Using ACT self-help manual with depression: experiences and observations Raimo Lappalainen Anna Granlund Aino Kohtala Department of Psychology University of Jyväskylä, Finland Depressioprojekti toteutettu keväällä 2010 Aiempia projekteja ollut edeltävinä vuosina Projektit olleet monen opinnäytetyön aiheena Aino Kohtala valmistelee aiheesta väitöskirjaa 1

Introduction Depression is one of the most common psychological problems. In Finland, the prevalence of at least moderate depressive episodes within the last 12 months is about 4% among men, and 8% among women. Overall, to our knowledge, few studies have examined the effects of brief interventions delivered by novice therapists using self-help manuals

The aim The purpose of this study was to increase our knowledge of using self-help manuals in brief ACT interventions delivered by psychology students.

Method Clients Newspaper advertisement: 59 contacted the clinic  44 interviewed by phone 36 started, 30 completed to Post-measurements Criterias: Self-reported mood problems No other treatments Henkilöt hoitoon ja tutkimukseen hankittiin lehti-ilmoituksella Keskisuomalaisessa. Kiinnostuneita oli paljon, enemmän kuin olisi ollut mahdollista hoitaakaan, joten esihaastattelut tutkimuskriteerien tarkistamiseksi tehtiin vain osalle. 15.4.2017 anna.a.granlund@jyu.fi 4

Method 30 subjects reporting depressive symptoms were treated either by 6-week ACT treatment alone or with 6-week ACT treatment combined with self-help manual (Get Out of Your Mind).

The self-help manual Get Out of Your Mind & Into Your Life Steven C. Hayes & Spencer Smith (2009) Translated into Finnish 6

Clients (n=30) Women = 21 (70 %), men = 9 (30 %) Age mean = 49 years No psychiatric diagnoses = 60 % Depression diagnoses = 27 % No prior psychotherapy = 70% No medication for depression = 73 % Hoitoon hakeutuneista henkilöistä enemmistö oli naisia. Keski-ikä asettui noin 49-50 vuoden tienoille, mutta mukana oli ihmisiä aina 20-kymppisistä 70-kymppisiin. Suurimmalla osalla ei ollut mielenterveysdiagnooseja, ei lääkitystä, eivätkä olleet aiemmin hakeneet keskusteluapua masennukseen.

The therapists N = 15 master’s level psychology students (women/men 14/1) Mean age = 25-years (SD=4.20; vaihteluväli 22–37) Mean time for psychology studies = 4.13; SD=1.06; range 2–6) Training CBT = 10 hours, ACT = 14 hours Manual in ACT (Lappalainen ym., 2009 including 32 metaphors ja 18 exercises) Supervision every week

Intervention Case formulation, value work, exercises, for example, mindfulness exercises, the observer exercise, metaphoras (during every session), home work Student therapist treated one client with the manual and one without The therapists in the manual group were instructed to use three Chapters: Introduction, Human Suffering and What Are Values? Rest of the manual was used individually Terapian alussa tehtiin käyttäytymisanalyysi, kuva, jossa asiakkaan esille tuomia asioita ja niiden keskinäisiä vuorovaikutussuhteita voidaan tarkastella. Menetelmät: keskustelua asiakkaan esille tuomista asioista, kotitehtäviä kuten konkreettisia tekoja jotka ovat linjassa asiakkaan arvojen kanssa, metaforia eli kielikuvia, joilla asioita voidaan tarkastella ja hahmottaa uudella tavalla, ja harjoituksia, esimerkiksi hengityksen seuraaminen Tämä oli siis hoidossa käytetty terapiamenetelmä. Seuraavaksi enemmän asiakkaista, tutkimuksen tekemisestä ja tuloksista. 9

Method Pre-Post measurements presented Time between Pre-Post: 6-8 weeks Therapists recorded after every session if they had worked with a particular ACT core prosess

Results Both treatments showed significant symptom improvement. But there were no clear differences between the groups. The majority of the students reported that the manual is useful part of the treatment, but only about half of the students estimated that the client had benefitted of the manual.

Pre-Post ACT+Manual (n=14) ACT (n=16) Pre Post BDI 22.79 (8.07) 22.79 (8.07) 10.64 (6.73)*** 19.75 (8.40) 7.88 (6.29)*** AAQ-II 34.86 (9.02) 45.21 (11.80)** 40.19 (7.80) 50.87 (10.21)*** KIMS 113.00 (9.59) 122.79 (15.05)* 117.56 (13.45) 130.12 (11.81)** BAI 16.21 (8.75) 11.86 (10.28) 13.94 (9.13) 7.81 (6.86)** SCL-90 1.17 (0.41) 0.71 (0.42)** 1.01 (0.47) 0.47 (0.36)** Social funct 32.29 (7.26) 36.57 (7.15)* 33.81 (7.98) 41.38 (7.30)** SelfConfid 46.14 (15.02) 55.21 (17.34) 55.53 (14.53) 71.13 (16.03)** Satisfaction 39.71 (14.90) 57.00 (18.32)** 51.07 (20.15) 70.47 (18.60)** Mood 32.93 (13.29) 53.79 (19.39)** 43.19 (21.67) 64.19 (19.51)** ***p< .001, **p <.01, *p <.05 12

Depression (BDI) change over time ACT ACT+Manual

Relationships between treatment change and ACT core processes In the ACT+manual group the change in depression scores during the treatment correlated significantly (ρ = .73) with how often mindfulness skills had been addressed The change in anxiety level was correlated with how often defusion skills had been addressed (ρ = .63) Change in mindfulness skills (KIMS) correlated with how often being present skills (mindfulness) had been addressed (ρ= .54) These relationships were observed in the ACT+manual group only Terapeutti kirjannut menetelmäpäiväkirjaan kun käsitellyt jotain prosessia Jokainen ydinprosessi poimittu kustakin päiväkirjasta 0-1: onko käsitelty vai ei Kunkin ydinprosessin maksimiarvo on siis ollut 6 = yhtä kuin tapaamisten määrä

Use of the manual According to the therapists, 43 % of the clients had completed weekly homework assignments from the manual 36 % had seldom completed homework assignments 43 % of therapists reported that they had used the book relatively seldom during the sessions

Impact of the manual There were 236 pages in the manual Of which the clients in the ACT+manual group read 133 pages Reading the manual was positively associated with the change in psychological symptoms (ρ= .59, p=0.03), depression (ρ= .50, p=0.07), anxiety (ρ= .51, p=0.06), and social functioning (ρ=.68, p=0.01).

Experiences of using the manual 88 % of the clients felt that the manual had been a useful part of their treatment 86 % of the therapists reported that practical therapy worked better with the manual than without it Clients were able to study once more topics addressed in sessions, but the manual also gave support to the therapists Those clients who actually had used the manual actively were also satisfied with it

Conclusions In general, 40-50 % of the clients and of the student therapist used the manual actively during the treatment. Active manual use was associated with better treatment outcome There were some indications that the processes of change were different when the manual was used or the therapists observed the core processes differently This study suggests that Master’s level psychology students and their clients may benefit of the use of the manual, but use should be planned carefully