Empirical researchChanges of valued behaviors and functioning during an Acceptance and Commitment Therapy Intervention
Introduction
Living according to one's values is beneficial for a person's well-being (Rogers, 1965). One therapy that explicitly concentrates on values is Acceptance and Commitment Therapy (ACT). ACT is a variant of cognitive behavioral therapy (CBT) and, one of the central goals of ACT is to help clients live more in touch with and act according to their values. In ACT, values are defined as “freely chosen, verbally constructed consequences of ongoing, dynamic, evolving patterns of activity, which establish predominant reinforces for that activity that are intrinsic in engagement in the valued behavioral pattern itself” (Wilson & DuFrene, 2009). Concentrating on values in the therapeutic context often reveals that individuals do not live in line with their stated values (Michalak et al., 2011, Wilson et al., 2010). Individuals may be clear about what they value but their behavior towards their values may be ineffectual or infrequent. The reason for this may include that individuals form behavior patterns that allow them to avoid experiences and events with uncomfortable sensations. As a result, values may be compromised.
Acceptance-Based Behavior Therapy is believed to help by linking specific actions to the client's own chosen values in order to achieve valued action. Valued action can be defined as effective behavior linked to chosen values (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Interestingly, patients with mental disorders may show less valued action compared to healthy counterparts. For instance, patients with Generalized Anxiety Disorder (GAD) reported less valued action compared to non-anxious controls, and after an Acceptance-Based Behavior Therapy intervention valued action increased significantly (Michelson, Lee, Orsillo, & Roemer, 2011) Patients with high levels of symptomatology increased less in valued action compared to those with lower levels of symptoms. Another study showed that engaging in valued action is associated with both improved quality of life and well-being and less seizures in epilepsy patients (Lundgren, Dahl, & Hayes, 2008).
Prior research showed that most complaints of individuals entering psychotherapy are about domains in interpersonal areas (Davies-Osterkamp, Strauss, & Schmitz, 1996). In another study more than half of the sample chose social relationships as most meaningful to them as opposed to religion, physical activities and other domains (Parks, Della Porta, Pierce, Zilca, & Lyubomirsky, 2012). Further, a considerable number of anxiety and depression patients rate social domains such as relationships, parenthood, and intimacy as essential treatment goals Grosse & Grawe (2002). Although the significance of social domains has been identified, to our knowledge no study has directly compared how patient's valued behaviors differs and changes within treatment in respect to social and non-social domains.
Given the concentration of values within ACT, it is reasonable to expect that this change is associated with an increase in functioning. That is, a person who is engaged in his/her life in a way that is subjectively meaningful is also likely to subjectively report high levels of functioning. Indeed, a number of studies investigated the impact of ACT on functioning, e.g., within the treatment of chronic pain (e.g. McCracken & Yang, 2006; Steiner, Bogusch, & Bigatti, 2013; Vowles & McCracken, 2008). In accordance with the WHO definition, functioning is in the present study understood as the ability to carry out objective performances and routine activities in a given life domain, for instance at home, work, school and other areas in which roles may have to be performed. Other outcome studies also showed that ACT interventions are associated with improved functioning, for instance in the treatment of eating disorders (Juarascio, Forman, & Herbert, 2010), substance use disorders (Luoma, Kohlenberg, Hayes, & Fletcher, 2012) and worksite stress (Flaxman & Bond, 2010). Vowles and McCracken (2008) showed that daily functioning improved significantly throughout the study period.
Of individuals starting treatments, a large number do not respond to treatment. For anxiety disorders a number between 33% and 50% were estimated (e.g. Taylor, Abramowitz, & McKay, 2012). That estimate does not include patients who have residual symptoms despite some treatment success (Brown et al., 1995, Fava and Mangelli, 1999). Treatment-resistant patients may especially benefit from ACT, as this treatment changes the focus from symptom reduction to the engagement in valued behaviors (Clarke et al., 2014, Clarke et al., 2012; Hayes, Strosahl & Wilson, 2012; Gloster, Sonntag, Hoyer, Meyer, & Heinze et al., 2015Gloster et al., 2015, Gloster et al., 2015). Further, in ACT patients learn to live more flexibly with their symptoms and include values in their every day life even though symptoms may persist (Gloster, Chaker, Klotsche, Hummel & Hoyer, 2011; Hayes, Strosahl & Wilson, 2012).
Thus, building on the relevance of valued behaviors (Michelson, Lee, Orsillo, & Roemer, 2011), and perhaps in particular in treatment-resistant patients (Clarke et al., 2014, Gloster et al., 2015 Gloster et al., 2015) we aim to investigate changes of valued behaviors and their association with functioning in a standardized randomized controlled trial with an ACT intervention. We hypothesize, (1a) that valued behaviors increase over the course of the study, (1b) that valued behaviors in social and non-social domains differ from each other at all time points and, (1c) that valued behaviors in social domains increase more than in non-social domains. Given that no research has examined how valued behaviors differs in respect to social and non-social domains, we considered our analyses addressing these hypotheses as exploratory. Further, we hypothesize (2) that initial lower levels of panic symptomatology are associated with a subsequent higher increase in valued action. Finally, we expect (3a) functioning to increase over the course of the study and (3b) a positive association between increases in valued action and increases in functioning.
Section snippets
Design
Data were collected within a randomized controlled trial (RCT) of ACT compared to Waiting list (WL) for patients with treatment-resistant PD and/or agoraphobia (PD/A) in Germany. Patients were randomized to immediate treatment (n =33) or a WL condition (n=10). Follow-Up (FU) took place after 6 months. A comprehensive description of the procedures can be found elsewhere (Gloster et al., 2015). That study examined the efficacy of patients with PD and/or agoraphobia that were non-responding to
Descriptives
The means and standard deviations of all variables involved in the analyses at pre-treatment, post-treatment and FU are displayed in Table 1. The table shows higher means for social compared to non-social facets across all four facets of patients’ valued behaviors. Between group effect sizes between social and non-social domains are presented in Table 2.
Valued behaviors increase over the course of the study (Hypothesis 1a)
Patients' reported valued living discrepancy decreased over the course of ACT (see Table 3), whereas patients' valued behaviors regarding
Discussion
The aim of this study was to investigate patients' changes in valued behaviors and functioning following an ACT intervention. To the best of our knowledge, this is the first study to examine whether patients’ valued behaviors of social and non-social domains differ or show different increases throughout treatment. We found that patients’ valued behaviors in social domains were consistently higher than in non-social domains at all time points of the study. The amount of change in social and
Acknowledgement
The study was funded by the German Federal Ministry of Education and Research (BMBF; project No. 01GV0615) as part of the BMBF Psychotherapy Research Funding Initiative and by the Swiss National Science Foundation (FNSNF, Grant Number # 100014_149524/1).
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