A systematic review of the use of Acceptance and Commitment Therapy (ACT) in chronic disease and long-term conditions
Introduction
Chronic diseases/long-term conditions such as diabetes, HIV, cancer or brain injury (henceforth long-term conditions) have a detrimental impact on well-being, as indicated by reduced quality of life (QoL) and mood (Barrios et al., 2015, Do et al., 2014, Graham et al., 2011, Jopson and Moss-Morris, 2003, Miners et al., 2014, Renn et al., 2011). Nonetheless, a large variation in QoL and mood across people with the same condition or with the same level of disease severity/disability level is often apparent (Graham et al., 2013, Miglioretti et al., 2008), and even those with the most severe symptoms may have preserved QoL and mood (Lule et al., 2008, Robbins et al., 2001). It therefore follows that factors other than the disease process, or its direct functional limitations, may help explain well-being in these conditions. Indeed, a large body of research shows that psychological factors are particularly important in this context. They explain significant proportions of the variation in QoL and mood, even after controlling for disease severity or disability level. Influential variables include, but are not limited to, illness perceptions, coping strategies, self-efficacy, psychological flexibility, and emotion regulation (de Ridder et al., 2008, Dennison et al., 2009, Graham et al., 2014b, Moss-Morris, 2013, Pakenham and Fleming, 2011, Petrie and Weinman, 2012).
Cognitive behavioural models, such as the well-known Self-Regulation Model (Leventhal, Nerenz, & Steele, 1984), posit that the explanatory value of psychological variables is derived from their influence on disease self-management behaviour and distress regulation. Any condition is likely to involve a range of adaptive self-management behaviours, such as adhering to medications, attending appointments with health professionals or amending one's activities and diet. A second parallel process of psychological adjustment may also occur, involving evaluation of the functional impact of the condition (for example on social and occupational functioning) and the regulation of any resultant distress (Leventhal et al., 1984).
Empirical support for the importance of psychological processes in long-term conditions has led to the development and application of cognitive behavioural interventions which target these processes to improve a range of outcomes, from QoL and mood to treatment adherence and disease self-management (Barlow et al., 2002, Graham et al., 2015, Petrie and Weinman, 2012). Consequently, clinical psychologists and healthcare professionals in related disciplines now play a key role in the treatment of people with long-term conditions.
Section snippets
Traditional cognitive behavioural therapy in long-term conditions
Mirroring its popularity in mental health conditions (Butler, Chapman, Forman, & Beck, 2006), interventions derived from traditional Cognitive Behavioural Therapy (traditional CBT) have been widely applied to improve distress and self-management in long-term conditions (Beatty and Lambert, 2013, Greer et al., 1992, Hind et al., 2014, Ismail et al., 2004, Petrie et al., 2012). These see one's beliefs as the central process in therapy (Beck, 1976, Halford and Brown, 2009), a target supported by
Acceptance and Commitment Therapy (ACT) in long-term conditions
ACT is a newer form of cognitive behavioural therapy (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), which has evolved from experimental work regarding the influence of language on behaviour (Zettle, 2005) and is, in part, informed by Relational Frame Theory (De Houwer, Barnes-Holmes, & Barnes-Holmes, 2016). While a full description of this theory is beyond the scope of this review, the main implication for treatment is that language processing is viewed from within the paradigm of behaviourism.
Why might ACT have utility in long-term conditions?
Many have expressed the opinion that ACT has utility over existing psychotherapeutic models in the context of long-term conditions (Angiola and Bowen, 2013, Graham et al., 2015, Hadlandsmyth et al., 2013, Low et al., 2012, Whittingham, 2014). For example, negative illness beliefs and distress may be realistic in certain conditions at certain times. Thus, ACT's focus on instigating valued behaviours while accepting such thoughts and feelings may prove more effective than attempts to directly
Efficacy of ACT in other contexts
The empirical status of ACT for chronic pain (Veehof, Oskam, Schreurs, & Bohlmeijer, 2011) and mental health populations (A-Tjak et al., 2015, Öst, 2008, Öst, 2014, Swain et al., 2013, Powers et al., 2009) has been previously reported. A-Tjak et al. (2015) noted that ACT has been trialled in a diverse group of conditions (psychosis, OCD, anxiety disorders). In their meta-analysis of primary outcomes in 39 studies, a medium effect size in favour of ACT was observed when compared with
Psychological processes and interventions: a transdiagnostic perspective
Medical intervention (e.g. medication, surgery) requires diagnoses defined by biological pathology, since such treatments target processes at this level. In contrast, psychological intervention targets consequent cognitive and behavioural processes that are common across long-term conditions. Supporting this, a critical review by de Ridder et al. (2008) advanced several components of psychological adjustment to long-term conditions, which apply across diagnoses; for example, disease
Procedures
The procedures were informed by accepted systematic reviewing guidelines (Khan et al., 2001, Moher et al., 2009). Ovid MEDLINE, EMBASE and Psych Info were searched from their earliest available listing to 22nd February 2015. Due to the large number of possible long-term conditions, a broad search strategy was applied. This used the key terms ACCEPTANCE AND COMMITMENT THERAPY and CONTEXTUTAL COGNITIVE BEHAVIO$. Abstracts were examined if the title suggested an intervention study with long-term
Results
The initial database search returned 1436 studies, from which 23 publications were retrieved in full. The removal of study protocols and interventions with insomnia populations left 15 remaining studies. Five additional studies were obtained from Google Scholar. However, upon closer inspection, a study which showed low fidelity to ACT and another with a healthy population, were removed. Thus, 18 studies were included in the systematic review (Fig. 1).
A summary of the use of ACT in long-term conditions
ACT has been applied across many long-term conditions, for example: cancer (Feros et al., 2013, Hawkes et al., 2013, Hawkes et al., 2014, Rost et al., 2012), epilepsy (Lundgren et al., 2006, Lundgren et al., 2008), paediatric illness (Brown et al., 2014, Burke et al., 2014, Whittingham et al., 2014), cardiac disease (Goodwin et al., 2012), multiple sclerosis (Nordin and Rorsman, 2012, Sheppard et al., 2010), and diabetes (Gregg et al., 2007). It has been used to elicit change in a range of
Conclusion
ACT has been applied in many different ways within a range of long-term conditions. However, there have been no trials of ACT for improving medication non-adherence. Most of the included studies were of low quality and there were very few RCTs. Therefore, ACT interventions are not yet well established for use in long-term conditions. Nonetheless, there was some promising evidence that ACT may improve the parenting of children with long-term conditions, seizure-control in epilepsy, psychological
Disclosure
The authors report no conflicts of interest.
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