of nine scoring rules for the Clinician-Administered Posttraumatic Stress Disorder Scale. Psychological Assessment, 11(2), 124-133.

Wegner, D. M., & Zanakos, S. (1994). Chronic thought suppression. Journal of Personality, 62, 616-40.

Figure 2. Pre-post and follow up differences in PTSD Symptoms, Acceptance, and Self-Reported Valued Living among patients diagnosed with PTSD.

Figure 1. Pre-post and follow up differences in treatment credibility, treatment satisfaction, and willingness to exposure treatment.

Aggregate Analyses (n=9)

• Preliminary results showed a significant decrease in average PTSD scores from pre- to post-treatment (mean ∆ = -6.8, SD = 8.6, p < .05) and a clinically significant but not statistically significant decrease from pre-treatment to 3 month follow-up (mean ∆ = -12.2, SD = 17.7, p =0.15).

•Valued living increased significantly from pre- to post- (mean ∆ = +1.3, SD = 1.4, p < .05) but not between pre- and follow-up (mean ∆ = +2.0, SD = 2.2, p = .08).

• Participants also reported non-significant improvements in several quality of life domains (WHOQOL-BREF): social relationships, psychological health, and physical health.

•Treatment satisfaction was high (means between 8.67-9.17 on a 10-point scale) at post-treatment and 3 month follow-up.

• There was a non-significant change in Veterans' willingness to engage in exposure treatments after completing ACT.

• There was a significant increase in patients’ self-reported acceptance from pre- to mid-treatment (mean ∆ = +5.8, SD= 6.2, p < .05) and from pre- to follow-up (mean∆ = +11.3, SD = 9.7, p <.05).

•Change in AAQ-2 scores from pre- to follow-up was significantly correlated with change in PCL-C scores over the same period.

•There was a non-significant downward trend in thought suppression from pre- to post-treatment and from pre- to follow-up.

Individual-Level Data

Pt. 1 = TBI patient lost to f/uPt. 4 = dropoutPt. 8 = treatment interruptionPt. 10= treatment not yet complete

Pt. 3 = TBI patient