Commitment Therapy (ACT) in practice:
ACT consistency of multidisciplinary professionals in the Dutch pain rehabilitation
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Author: Alicia Hoppe
Supervisors:
Hester R. Trompetter, Msc.
Karlein M. G. Schreurs, PhD Department of Psychology
University of Twente, Netherlands Date: 26.05.2014
Abstract
Objective: This study investigates the implementation of Acceptance and
Commitment Therapy (ACT) in nine Dutch chronic pain rehabilitation centers. In this study, an existing, qualitative coding scheme was evaluated and adjusted. Afterwards, consistency in ACT practice was analyzed. Therefore adherence to the ACT protocol and competence in working with ACT were scored.
Method: In an iterative process the coding scheme of Scholten (2014) was reviewed.
Using the revised coding scheme, adherence to the ACT protocol and competence in working with ACT of three psychologists, five occupational therapists, three
physiotherapists and four social workers were analyzed.
Results: The final coding scheme uses a coding unit of one minute, adds a column to write down the content, scores every competence separately, and allows scoring of ACT processes twice (or more). All participating professionals worked in adherence to the ACT protocol and were competent in working with ACT. No significant differences were found between both adherence and competence and the different subgroups. The implementation can be rated as successful.
Implications: Other researchers will have advantages for the implementation of ACT using the presented scoring scheme which will improve the development of ACT in the treatment of patients experiencing chronic pain and of other areas. Further research is necessary to show if the ACT treatment has the expected positive influence on the functionality of chronic pain patients.
Samenvatting
Achtergrond: In deze studie werd de implementatie of Acceptance and Commitment Therapie (ACT) in negen chronisch pijn revalidatiecentra in Nederland geëvalueerd.
Daarnaast werd een bestaand kwalitatieve codeerschema geëvalueerd en aangepast.
Op basis van dit schema, werd vervolgens ACT consistent werken geanalyseerd.
Hiervoor werden adherence aan het ACT protocol en competentie in werken met ACT gescoord.
Methode: In een iteratief proces werd het codeerschema van Scholten (2014) herzien.
Met het finale codeerschema werd adherence aan het ACT protocol en competentie in ACT consistent werken van drie psychologen, vijf ergotherapeuten, drie
fysiotherapeuten en vier maatschappelijke werkers geanalyseerd.
Resultaten: Het finale codeerschema gebruikt een codeereenheid van een minuut, bevat een kolom om de inhoud neer te schrijven, iedere competentie wordt
afzonderlijk gescoord en ACT processen kunnen in het geval dat ze langer aanwezig zijn meer dan een keer gescoord worden. Alle participanten hebben adherent aan ACT en competent met ACT gewerkt. Geen significante verschillen zijn gevonden tussen adherence en competentie en tussen de verschillende subgroepen. Dit geeft
aanwijzing dat de implementatie of ACT succesvol is geweest.
Implicaties: Andere onderzoekers kunnen het bestaand codeerschema gebruiken voor het implementeren van ACT, waardoor de ontwikkeling van ACT in de behandeling van patiënten met chronische pijn en op andere gebieden verder wordt bevorderd.
Verder onderzoek is noodzakelijk om te laten zien in hoeverre de ACT behandeling positieve effecten heeft op het functioneren van patiënten met chronische pijn.
Table of Contents
Introduction ... 5!
Treatment of patients with chronic pain ... 5!
Acceptance and Commitment Therapy ... 6!
Treatment Integrity ... 9!
Purposes and Hypotheses ... 10!
Method ... 12!
Previous implementation (October 2010-October 2012) ... 12!
Material ... 13!
Participants ... 15!
Data analysis ... 15!
Study 1 ... 16!
Study 2 ... 16!
Results ... 17!
Study 1 ... 17!
Study 2 ... 19!
Discussion ... 24!
Limitations ... 28!
Future research ... 29!
Conclusion ... 31!
References ... 32!
Appendix ... 35!
Appendix A ... 35!
Appendix B ... 39!
Appendix C ... 45!
Appendix D ... 68!
Introduction
In the Netherlands, an estimated 18% of the population suffers from chronic pain, with prevalence in Europe ranging from 12% to 30% (Breivik, Collett, Ventafridda, Cohen, & Gallacher, 2006). Chronic pain has severe impact on patients’ daily functionality. It is a substantial problem for the individual person, their social environment and our society in general. Many patients experiencing pain were less able or no longer able to take part in various activities such as sleep, household chores, and social activities. A total of 19% had lost their jobs because of pain (Breivik et al., 2006). The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (IASP Taxonomy Working Group, 2011). Notably, the subjectivity of the experienced pain are central in this definition, rather than its cause, whether they be physiological, tissue damage, or otherwise. Common chronic pain conditions are headache, back or neck pain, and arthritis or joint pain (Tsang et al., 2008). Pain is said to be chronic if it persists or occurs repeatedly over a period of more than three month (Merriam-
Webster, 2014).
Treatment of patients with chronic pain
A study on chronic pain and its treatment in the Netherlands indicates that a substantial proportion of patients receive drug treatment for their pain, and a
significant number of patients reported using a range of different non-
pharmacological interventions such as physiotherapy, acupuncture and postural advice (Bekkering et al., 2011). Contrary to the study, almost half of the chronic non- cancer pain patients did not receive treatment. Furthermore, up to 80% of the patients believe their pain is inadequately treated (Bekkering et al., 2011; Breivik et al., 2006).
The results of a study of Turk, Wilson, and Cahana (2011) suggest that none of the more commonly prescribed treatment regimens are, by themselves, sufficient to eliminate pain and to increase physical and emotional functionality in most patients with chronic pain. Gatchel, Peng, Peters, Fuchs, and Turk (2007) and Turk et al.
(2011) advocated the multidisciplinary pain management approach, which implied the use of comprehensive treatment of emotional, cognitive, behavioral and psychosocial dimensions. Furthermore, Turk et al. (2011) recommended including dialogue with the patient about realistic expectations of pain relief focusing on improvement of functionality instead of fighting the pain.
Acceptance and Commitment Therapy
The Acceptance and Commitment therapy (ACT) focuses not on fighting the pain but on improving the functionality of chronic pain patients, which can be performed by a multidisciplinary team. According to ACT, the primary source of psychopathology is the way language and cognition react to negative events, such as pain, producing an inability to change behavior (Hayes, Luoma, Bond, Masuda, &
Lillis, 2006). The result is psychological inflexibility. ACT has the goal to change behavior, but if behavior changes, psychological barriers are met. Those barriers are, at the same time, addressed through the processes of ACT (Hayes et al., 2006;
Luoma, Hayes, & Walser, 2007). Thus, to overcome those barriers and the
psychological inflexibility, ACT consists of six core processes, with none of them standing alone, but being all interrelated and influenced by each other (Figure 1; A- Tjak, 2009; A-Tjak & De Groot, 2008; Hayes et al., 2006; Hayes, Strosahl, & Wilson, 2012; Luoma, Hayes, & Walser, 2007). The six processes can be combined in three response styles. The first is the ‘open response style’ that unites the core processes acceptance and cognitive defusion. Those two aim to enable the person to distance
himself or herself from negative events and embrace them actively and with
awareness to let go of the control of feelings and thoughts. Patients learn to consider thoughts as what they are: no more and no less than words or pictures that do not necessarily refer to reality (Hayes et al., 2006; Hayes et al., 2012). The second is the
‘centered response style’ which unites the core processes being present and self as context. ACT techniques help to stay in the here and now, without judging the events.
ACT attempts to help the patient observe an event without being attached to inner experiences but being aware of events from an objective point of view (Hayes et al., 2006; Hayes et al., 2012). This also helps the patients to adhere to behavior that serves their values. This leads to the third, ‘engaged response style’ which unites the core processes values and committed action. In ACT, patients are asked to step back from everyday problems of life and to find out what gives life meaning and how situations can lead to more constructive actions. Committed action means doing what is important to live in harmony with one’s values, even if it is painful and unpleasant (Hayes et al., 2006; Hayes et al., 2012).
Figure 1. The six core processes of ACT
Participants, who completed an ACT treatment, reported on average significantly higher levels of satisfaction with the treatment than patients who
received cognitive behavioral therapy (Wetherell et al., 2011). Results from a study of Wicksell, Melin, Lekander, and Olsson (2009) suggest that an ACT oriented
treatment can contribute to the improvement of functionality and quality of life for patients with longstanding pain and a study of Vowles et al. (2007) observed that a pain acceptance group demonstrated greater overall functionality compared to the
pain control groups. The effectiveness of ACT has also been supported through the findings of additional studies (Dahl, Wilson, & Nilsson, 2004; Kratz, Davis, &
Zautra, 2007; McCracken, MacKichan, & Eccleston, 2007; Vowles, Wetherell, &
Sorrell, 2009; Wicksell, Olsson, & Hayes, 2010). The results of an exploratory meta- analysis of studies on the effects of acceptance-based therapies on mental and physical health in patients with chronic pain, suggest that ACT can be a good alternative to CBT, but additional high-quality studies are needed for a more definitive conclusion (Veehof, Oskam, Schreurs, & Bohlmeijer, 2011).
Treatment Integrity
ACT has been implemented systematically in nine Dutch rehabilitation centers between 2010 and 2012. Over the course of two years professionals were trained in ACT through various workshops, interventions and supervision (more information:
Trompetter, Schreurs, & Heuts, 2014). In order to investigate if the implementation of ACT is performed successfully, treatment integrity will be examined in this study.
Treatment integrity refers to the degree in which a treatment is implemented consistently with the underlying theory (Perepletchikova, Treat, & Kazdin, 2007;
Plumb & Vilardaga, 2010; Southam-Gerow & McLeod, 2013). Even though
establishing treatment integrity is a necessary and important part of clinical research, science and documentation protocols of treatment integrity are underdeveloped (McLeod, Southam-Gerow, & Weisz, 2009; Perepletchikova et al., 2007; Southam- Gerow & McLeod, 2013). In the available literature different strategies such as treatment adherence, treatment differentiation, therapist competence and relational elements are discussed to operationalize treatment integrity (McLeod et al., 2009;
Perepletchikova et al., 2007; Plumb & Vilardaga, 2010; Southam-Gerow & McLeod, 2013; Waltz, Addis, Koerner, & Jacobson, 1993). The two strategies, adherence and
competence, are highlighted in most definitions, with adherence referring to the extent to which a professional uses interventions prescribed by the treatment manual, protocol or model and with competence referring to the level of skill at which the professional is operating (Plumb & Vilardaga, 2010; Waltz et al., 1993). Additionally, it is defined that adherence does not necessarily encompass competence, meaning that following the protocol does not automatically equate to therapist competence (Plumb
& Vilardaga, 2010; Waltz et al., 1993).
Investing treatment integrity has several advantages, including linking treatment effects to the specific processes the model predicts to be related to change.
Second, treatments can be compared across settings as well as across therapists and studies. Third, treatment integrity checks provide information for training and supervision procedures and are an essential tool to discriminate between different treatments (Waltz et al., 1993). Additionally, if we know about the quality of the ACT implementation performed in the Netherlands, the quality of further research on the effectiveness of ACT for chronic pain patients will be higher and the contribution to future research will be greater.
Purposes and Hypotheses
The paper of Plumb and Vilardaga (2010) gives an example of an ACT integrity coding system for patients with an obsessive compulsive disorder and provides tools for ACT researchers to develop further treatment integrity protocols.
Additionally, it provides tools for objective data like video material. On the basis of their work, Scholten (2014) developed a scheme to code and score ACT consistency.
Scholtens’ scheme is based on theoretical and practical considerations, but it is not yet used in practice. This study is based on the scheme in practice after review and
enhancement. The aim of the first study is to support the development of a scheme, which provides necessary tools for future integrity checks of ACT.
In order to measure the success of the ACT implementation, the second study examines the treatment integrity of the participating professionals in working with ACT. The emerging research question of the explorative study 1 is ‘To what extent is the existing treatment integrity scheme sufficient, and what needs to be added to the existing treatment integrity scheme to make it more sufficient?’ For study 2, the research questions ‘To what extent were the participating professionals adhering to the ACT protocol and were they competent in working with the ACT protocol’
emerges. We expected that the participating professionals would score above average in adherence and competence. Furthermore, we expected differences in adherence and competence between the different groups of professionals, between early and late adopters, and among participating professionals with various levels of work
experience with ATC, with ‘junior’ having lower and ‘senior’ having higher scores in adherence and competence.
We found the competence to use ACT processes and interventions flexible depending on the client, and the content of the sessions to be more ACT specific than the other competences which led us to the assumption that more training or
experience will lead to higher scores on this competence. We expected that there may be a difference among the scores of the various subgroups (early and late adopters, participating professionals with a different amount of work experience with ACT) on that ACT specific competence. We further explored this interesting indication in a post-hoc analysis.
Method
Previous implementation (October 2010-October 2012)
The current study evaluates the implementation of ACT in nine Dutch pain rehabilitation centers between October 2010 and October 2012, all of which had no prior experience with the technique. ACT was introduced using a two-part ‘train-the- trainer’ approach (Figure 2). In each institution a multidisciplinary team received an initial 6-day training course called ‘ACT for pain-teams’, in which the theoretical background as well as the practical application of ACT was conveyed. Over the following 6 months, the team adopted ACT while being supported by three external supervisions. During the initial 6 month adoption period, the participating
professionals received continuous online support and met every 4-6 weeks to discuss progress and possible problems in working with ACT. After these 6 months, the participating professionals took over the role of mentors and trained other
practitioners from their institution in a 2-day workshop. They continued working with ACT for additional 6 months and were again supported by external supervision, intervision, and a website. Hereafter, those two groups are referred to as ‘early adopters’ and ‘late adopters’. For more information on the implementation, visit http://www.actinderevalidatie.nl.
Figure 2. ‘Train-the-Trainer’ approach used for the implementation of ACT. In each institution a team received a 6-day training course called ‘ACT for pain-teams’. After this team (‘early adopters’) gained experience in working with ACT, they started to train other practitioners, based on their training in a 2-day workshop (‘late adopters’).
Material
Questionnaires. At the beginning of the implementation in October 2010 all participating professionals were asked to fill in a standardized questionnaire
developed by the main researcher, Hester Trompetter, to provide relevant background information such as age, profession and work experience with ACT (Appendix C).
Video data. All video recordings were made at the beginning of a therapy session, except two, which were done in the middle of a treatment session. The video recordings had a mean duration of ten minutes, with a range from a minimum of six minutes to a maximum of 48 minutes. In each video recording the participating professionals and the patient are in the picture, unless the patient did not want to be filmed. In case where the patient is not seen in the video recording, his or her voice is
recorded. Furthermore, twelve recorded therapy sessions were held in consulting offices. Three recorded therapy sessions were held in work or gymnastic rooms where the patients were working with material provided by the participating professionals.
The data received through the participating professionals was treated completely anonymously, allocating one ID-code to a video recording and the associated questionnaires (Appendix A).
Scoring scheme of Scholten (2014). The coding scheme of Scholten (2014) provides instructions on how to score and rate the consistency of professionals working with ACT. According to this coding scheme, every minute of a video recording should be watched and scored (cf., Appendix B). The first step is to determine which of the six ACT processes the participating professional applies.
Second, adherence is rated by assigning scores ranging from 1 (not adhering to ACT interventions appropriate to core process) to 5 (complete adherence to ACT
interventions appropriate to core process) to every minute. Coding adherence requires a focus on the observable behavior of the therapist rather than considering what the therapist’s intention might have been. It is also important to only observe the therapist’s behavior and not the response of the client. If the therapist presented the material accurately, his work was adherent to the process (Plumb & Vilardaga, 2010).
Third, Scholten (2014) rates competence in working with ACT. She defined three ACT competencies using the nine core competencies stated by Luoma et al. (2007).
The first competency is the willingness to address difficult and problematic inner experiences of the therapist and the client inside and outside of the therapy session.
The second competency includes the degree of equivalence of the therapeutic relationship. The third competency is the degree of flexibility in using various ACT processes and interventions depending on the client and the content of the session, in
order to create room for experience instead of just talking about it (Scholten, 2014).
Competence is rated by assigning a score from 1 (not complying to ACT
competencies) to 5 (completely complying with ACT competencies). This should also be done for every minute. In case of absence of an ACT process, the rater is still allowed to assign scores to the competencies.
Participants
At the end of the implementation of ACT in the rehabilitation centers, video data of 25 professionals were collected. For this specific study, we analyzed 15 video recordings. The inclusion criterion was that the participating professionals had the profession of a psychotherapist, occupational therapist, physiotherapist or a social worker. The 15 analyzed video recordings include material from five participating professionals from the Roessingh rehabilitation center in Enschede, six from the Rijndam rehabilitation center in Rotterdam (Vlietlandplein) and four from the
Bethesda hospital in Hoogeveen. The mean age of the participating professionals was 44.47 years (SD = 12.23), with a minimum age of 21 years and a maximum age of 60 years. Eighty percent of the participating professionals were female (n = 12). The participants’ professions were psychologists (n = 3), occupational therapists (n = 5), physiotherapists (n = 3) and social workers (n = 4), and their average work experience with their current profession was 14.64 years (SD = 5.6). More background
information is available in Table 1 in Appendix A.
Data analysis
First of all, the knowledge about ACT was established through an extensive literature review on ACT, using the books Learning ACT (Luoma et al., 2007), Leven met Pijn (Veehof, Schreurs, Hulsbergen, & Bohlmeijer, 2010), Voluit Leven
(Bohlmeijer & Hulsbergen, 2009) and Acceptance and Commitment Therapy – An experimental approach to behavior change (Hayes, Strohsahl, & Wilson, 1999).
Study 1
To answer the research question ‘to what extent is the existing treatment integrity scheme of Scholten (2014) sufficient, and what needs to be added to the existing treatment integrity scheme to make it more sufficient’, an iterative process was used.
In this iterative process the randomly chosen video recording ‘Roessingh 6’
was watched alongside the main researcher Karlein Schreurs. In each repetition, the focus was placed on a different point. The steps taken in order to achieve the current coding scheme are presented in the result section.
Study 2
Video coding. Based on the adjusted coding scheme all 15 video recordings were coded pausing every minute of the video recording. In the first replay, it was checked to see if an ACT process was present, and in the second and third, adherence and competence were rated respectively. Afterwards, average scores for adherence and competence were calculated (Table 3).
Quantitative analysis. The Pearson correlation was used to analyze if there is a relationships between the mean scores of adherence and competence. Next, it was investigated to determine if there was a relationship between any of the four different professions to the degree of either adherence and competence. Using a one-way ANOVA it was checked to see if there is a difference between the various professions and their score on adherence and/or competence. We also investigated using the Pearson correlations to determine the relationship between the level of work experience with ACT (Junior, Intermediate, Senior) and adherence and/or competence.
Furthermore, we used an independent samples t-test to examine the
relationship between the participant’s designation as ‘early adopter’ or ‘late adopter’
to adherence and competence and investigated if there is a possible difference between those two conditions.
Post hoc analysis. We further explored the possibility that there might be a correlation between participating professionals with a different amount of work experience or being an early or late adopter and their scores on the competence to use different ACT processes and interventions flexibly depending on the client and the content of the session.
Results
Study 1
Listed below are the steps taken to adjust the coding scheme developed by Scholten (2014).
Material: Video recording ‘Roessingh 6’ has been watched and coded using the coding scheme developed by Scholten (2014).
Considerations:
1. The coding unit of one minute is reviewed, because the researchers experienced difficulties to adhere to this unit. The alternative idea was to operate a unit based on content.
2. We tested the potential benefit of adding a summary of each minute’s contents to the scale.
3. We tested whether important information would be lost when one
comprehensive score for competence is used, compared to when the three competences are scored separately.
4. We tested whether the code ‘the scoring runs through’ is sufficient or not. The alternative idea tested was to code one process twice (or more), thus in one minute and also in the other(s) if it was present longer than one (or more) minutes.
5. The idea was to automatically calculate the mean of the adherence and competence scores. Therefore it was tested to put the coding scheme into spreadsheet software.
Results:
1. A unit based on content was found to be too subjective, with the consequence being that there has been too much difference between the coding results of the researchers. It is preferable to use a unit of one minute, running from 0.00 – 0.59 minute to evaluate every minute. The aim is to collect data, which can be evaluated with statistical methods.
2. A column to note the content of every minute was added as a first column of the revised scheme. The benefit is that the coder actively works with the content before coding, which makes the coding more accurate.
3. Each of the three competences was scored separately. This allows for a more accurate scoring of the competences because all three competences differ in their content, and raters can vary the scores between the competences.
Furthermore, more information is available over the competences of the practitioners.
4. An ACT process can be present two or more times in a video recording if the ACT process is continuously present for a longer period. Also, more than two ACT processes can be present at the same time.
5. The scheme is in a spreadsheet software. The coder fills this in while scoring.
Study 2
All video recordings were scored using the adjusted scheme. The mean scores of adherence are spread over the full range of the scale (1 to 5), with an overall mean of 3.84 (SD = 1.05). The mean scores for competence range from 1.71 to 4.59, with an overall mean of 3.89 (SD = 0.69; Table 3). These scores indicate that the
implementation is done sufficiently. Further, a strong positive correlation was found between the scores of adherence and competence (r = .88, p ≤ .001). This indicates that one and two are strongly linked.
Table 3
Mean adherence and competence scores of all videos
Video
Adherence M
Competence M
Roess_6 3.00 3.13
Beth_1 4.70 4.29
Rijndam_5 4.67 4.07
Beth_3 4.50 4.17
Rijndam_7 1.00 1.71
Roess_3 5.00 4.45
Roess_1 4.42 3.87
Beth_4 4.25 4.27
Roess_10 4.57 4.59
Roess_9 3.40 4.00
Rijndam_1 4.63 4.11
Beth_2 4.00 4.00
Rijndam_4 3.70 3.73
Rijndam_3 3.00 4.00
Rijndam_2 3.00 3.90
Overall mean (SD) 3.84 (1.05) 3.89 (0.69)
Scores of adherence and competence compared along different
professions. Table 4 summarizes the average adherence and competence scores with the variation and range from the four different participating professions. The
psychologists (n = 3) have the highest scores with a mean adherence score of 4.74 (SD = 0.24) and a mean competence score of 4.20 (SD = 0.29). The social workers (n
= 4) have the lowest scores with a mean for adherence of 3.29 (SD = 1.7) and a mean for competence of 3.27 (SD = 1.14). Analyzing the data with a one-way ANOVA no significant differences in adherence, F(3,11) = 1.63, p = .240, and competence, F(3,11) = 1.72, p = .220, between the different professions were found.
Table 4
Participants with various professions fare similarly well on measures of adherence and competence
M SD Minimum Maximum
Psychologists (n = 3)
Adherence 4.74 0.24 4.52 5.00
Competence 4.20 0.29 3.87 4.45
Social workers (n = 4)
Adherence 3.29 1.70 1.00 4.67
Competence 3.27 1.14 1.71 4.17
Occupational therapists (n = 5)
Adherence 3.53 0.57 3.00 4.25
Competence 4.03 0.14 3.90 4.27
Physiotherapists (n = 3)
Adherence 4.30 0.52 3.70 4.63
Competence 4.10 0.43 3.73 4.59
Scores of adherence and competence compared along early and late adopters. The mean score of the early adopters for adherence is 3.95 (SD = 1.33) and for competence 3.85 (SD = 0.89). The late adopters have similar scores, with a mean score of 3.76 (SD = 0.69) for adherence and 3.93 (SD = 0.44) for competence (Table 5). Differences between groups of early and late adopters were insignificant; t(13) = .34, p = .742, and t(13) = -.23, p = .821, respectively (independent samples t-tests).
Table 5
Early and late adopters fare similarly well on measures of adherence and competence.
M SD Minimum Maximum
Early adopters
Adherence 3.95 1.33 1.00 5.00
Competence 3.85 0.89 1.71 4.45
Late adopters
Adherence 3.76 0.69 3.00 4.67
Competence 3.93 0.44 3.13 4.59
Scores of adherence and competence compared along work experience with ACT. Table 6 summarizes the average adherence and competence scores of the three groups - junior, intermediate, and senior, categorized by their self-assessed work experience with ACT. There was neither a correlation found between the level of work experience with ACT and adherence (r = .13, p = .664) nor with competence (r = -.02, p = .952).
Table 6
Participants with varying amount of work experience with ACT fare similarly well on measures of adherence and competence
M SD Minimum Maximum
Junior (n = 7) Adherence 3.70 0.74 3.00 4.67
Competence 3.92 0.44 3.13 4.59
Intermediate (n = 6)
Adherence 4.01 1.50 1.00 5.00
Competence 3.83 1.05 1.71 4.45
Senior (n = 2) Adherence 3.96 0.79 3.40 4.52
Competence 3.94 0.09 3.87 4.00
Post Hoc Results. There were no correlations found between the competence to apply ACT processes and interventions flexibly depending on the client and the content of the session and the level of work experience (r = .26, p = .352) and being an early or late adopter t(13) = .43, p = .224. A summary of the average adherence and competence scores of the different subgroups is available in the Appendix A.
Discussion
The overall goal of this study was to support the development of a sufficient treatment of patients with chronic pain. As an alternative to the current chronic pain treatments, ACT was implemented in nine Dutch chronic pain rehabilitation centers. We
investigated if this implementation was performed successfully.
First, the existing scoring scheme of Scholten (2014) was reviewed and improved. Our resulting coding scheme uses a coding unit of one minute, adds a column to note the content of every minute, scores all three competences separately, does score one ACT process twice or more if the process is present longer than a minute, and is available as an spreadsheet file which automatically calculates the average scores of the adherence and competence scores.
Second, the treatment integrity of the participating professionals in working with ACT was analyzed. The general hypothesis, that participating professionals score above average on both adherence and competence, was confirmed. This leads to the conclusion that the implementation was successful. The participating
professionals, who received ACT training, are able to apply ACT. Furthermore, no significant differences between the various subgroups have been found. Participants with different professions do not seem to differ in their ability to apply ACT, and neither do early and late adopters. Additionally, the level of work experience does not seem to have influenced the ability to use ACT. This indicates that the
implementation is equally successful for all participating professionals. They are all able to use ACT sufficiently and independently from the time which the participants received treatment. This leads to the conclusion that if a small group of professionals from an institution is trained well, they can than train other professionals in their
institution without a noticeable loss in quality. Training a small group of professionals in ACT is thus a one-time investment.
Some points deserve further consideration. Contrary to our hypotheses, no differences were found in the competence of early and late adopters, in the
competence of different professions, and in the competence of professionals with varying amounts of work experience with ACT. To evaluate this outcome, the scoring approach of competence was examined. In the approach of scoring competence, we first scored three different competencies separately, and then calculated an average of all scores. This procedure might have had negative effect on the results. Taking a look at the competencies, we find that two out of three competencies are generic
competencies, as already introduced in the client-centered theory of Rogers (Rogers, 1957). ‘Rogerian’ psychotherapy is considered as a founding work in the humanistic school of psychotherapies which means most of professionals in the social work area studied his work during their education. The generic competencies are composed of first, the willingness to address difficult and problematic inner experience of the therapist and the client both during and outside the therapy session, and second, maintaining an equivalent therapeutic relationship. Non-generic and ACT specific is the third competency, which refers to the flexibility to use ACT processes and interventions depending on the client and the content of the session. Looking at the competencies separately leads us to the assumption that the scores on the ACT
specific competency might reflect the effect of the ACT training more accurately than the scores on the two generic competencies. On basis of this assumption, a post hoc analysis was performed to investigate if the scores on the ACT specific competency indicate differences between the scores of the subgroups, such as the amount of work experience or being an early or late adopter. We expected that both early adopters and
participants with a greater level of work experience would have greater scores on the ACT specific competency because they had more time to practice and use the specific characteristics belonging to this competency. Contrary to our hypothesis, no
significant differences were found. Reason for this might be the small amount of participating professionals, especially the lack of abundant number of participants with a great amount of work experience with ACT.
Furthermore, we decided to score competence in working with the ACT protocol even in instances where there is no ACT process present. In contrast, Waltz et al. (1993) and Plumb and Vilardaga (2010) state that adherence is necessary to be able to work competently with a protocol. Although, the approach of the final scheme is in contrast with the theory of Waltz et al. (1993), scoring competence worked well.
With the ACT competencies being similar to generic competencies and CBT specific competencies, adherence to the ACT protocol is not necessary to be able to score competence. Overall, further research is necessary to explore the competence scoring approach, with a special focus on the scoring of the third competency, because that is, in contrast to the other competencies, linked to the use of ACT processes.
Moreover, in contrast to our hypotheses, no difference was found between professions in the competence in working with ACT. Of all four analyzed professions, psychologists gathered probably the most experience with CBT’s, and in
multidisciplinary teams, psychologists were both expected to be the initiators of new therapeutic implementations or concepts (Brown & Folen, 2005), and expected to perform better in therapeutic sessions, in this case in applying ACT. An explanation why no significant differences between the professions were found might be that the used data do not distinguish between the different ACT processes. Therefore,
information on which of the processes the participating professions scored higher or
lower is missing. Trompetter, Schreurs and Heuts (2014) differentiated between the six different ACT processes in their study in the same implementation focusing on the subjective competence of the participating professionals. They found that at the end of the implementation, both early and late adopters rated their self-perceived
competencies adequate on almost all therapeutic processes, except on self as context and cognitive defusion. Those two processes show little overlap with generic
competencies as well as other processes of CBT’s and are thus more challenging to learn and use compared to ACT processes such as adherence or values (Trompetter, Schreurs, & Heuts, 2014). Therefore, it is conceivable that an analysis of the use of ACT processes could indicate differences in the ability of the different professions in operating with ACT. Further research on the competence in working with the
different ACT processes is necessary to obtain better insight into this context and to learn if the participating professionals need more support on some of the ACT processes.
Another point, which deserves consideration, is that given the limited number of participating professionals, statistical power was too small to detect existing differences. Due to practical limitations, more video recordings could not be analyzed. It is recommended to replicate this study with a greater number of participants to get more reliable results.
Even though the results are contrary to our hypothesis, they also unveiled intriguing results. The participating professionals were trained extensively for a lengthy period of time. The results lead as to the conclusion that the training seems to be sufficient and that the ‘train-the-trainer’ approach worked well.
Limitations
Some methodological limitations of this study need to be reviewed. First, the results cannot be controlled for inter-rater reliability. Due to practical limitations, the video recordings are scored only by one rater. It is important to calculate the inter- rater reliability to establish that the coders have been properly trained (Plumb and Vilardaga, 2010). At the same time, a high inter-rater reliability allows for
generalization of results and results in conclusion that the developed scheme is an objective method in scoring video recordings of participating professionals applying ACT (Kottner et al., 2011).
Second, the main data sources are ten minutes of video recording of one session per participating professional. In those video recordings the participating professionals show that they are competent in working with ACT. However, one video recording might not be representative of the adherence to the protocol during the entire therapy because the professionals could decided on when and under what circumstances the sessions were recorded (Nezu & Nezu, 2008; Plumb & Vilardaga, 2010). Furthermore, we may have to concede a ceiling effect. If all participants are trained sufficiently enough to work effectively with ACT, factors such as work experience and general education may become secondary. Each individual nearly reached the (here) maximum measurable scores on adherence and competence, and the results therefore, show no differences. This does not necessarily indicate that there are zero differences. A psychologist with a work experience of ten years will most likely score higher in extreme situations like dealing with an aggressive patient, than a social worker with one year of work experience. It shows that the currently used scheme did not set especially high standards. This is acceptable because the aim of the study was not to find differences but to investigate if the implementation was done
sufficiently. The ideal result was to have all participants obtain high scores, especially if the therapy will be found to have positive effects for the patients.
Third, a large variability is found in the assigned scores of the social workers, suggesting large intra-group differences in the ability to operationalize ACT greatly.
However we only analyzed a small group of social workers, with one social worker scoring much lower than the others. Analysis with a greater number of participants is recommended to investigate the higher level of intra-group difference among the social workers.
Future research
The overall goal was to develop a sufficient treatment for chronic pain patients to increase the treatment satisfaction and their overall well-being. We found all
participating professionals to be able to work sufficiently with ACT. The next step should be to investigate if the use of ACT is successful in increasing the treatment satisfaction and the well-being of the patients. It should be studied to see if the treatment sessions of all participating professionals had the same (positive) effect on the patients’ well-being. If differences between the participating professionals exist, they should be examined, even though there were not visible before due to the potential ceiling effect. Overall, if the study shows positive results, a change in the currently unsuccessful treatment of chronic pain patients is done.
Further research should be carried out to confirm if it is possible to improve the implementation and to make it even more effective. The qualities of a
multidisciplinary team should be better utilized, noting the varying expertise of different professions. The data show that the ACT processes acceptance and values are used more often than other such as the ACT processes cognitive defusion and present moment. We cannot conclude if some professionals avoid working with some
ACT processes because they experience difficulties applying them or vice versa. If this were the case, it should to be investigated to see if the ACT processes can be subdivided into different professions so that not every professional has to learn and be able to use every ACT process. Advantages would be a higher quality in all processes as well as a shorter mandatory training period, because not everybody has to learn all processes. Further research with a focus on the use of the different processes is necessary to give more insight into this context.
Further more, since no significant differences were seen between the ‘early adopters’ and ‘late adopters’ in the ability to work with ACT, it should be evaluated to determine if a shorter training period will show the same positive results.
Therefore, further implementation should be carried out with a difference in the training period to discover the shortest sufficient training period. Being able to apply a shorter training period would save time and make the training more efficient.
Additionally, the professional background in multidisciplinary teams is typically more varied than in the current study which features only four different professional backgrounds. Future research should take other professions into account to provide more insight into multidisciplinary teams applying ACT.
This study was one of the first to investigate treatment integrity of ACT in the area of chronic pain rehabilitation. The implementation of ACT was successful and can be carried out as described. Trained professionals were successful in working with ACT and in training other professionals in ACT. The application of the ‘train-the-trainer’
approach was successful which provides advantage for future systematic implementations over time. Further research is necessary to show if the ACT treatment has the expected positive influence on the functionality of chronic pain patients and if the high standard of the professionals in working with ACT can be maintained without retraining.
References
A-Tjak, J. (2009). Acceptance and Commitment Therapy: hoe nieuw taalgebruik kan bijdragen aan een rijker leven. Psychopraktijk, 1(4), 124–130.
doi:10.1007/BF03080455
A-Tjak, J., & De Groot, F. (2008). Acceptance and Commitment Therapy - Een praktische inleiding voor hulpverleners (pp. 1–133). Houten, Netherlands: Bohn Stafleu van Loghum.
Bekkering, G. E., Bala, M. M., Reid, K., Kellen, E., Harker, J., Riemsma, R., Huygen, F. J. P. M., et al. (2011). Epidemiology of chronic pain and its treatment in The Netherlands. The Netherlands journal of medicine, 69(3), 141–53. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21444943
Bohlmeijer, E., & Hulsbergen, M. (2009). Voluit leven (p. 187). Amsterdam:
Uitgevereij Boom.
Breivik, H., Collett, B., Ventafridda, V., Cohen, R., & Gallacher, D. (2006). Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment.
European journal of pain (London, England), 10(4), 287–333.
doi:10.1016/j.ejpain.2005.06.009
Brown, K. S., & Folen, A. F. (2005). Psychologists as Leaders of Multidisciplinary Chronic Pain Management Teams: A Model for Health Care Delivery.
Professional Psychology: Research and Practice, 36(6), 587–594.
doi:10.1037/0735-7028.36.6.587
Dahl, J., Wilson, K., & Nilsson, a. (2004). Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior Therapy, 35(4), 785–
801. doi:10.1016/S0005-7894(04)80020-0
Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological bulletin, 133(4), 581–624. doi:10.1037/0033- 2909.133.4.581
Hayes, S. C., Strohsahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy (2003rd ed.). New York: Guilford Press.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: model, processes and outcomes. Behaviour research and therapy, 44(1), 1–25. doi:10.1016/j.brat.2005.06.006
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and Commitment therapie (2nd ed., p. 456). Pearson Assessment and Information.
IASP Taxonomy Working Group. (2011). Pain Terms.
Kottner, J., Audige, L., Brorson, S., Donner, A., Gajewski, B. J., Hróbjartsson, A., Roberts, C., et al. (2011). Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed. International journal of nursing studies, 48(6), 661–71. doi:10.1016/j.ijnurstu.2011.01.016
Kratz, A. L., Davis, M. C., & Zautra, A. J. (2007). Pain acceptance moderates the relation between pain and negative affect in female osteoarthritis and
fibromyalgia patients. Annals of behavioral medicine!: a publication of the Society of Behavioral Medicine, 33(3), 291–301.
doi:10.1080/08836610701359860
Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT. An Acceptance &
Commitment Therapy. Skills-Training Manual for Therapists. Oakland: New Harbinger Publications, Inc.
McCracken, L. M., MacKichan, F., & Eccleston, C. (2007). Contextual cognitive- behavioral therapy for severely disabled chronic pain sufferers: effectiveness and clinically significant change. European journal of pain (London, England), 11(3), 314–22. doi:10.1016/j.ejpain.2006.05.004
McLeod, B. D., Southam-Gerow, M. A., & Weisz, J. R. (2009). Conceptual and Methodological Issues in Treatment, 38(4), 541–546.
Merriam-Webster. (2014). chronic. Merriam-Webster Dictionary. Retrieved January 24, 2014, from http://www.merriam-webster.com/dictionary/chronic
Nezu, A. M., & Nezu, C. M. (2008). Evidence-Based Outcome Research: A Practical Guide to Conducting Randomized Controlled Trials for Psychological
Interventions (1st ed., p. 512). New York: Oxford University Press.
Perepletchikova, F., Treat, T. A., & Kazdin, A. E. (2007). Treatment integrity in psychotherapy research: analysis of the studies and examination of the associated factors. Journal of consulting and clinical psychology, 75(6), 829–41.
doi:10.1037/0022-006X.75.6.829
Plumb, J. C., & Vilardaga, R. (2010). Assessing Treatment Integrity in Acceptance and Commitment Therapy": Strategies and Suggestions, 6(3), 263–295.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of consulting psychology, 21, 95–103.
Scholten, E. (2014). Acceptance and Commitment Therapy ( ACT ) in de praktijk.
University of Twente, Enschede.
Southam-Gerow, M. A., & McLeod, B. D. (2013). Advances in Applying Treatment Integrity Research for Dissemination and Implementation Science": Introduction to Special Issue, 1–13.
Trompetter, H. R., Schreurs, K. M. G., & Heuts, P. H. T. G. (2014). The systematic implementation of Acceptance & Commitment Therapy ( ACT ) in Dutch multidisciplinary chronic pain rehabilitation. University of Twente, Enschede.
Tsang, A., Von Korff, M., Lee, S., Alonso, J., Karam, E., Angermeyer, M. C., Borges, G. L. G., et al. (2008). Common chronic pain conditions in developed and
developing countries: gender and age differences and comorbidity with depression-anxiety disorders. The journal of pain!: official journal of the American Pain Society, 9(10), 883–91. doi:10.1016/j.jpain.2008.05.005 Turk, D. C., Wilson, H. D., & Cahana, A. (2011). Treatment of chronic non-cancer
pain. Lancet, 377(9784), 2226–35. doi:10.1016/S0140-6736(11)60402-9 Veehof, M. M., Oskam, M.-J., Schreurs, K. M. G., & Bohlmeijer, E. T. (2011).
Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis. Pain, 152(3), 533–42. doi:10.1016/j.pain.2010.11.002 Veehof, M., Schreurs, K., Hulsbergen, M., & Bohlmeijer, E. (2010). Leven met pijn
(3rd ed., p. 229). Amsterdam: Uitgevereij Boom.
Vowles, K. E., McNeil, D. W., Gross, R. T., McDaniel, M. L., Mouse, A., Bates, M., Gallimore, P., et al. (2007). Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain. Behavior therapy, 38(4), 412–25. doi:10.1016/j.beth.2007.02.001
Vowles, K. E., Wetherell, J. L., & Sorrell, J. T. (2009). Targeting Acceptance, Mindfulness, and Values-Based Action in Chronic Pain: Findings of Two Preliminary Trials of an Outpatient Group-Based Intervention. Cognitive and Behavioral Practice, 16(1), 49–58. doi:10.1016/j.cbpra.2008.08.001
Waltz, J., Addis, M. E., Koerner, K., & Jacobson, N. S. (1993). Testing the integrity of a psychotherapy protocol: assessment of adherence and competence. Journal of consulting and clinical psychology, 61(4), 620–30. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/8370857
Wetherell, J. L., Afari, N., Rutledge, T., Sorrell, J. T., Stoddard, J. a, Petkus, A. J., Solomon, B. C., et al. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain, 152(9), 2098–107. doi:10.1016/j.pain.2011.05.016
Wicksell, R. K., Olsson, G. L., & Hayes, S. C. (2010). Psychological flexibility as a mediator of improvement in Acceptance and Commitment Therapy for patients with chronic pain following whiplash. European journal of pain (London, England), 14(10), 1059.e1–1059.e11. doi:10.1016/j.ejpain.2010.05.001
Appendix
Appendix A Table 1
Summary of relevant background factors of participating professionals Bethesda
(n = 4)
Roessingh (n = 5)
Rijndam (n = 6)
Total (N = 15) Professionals
Female 4 4 4 12
Male 0 1 2 3
Mean age 44.75
(SD = 7.14)
52.40 (SD = 10.64)
37.67 (SD = 13.37)
44.47 (SD = 12.23) Mean years
Profession 12.25 (SD = 3.59)
11.75 (SD = 6.65)
9.4
(SD = 6.66) 11
(SD = 5.55) Kind of profession
Psychologist 1 2 0 3
Occupational therapists
2 1 2 5
Physiotherapist 0 1 2 3
Social Worker 1 1 2 4
Implementation group
Early adopter 3 2 3 8
Late adopter 1 3 3 7 Self-assessment: level of
work experience with ACT at beginning of implementation
Junior 1 2 4 7
Intermediate 3 1 2 6
Senior 0 2 0 2
Table 2
Analyzed video recordings with associated ID-Codes
Video recording ID-Code
1. Roessingh06 610
2. Bethesda1 103
3. RijndamV05 807
4. Bethesda3 105
5. RijndamV07 809
6. Roessingh03 616
7. Roessingh01 618
8. Bethesda4 104
9. Roessingh10 609
10. Roessingh09 619
11. RijndamV01 803
12. Bethesda2 108
13. RijndamV04 806
14. RijndamV03 805
15. RijndamV02 804
Table 7
Descriptive statistics of the third competence ‘Degree of flexibility to use ACT processes and interventions depending on the client and the content of the session’
and the subgroups
M SD Minimum Maximum
Psychologist (n = 3)
3.73 0.55 3.10 4.10
Occupational therapists (n = 5)
4.31 0.27 4.00 4.70
Physiotherapists (n = 3)
2.67 1.44 1.00 3.50
Social Workers (n = 4)
3.90 0.34 3.40 4.11
Early adopter (n = 8)
3.86 0.47 3.10 4.43
Late adopter (n = 7)
3.64 1.22 1.00 4.70
Junior (n = 7)
3.60 1.18 1.00 4.43
Intermediate (n = 6)
3.74 0.47 3.10 4.25
Senior (n = 2)
4.35 0.50 4.00 4.70
Codeer- en scoorschema voor ACT consistent handelen van professionals tijdens de behandeling van chronische pijn in Nederlandse revalidatiecentra
Video-opnames zullen de eerste 10 minuten bekeken en gescoord worden, waarbij de opname iedere minuut gepauzeerd word om te scoren. Hierbij loopt de 1e minuut van 0.00 tot 1.00 seconden, de 2e minuut van 1.01 tot 2.00 en zo verder. Mocht blijken dat hetgeen de therapeut zegt of doet behorende tot een ACT interventie of competentie doorloopt in de volgende minuut, dan geeft men met de woorden “scoring loopt door”
aan dat men meerdere minuten achter elkaar bekijkt en scoort.
De volgorde waarin men de video-opname scoort is als volgt; 1. Geef aan om welk(e) ACT-kernproces(sen) het gaat (acceptatie en bereidheid, cognitieve defusie, hier-en- nu, zelf-als-context, waarden en/of toegewijde actie). Dit wordt genoteerd door het betreffende ACT kernproces volledig uit te schrijven. Wanneer er echter geen ACT- kernproces aanwezig is noteert men ‘n.v.t.’. 2. Scoor de mate van ‘adherence’.
Wanneer men echter heeft aangegeven dat er geen ACT-kernproces aanwezig is, dan kan men ook geen score geven op ‘adherence’. 3. Scoort de mate van ‘competence’, dit is mogelijk ongeacht of men eerder heeft aangegeven dat er geen ACT- kernproces aanwezig is. 4. Geef een over-all score over de mate van ‘adherence’ en ‘competence’
gedurende de gehele video-opname.
Adherence
Bij ‘adherence’ wordt er gekeken naar de mate waarin ACT interventies behorende tot het behandelmodel en het ACT kernproces uitgevoerd worden. Scoring verloopt via een Likertschaal --/-/+-/+/++ (- - interventie helemaal niet passend bij ACT kenproces /++ interventie helemaal passen bij ACT kernproces).
Voorbeelden van ACT interventies
(uitgaande van het boek ‘Leven met pijn’ (Veehof et al., 2010) en ratinglijst (Plumb
& Vilardaga, 2010).
• Acceptatie en bereidheid
- Metaforen ‘Gevangene met loden kogel’ en/of ‘Ongewenste gast’
- Oefening leed op kaartjes en met je meedragen
- In welke mate faciliteerde de therapeut bij de cliënt de bereidheid om contact te maken met moeilijke gevoelens, gedachten, herinneringen en lichamelijke sensaties en deze de accepteren zowel tijdens als buiten de behandeling/sessies?
- In welke mate hielp de therapeut de cliënt om zijn/haar gevoelens of lichamelijke sensaties gerelateerd aan huidige problemen te
onderzoeken?
- In welke mate faciliteerde de therapeut opmerkzaamheid en bewustzijn van de huidige ervaringen bij de cliënt?
- In welke mate moedigde de therapeut de cliënt aan om moeilijke gevoelens, gedachten, herinneringen of lichamelijke sensaties te ervaren in het dagelijks leven buiten de behandeling/sessies?
• Cognitieve defusie
- Metafoor ‘De muppet-show’
- Afscheid nemen van ‘maren’ en excuses
- In welke mate gebruikte, leerde of herinnerde de therapeut de cliënt om taal te gebruiken om de cliënt te helpen herinneren dat gedachten en gevoelens gewoon gedachten en gevoelens zijn en niet de realiteit?
- In welke mate identificeerde de therapeut dat een gedachte/gevoel van de cliënt niet ertoe lijdt dat een cliënt zich op een bepaalde manier gedraagt?
- In welke mate faciliteerde de therapeut bij de cliënt het gevoel van zelf-bewustzijn of identificatie met de context waarin hun gedachten en gevoelens gebeuren (het observerende zelf)? behoort ook tot zelf- als-context
• Hier-en-nu
- Mindfulness-oefeningen (ademhaling, bodyscan)
• Zelf-als-context
- Metafoor ‘De hemel’
- Onderscheid maken tussen observerend en denkend zelf
• Waarden
- Formuleren van waarden op verschillende levensgebieden - Metafoor ‘Ladder tegen de verkeerde muur’
- In welke mate hielp de therapeut de cliënt om zijn/haar waarden en doelen behorende tot deze waarden te bespreken?
• Toegewijde actie
- Oefening en metafoor ‘De roos’
- Doelen stellen en acties bepalen
- In welke mate moedigde de therapeut de cliënt aan om zijn/haar commitments op te stellen en zich eraan te houden tijdens alle aspecten van zijn/haar leven?
Competence
Bij ‘competence’ wordt er gekeken naar de mate van technische en relationele ACT competenties of vaardigheden die de therapeut bezit en toepast tijdens de
behandeling. Scoring verloopt voor iedere competentie afzonderlijk via een
Likertschaal --/-/-+/+/++ ( - - helemaal niet volgens ACT competenties / ++ helemaal volgens ACT competenties). Hierbij dient aangegeven te worden om welke
competentie(s) het gaat, dit doet men door het cijfer voor de betreffende competentie te noteren, vervolgens noteert men hier de gegeven score achter.
ACT competenties
Competentie 1: De bereidheid om moeilijke en problematische innerlijke ervaringen (gedachten/gevoelens/ herinneringen/lichamelijke sensaties) zowel van de therapeut als van de cliënt bespreekbaar te maken er te laten zijn zowel binnen als buiten de behandeling.
Competentie 2: Een gelijkwaardige therapeutische relatie.
Competentie 3: Flexibele toepassing van ACT processen/interventies afhankelijk van de context en cliënt, zodat er ruimte ontstaat om te ervaren in plaats van er alleen over
te spreken.
Minute Extent of adherence --: Not according to ACT interventions appropriate to core process
-: A little bit according to ACT interventions appropriate to core processes
-/+: Somewhat according to ACT interventions
appropriate to core processes
+: Considerably according to ACT interventions appropriate to core processes
++: Completely according to ACT interventions appropriate to core process
Extent of competence --: Not according to ACT competences -: A little bit according to ACT competences -/+: Somewhat according to ACT competences +: Considerably according to ACT competences ++: Completely according to ACT competences
Specify the
competence(s) involved and give a score for each competence.
What ACT core
proces(ses)?
(Acceptance, Cognitive defusion, Contact with the present moment, Self-as- context, values, committed action)
1 2 3 4
5 6 7 8 9 10
Overall score whole video
Figure 2. Empty basis-coding scheme developed by Scholten (2014), with ++ being the same as 5 and -- being the same as 1.
Final coding scheme
Figure 3. Final coding scheme
Appendix C
The questionnaire the participating professionals filled in the beginning of the implementation and thus before the start of their ACT training:
Beste professional,
We willen u vragen de volgende vragenlijst in te vullen. De vragenlijst wordt aangeboden aan alle professionals die deelnemen aan de implementatie van ACT in de pijnrevalidatie. Er wordt hierbij geen onderscheid gemaakt tussen mensen die nu al ACT (gaan) toepassen of dit pas later in de implementatie gaan doen. Ook als u op dit moment nog geen ACT toepast is het dus belangrijk dat u de vragenlijst invult. De vragenlijst gaat over uw scholing en ervaring (algemeen & specifiek voor ACT), uw therapeutische vaardigheden in ACT en over verschillende factoren die een rol kunnen spelen bij de implementatie.
Deze vragenlijst ontvangt u aan het begin van de implementatie in uw instelling. Op twee andere momenten, later dit jaar, krijgt u opnieuw een vragenlijst. Dit zal halverwege (over ongeveer een half jaar) en aan het einde (over ongeveer een jaar) van het implementatietraject zijn. Door de vragenlijst meerdere malen af te nemen kunnen we de ontwikkelingen in de implementatie in kaart brengen.
Het invullen van de vragenlijst neemt ongeveer 50 minuten in beslag. Het is in het belang van het onderzoek dat u de vragenlijst zo waarheidsgetrouw mogelijk invult.
Het is de bedoeling dat u per vraag één antwoord kiest, tenzij anders vermeld staat.
Ook willen we u vragen de vragenlijst, wanneer u eenmaal begonnen bent, in één keer in te vullen. De ingevulde vragenlijsten worden vertrouwelijk behandeld en
geanonimiseerd verwerkt. Geen van uw collega’s of leidinggevenden zal de ingevulde vragenlijst te zien krijgen. Er zijn geen goede of foute antwoorden.
Alvast hartelijk dank voor het invullen!
Vriendelijke groet,
Hester Trompetter (Psycholoog/Onderzoeker Roessingh Research and Development
& Universiteit Twente)
Karlein Schreurs (GZ-Psycholoog het Roessingh Revalidatiecentrum & onderzoeker Universiteit Twente
Algemene gegevens
Allereerst willen we u vragen enkele algemene gegevens in te vullen. Uw naam zal voor verwerking van de gegevens worden omgezet in een cijfercode, die enkel door de hoofdonderzoeker naar u te herleiden is.
Algemeen
1) Naam ………
2) Leeftijd ………… jaar 3) Geslacht 0 man
0 vrouw
4) Datum van invullen ... / ………. / ………...
Professioneel
5) In welke instelling werkt u?
………
6) Tot welke van de volgende groepen in de implementatie behoort u?
0 Trekker (u behoort tot een team binnen uw instelling dat de cursus ‘ACT bij pijnteams’ heeft gevolgd)
0 Volger (u behoort tot een team dat ACT zal gaan toepassen, nadat u scholing van collega’s hebt ontvangen)
0 Weet ik niet
7) Wat is uw functie?
0 Revalidatiearts 0 Psycholoog 0 Ergotherapeut 0 Fysiotherapeut
0 Maatschappelijk werker 0 Verpleegkundige 0 Sportdeskundige 0 Arbeidsdeskundige 0 Agogisch werker
0 Anders, namelijk ………
8) Staat u geregistreerd in het BIG-register? 0 Ja
0 Nee
9) Staat u geregistreerd in een Kwaliteitsregister van uw beroepsgroep?
0 Ja
0 Nee
10) In welk jaar bent u afgestudeerd? ………
11) Hoe lang bent u werkzaam als professional in de pijnrevalidatie?
... jaar
12) Hoe lang bent u werkzaam in uw huidige functie? ………….. jaar
13) Hieronder onderscheiden we drie ‘categorieën van deskundigheid’. Tot welke vindt u zichzelf behoren binnen uw eigen functiegebied?
0 Junior (starter, weinig ervaring)
0 Medior (nog niet geheel volleerd, enkele ervaring) 0 Senior (een expert, veel ervaring)
A. ACT: Scholing en ervaring
Hieronder stellen we u enkele vragen die specifiek over ACT gaan. De vragen gaan voornamelijk over eventuele scholing in ACT en uw (werk)ervaring met ACT.
14) Hoe lang geleden hebt u voor het eerst kennis gemaakt met ACT?
0 In de laatste 6 maanden 0 6 tot 12 maanden geleden 0 1 tot 2 jaar geleden 0 2 tot 3 jaar geleden 0 3 tot 5 jaar geleden 0 5 tot 7 jaar geleden 0 langer dan 7 jaar geleden
15) Hebt u de cursus ‘ACT voor Pijnteams’ (van Peter Heuts en Karlein Schreurs) gevolgd?
0 Ja 0 Nee
0 Gedeeltelijk
16) Hebt u (naast de cursus ‘ACT voor pijnteams’) andere cursussen, workshops, en/of bijeenkomsten (die u als scholing beschouwt) in ACT gevolgd, die minstens 1 dagdeel duurden? Het gaat hierbij niet om intervisies of andere uren ter kennisdeling met collega’s.
0 Ja (beantwoordt ook 16a) 0 Nee (ga door naar 17)
16a) Hoeveel dagdelen heeft u in totaal deelgenomen aan dergelijke cursussen, workshops of andere vormen van scholing in ACT (naast de cursus ‘ACT voor pijnteams’)?
0 Minder dan 1 dagdeel 0 1 – 2 dagdelen
0 2 – 4 dagdelen 0 4 – 6 dagdelen 0 6 – 8 dagdelen 0 8 – 10 dagdelen 0 10 – 12 dagdelen 0 Meer dan 12 dagdelen
17) Hoeveel boeken over ACT hebt u gelezen?
0 Geen boeken 0 1 boek 0 2 boeken 0 3 boeken 0 > 3 boeken
18) Hebt u andere vormen van literatuur over ACT gelezen (artikelen, stukken in vakbladen etc)?
0 Ja 0 Nee
19) Kunt u (bij benadering) aangeven welk aandeel van uw wekelijkse behandeltijd u op dit moment ACT toepast of gebruik maakt van ACT?
0 0 – 20%
0 20 – 40%
0 40 – 60%
0 60 – 80%
0 80 – 100%
20) Hieronder onderscheiden we opnieuw drie ‘categorieen van deskundigheid’.
Tot welke vindt u zichzelf behoren als ACT-professional, binnen uw eigen beroepsgroep?
0 Junior (starter, weinig ervaring)
0 Medior (nog niet geheel volleerd, enkele ervaring) 0 Senior (een expert, veel ervaring)
B. Factoren die een rol kunnen spelen in de implementatie
Hieronder staan uitspraken over factoren die - in meer of mindere mate - betrekking hebben op de implementatie van ACT. We willen u vragen bij iedere uitspraak aan te geven in hoeverre u het op dit moment met die uitspraak eens bent. We gaan er van uit dat u ook een mening hebt over (de meeste van) onderstaande uitspraken wanneer u ACT nog niet toepast. Wanneer het nodig is kunt u de optie 'niet van
toepassing/weet niet' aankruisen.
Uzelf & ACT mee
oneens
beetje mee oneens
niet mee oneens/ni et mee
eens
beetje mee eens
mee eens
n.v.t./
weet niet
Ik ben enthousiast over ACT als behandelvorm binnen de
pijnrevalidatie.
0 0 0 0 0 0
Het toepassen van ACT levert me meer werkdruk op.
0 0 0 0 0 0
Ik zie ACT als een zinvolle aanvulling op de bestaande vormen van therapie.
0 0 0 0 0 0
Het toepassen van ACT is mij opgelegd.
0 0 0 0 0 0
Ik voel me betrokken bij de invoering van ACT in onze instelling.
0 0 0 0 0 0
Ik vind het moeilijk om ACT uit te voeren.
0 0 0 0 0 0
De visie achter ACT sluit goed aan bij mijn professionele ideeën over pijnrevalidatie.
0 0 0 0 0 0
ACT sluit goed aan bij de taken die ik heb binnen mijn
behandelteam.
0 0 0 0 0 0
Uw omgeving & ACT mee oneens
beetje mee oneens
niet mee oneens/ni et mee
eens
beetje mee eens
mee eens
n.v.t./
weet niet
Ik voel me gesteund door mijn directe collega’s in het uitvoeren van ACT.
0 0 0 0 0 0
Ik voel me gesteund door het 0 0 0 0 0 0
