1. Jeanie Stafford-Brown & Kenneth Pakenham School of Psychology The University of Queensland Brisbane, Australia

2.  Elevated levels of stress in mental health professionals ◦ Clinical psychologists 29 - 74% (eg. Cushway et al, 1996; Gilroy et al, 2001; Guy et al, 1989) ◦ Trainee clinical psychologists 75% - (eg. Cushway, 1992)  Excessive stress can negatively impact personal and professional functioning and result in less than optimal standards of care for clients  Dearth of empirical studies on stress in trainee clinical psychologists, and there is no published intervention research  Mindfulness-based interventions have been efficacious in similar populations e.g., med students, student counsellors

3.  To evaluate the efficacy of a group ACT stress management intervention for post- graduate clinical psychology interns in: ◦ reducing stress and enhancing adjustment ◦ fostering therapist characteristics associated with better therapy outcomes

4. 1. Relative to a control group ACT intervention participants would report greater improvements in: ◦ Adjustment outcomes  stress  psychological distress  life satisfaction ◦ Therapist qualities  self-compassion  self-efficacy  therapeutic alliance ◦ ACT process variables  acceptance and action  mindfulness  defusion  valued living 2. That changes in adjustment outcomes and therapist qualities, would be mediated by changes in some or all of the ACT processes

5. A non-randomised controlled trial with repeated measures ConditionPre-treatment assessment InterventionPost-treatment assessment 10-week follow-up ACT Intervention (2 universities) n = 28 n = 27n = 26 Control (2 universities) n = 28

6.  56 students from Australian Psychological Society accredited clinical post-graduate training programs at 4 universities in South East Queensland  Inclusion criterion = current enrolment in the internship component of their degree  No exclusion criteria  Characteristics: ◦ Gender: 49 females; 7males ◦ Age: mean = 28.5 years (SD = 8.3; range = 21 to 52) ◦ Relationship status: 70% single ◦ Degree enrolled in:  57% masters degree  29% doctorate  14% PhD ◦ Full-time study = 95% ◦ 86% had completed their undergraduate studies in Queensland

7.  Adjustment Outcomes ◦ Stress Scale for Mental Health Professionals (MHPSS; Cushway & Tyler, 1996) ◦ General Health Questionnaire – 28 (Goldberg, 1981) ◦ Satisfaction With Life Scale (SWLS; Diener et al, 1985)  Therapist Qualities ◦ Working Alliance Inventory-therapist version (WAI-SF; Horvath, 1991) ◦ Self-Compassion Scale (SCS; Neff, 2003) ◦ Counselor Activity Self-Efficacy Scales (CASES; Lent et al, 2003) 

8.  ACT Processes ◦ Five Facet Mindfulness Questionnaire (FFMQ; Baer et al, 2006) ◦ Acceptance and Action Questionnaire (AAQ; Hayes et al, 2004) ◦ Valued Living Questionnaire (VLQ; Wilson & Groom, 2002) ◦ White Bear Suppression Inventory (WBSI; Wegner & Zanakos, 1994)  Social Validation of the Intervention ◦ 14 forced choice – for example:  whether personally and professionally useful  whether participation increased their interest in ACT  whether they had improved in the six core ACT processes  whether they would recommend the intervention to other students whether it should be offered each year to new students ◦ 6 open-ended – for example:  challenging aspects of the intervention  would they continue to use ACT strategies/processes personally or professionally  should ACT be included in clinical training

9.  Aims to: ◦ build rapport ◦ provide a brief overview of ACT ◦ undermine the effectiveness of experiential avoidance tactics ◦ illustrate that regarding thoughts and emotions, control is the problem, not the solution ◦ present willingness as the alternative to experiential avoidance ◦ introduce mindfulness as a willingness strategy  Strategies: ◦ brief overview of ACT and RFT ◦ identify signs of stress and strategies used to deal with them ◦ explore effectiveness of these strategies in the short- and long-term ◦ The Man-in-the-Hole Metaphor (Hayes et al, 1999) ◦ Chinese Handcuffs Metaphor (Hayes et al, 1999) ◦ The Rule of Private Events (Hayes et al, 1999) ◦ Polygraph Metaphor (Hayes et al, 1999) ◦ The Chocolate Cake Exercise (Hayes et al, 1999) ◦ The Two Scales Metaphor (Hayes et al, 1999) ◦ Quicksand Metaphor (Hayes & Smith, 2005) ◦ mindfulness of breathing exercise (Harris, 2007) ◦ informal mindfulness exercises ◦ indentify “stress buttons” (triggers of stress) (Bond & Hayes, 2002)

10.  Between Session Practice: ◦ Notice how cognitive avoidance and cognitive struggle amplifies or helps maintain the stress process, when your “stress buttons” have been pressed (Bond & Hayes, 2002) ◦ Practice mindfulness of breathing from CD once every day ◦ Do one “informal” mindfulness activity daily

11.  Aims to: ◦ Broaden repertoire of mindfulness exercises ◦ build willingness/acceptance by defusing language ◦ foster contact with the “observing self” & undermine attachment to conceptualised self  Strategies: ◦ Guided mindfulness ◦ Body Scan (Walser & Westrup, 2007) ◦ Participants instruct facilitator how to walk from chair to door - response to each instruction “how do I do that” (Luoma et al, 2007) ◦ Milk, Milk, Milk Exercise (Hayes et al, 1999) ◦ twinkle, twinkle, little ……. (Hayes & Smith, 2005) ◦ What are the Numbers Exercise (Hayes et al, 1999) ◦ Passengers on the Bus Metaphor (Hayes et al, 1999) ◦ defusion techniques discussed and practiced ◦ Leaves on a Stream Exercise (Hayes & Smith, 2005) ◦ Bad Cup Metaphor (Hayes et al, 1999) ◦ substituting self-referential uses of the word “but” with “and” (Hayes et al, 1999) ◦ Chessboard Metaphor (Hayes et al, 1999) ◦ Observer Exercise (Hayes et al, 1999)

12.  Between Session Practice: ◦ Practice “Leaves on a Stream” track 4 on CD (12 mins) and “The Observing Self” track 5 on CD (15 mins) by alternating each day ◦ Experiment daily with other defusion techniques outlined in handout

13.  Aims to: ◦ promote willingness of difficult internal events ◦ clarify values as chosen life directions ◦ identify and undermine barriers to values-based action ◦ link willingness & values-based action  Strategies: ◦ Passengers on the Bus Metaphor ◦ Tin Can Monster Exercise (Hayes & Smith, 2005) ◦ Eulogy Exercise (Bond, 2004) ◦ Values Worksheet ◦ Values Assessment Rating Form ◦ The Bubble in the Road Metaphor (Hayes et al, 1999)  Homework: ◦ Practice the Tin Can Monster Exercise from CD daily using the stress buttons identified in session 1 ◦ Continue daily practice of defusion techniques and “informal” mindfulness ◦ Reflect on values

14.  Aims to: ◦ identify values as a therapist ◦ identify value-directed goals, and related barriers ◦ highlight the experiential qualities of applied willingness, and the nature of commitment ◦ understand the link between willingness and commitment ◦ introduce the notion of self-compassion, and highlight its relevance to self- care and the ACT therapeutic stance ◦ bring it all together  Strategies: ◦ Guided mindfulness exercise ◦ Identifying Your Values as a Therapist Exercise (Luoma et al., 2007) ◦ The Bubble in the Road Metaphor revisited (Hayes et al, 1999) ◦ Goals Actions & Barriers Form completed (Hayes et al, 1999) ◦ The Joe the Bum Metaphor (Hayes et al, 1999) ◦ The Jump Exercise (Hayes et al, 1999) ◦ Swamp Metaphor (Hayes et al, 1999) ◦ Self-compassion introduced - Loving Kindness Meditation (Harris, 2007) ◦ FEAR and ACT algorithms (Hayes et al, 1999)

15. Clinical background% n Counselling/therapy exp Meditation training Current meditation practice None Very occasional Once per week Training in MBSR Training in MBCT Training in DBT Training in ACT 50 25 63 31 6 21 6 4 9 28 14 34 17 3 12 3 2 5

16.  Satisfaction with clinical training (5-point response scale - 1 “totally dissatisfied” to 5 “totally satisfied”) ◦ Mean = 3.60 (SD =.80; range 1 - 5)  At Pre-treatment ‘Caseness’ Levels using GHQ (cut-off score of ≥ 5) = 73%

17. Adjustment outcomes Relative to the control group the intervention group reported lower:  Stress  Psychological distress (Somatic symptoms) Therapist characteristics & therapeutic alliance Relative to the control group the intervention group reported greater improvements in:  Self-compassion (overidentification)  Self-efficacy (insight skills)  Therapeutic alliance (bond)

18. ACT processes Relative to the control group the intervention group reported greater improvements in:  Acceptance and action ◦ Willingness)  Mindfulness ◦ Acting with awareness ◦ Non-judging  Defusion  Valued living

19.  All treatment gains were maintained at the 10-week follow-up

20.  Bootstrapped nonparametric multiple mediator tests showed that ACT processes mediated changes in: ◦ psychological distress ◦ somatic symptoms ◦ self-compassion (overidentification subscale) ◦ self-efficacy (insight skills) ◦ therapeutic alliance (bond subscale)  Key ACT mediators: ◦ present moment awareness ◦ self-as-context ◦ defusion ◦ acceptance ◦ values action

21. o minimal attrition o take up of options to join other group or 1:1 session o on time and stayed until the end of each session o high participation in discussions o high participation in experiential exercises o 82 – 97% did some between session practice each week

22. ◦ personally useful M = 3.9 (1 “not useful” – 5 “very useful”) ◦ professionally useful M = 3.9 (1 “not useful” – 5 “very useful”) ◦ 96% increased interest in ACT ◦ 96% ACT offered as part of training ◦ 78% would recommend the program (22% unsure) ◦ all reported improvement on 1 or more ACT processes ◦ 92% personally use ACT strategies or processes ◦ 85% professionally use ACT strategies or processes

23. 23 Resilience for every Day Nicola Burton, Ken Pakenham, Wendy Burton

24.  Resilience = effective coping and adaptation in the face of significant life challenges (Tedeschi & Kilmer, 2005)  It is characterized by good mental and physical health, functional capacity, and social competence, despite cumulative and current stressful life events.  Resilience is a dynamic process of adaptation to stressful events that involves an interaction between protective factors & stressors.

25.  Prior research focused on: ◦ children ◦ specific resilience-related intra-personal characteristics ◦ individuals in specific adverse circumstances (eg. chronic physical illness, bereavement, divorce)

26. 5 key resilience protective factors (Southwick, Vythilingam & Charney, 2005) 1. Positive emotions 2. Cognitive flexibility 3. Meaning 4. Social support 5. Active coping strategies (eg. problem solving, positive reappraisal, humour, acceptance, exercise)  Each protective factor shown to be related to: ◦ better mental health ◦ lower risk of disease ◦ better health outcomes for those already diagnosed with illness ◦ neurobiological resilience factors (eg. a highly functional dopamine- mediated reward system) (Ryff & Singer, 2003; Southwick et al., 2005)

27.  Resilience training targets protective factors that can be modified, to increase an individual’s hardiness for remaining healthy in the face of cumulative stress.  Few intervention studies have attempted to increase resilience among adults in the general population. ◦ Worksite RCT (prevention): Improvements in resilience, self esteem, locus of control, life purpose, & interpersonal relations (Waite & Richardson, 2004) ◦ Diabetes: negligible improvements relative to care-as-usual group (Bradshaw et al., 2007) ◦ Worksite trial (ill participants): increases in effective coping and decreases in depression (Steensma et al, 2006)

28.  CBT and ACT informed intervention  involved 11 x 2 hour group-based sessions over 14 weeks  Session format: ◦ discussion ◦ experiential exercises ◦ skills rehearsal and practice ◦ didactic input ◦ between session practice activities ◦ review of between session practice  Resources: ◦ participant manual ◦ CD ◦ therapist manual

29. SessionSession topic Assessment 1 Introduction 2 Physical Activity 3 Mindfulness 4 Defusion I 5 Defusion II 6 Acceptance 7 Review and Consolidation 8 Values and Meaningful Action 9 Social Support 10 Relaxation and Pleasant activities 11 Review and Planning for the Future Evaluation

30.  Welcome, general introductions & housekeeping  What is resilience?  READY model of resilience  Warning signs of low resilience  READY program overview  Introduction to READY workbook and READY personal plan  Review and READY personal plan

31. Positive emotions Coping strategies Cognitive flexibility Social support Meaning Being Thinking FeelingDoing Relations Resilience

32.  Physical activity & resilience  Physical activity recommendations  Physical activity definitions and domains  Step counting, pedometers and sitting time  Physical activity and goal setting  Physical activity and problem solving

33.  Session 3: Mindfulness ◦ Mindfulness of: eating sultana, environment, breath, body ◦ CD  Session 4: Defusion I  Session 5: Defusion II (including observer self)  Session 6: Acceptance  Session 7 : Review  Session 8: Values

34.  Session 9: Social Support & Connectedness  Session 10: Relaxation & Pleasurable Activities  Session 11: Planning for the Future

35.  Pre-post single group design  18 volunteers recruited from administrative staff at University of Queensland  15 women; 3 men  mean age 36.5 years (SD 8.6) were  2 drop-outs

36.  Psychological Well-being (Ryff, 1989) ◦ autonomy ◦ environmental mastery ◦ personal growth ◦ positive relations ◦ purpose in life ◦ self-acceptance  Depression (CES-D; Radloff, 1977)  Stress & Anxiety (DASS-21; Lovibond & Lovibond, 1995)  Positive affect (PANAS-X; Watson & Clark, 1999)  Values (Valued Living Questionnaire, Wilson & Groom, 2002)  Mindfulness (Mindful Attention Awareness Scale, Brown, 2003)  Acceptance & Action Questionnaire II (AAQII; Hayes et al., 2006)  MOS Social Support Survey (Sherbourne & Stewart, 1991)

37.  Physical activity ◦ Self-reported time spent in physical activity in previous week  total time spent in walking for transport, for exercise or recreation, moderate & vigorous physical activity (summed to provide a measure of activity minutes/week) ◦ Daily steps  for 7 consecutive days recorded by pedometer (used to derive average steps/day)  BMI  Blood pressure (BP_Sys and BP_Dias)  Hematological data involved a fasting blood sample to measure: ◦ blood glucose ◦ total cholesterol ◦ C-Reactive protein (CRP) ◦ cortisol

38.  Data were analyzed using standardized mean differences and paired t-tests.  There was a significant difference between baseline and post intervention scores on measures of: ◦ mastery (p=.001) ◦ positive emotions (p=.002) ◦ personal growth (p=.004) ◦ mindfulness (p=.004) ◦ acceptance (p=.012) ◦ stress (p=.013) ◦ self acceptance (p=.016) ◦ valued living (p=.022) ◦ autonomy (p=.032) ◦ total cholesterol (p=.025)

39.  The average proportion of sessions attended = 81%  3 participants attending all 11 sessions  37% (n=6) missed 1 or 2 sessions  44% (n=7) missed 3 or 4 sessions  The most common reasons given for missing sessions were clashes with work meetings and planned recreation leave.  High level of in-session participation

40.  Satisfaction: the mean rating 4.67 ◦ (5-point scale; 5 excellent & 4 very good)  Personal helpfulness: mean rating 4.44 ◦ (5-point scale; 5 a lot & 4 moderately so)  Workbook: mean rating 3.87 ◦ (4-point scale; 4 very helpful & 3 moderately helpful),  READY Personal Plan: mean rating 3.5  75% agreed with weekly frequency  87% agreed with 2 hour session duration  56% agreed with overall program length (31% thought it was too short)

41.  Cluster randomized trial  75 participants allocated to either a waitlist or 1 of 2 intervention conditions: ◦ READY including physical activity module ◦ READY excluding physical activity module  Both intervention conditions received a 10x2.5 hour group resilience training program (READY) over 13 weeks.  Measures as per pilot

42.  Clinical Training: ◦ Group READY program in University Psychology Clinic ◦ Experienced facilitator + 3 trainee clinical psychologists as co-facilitators ◦ Target population: people referred to clinic ◦ Screening ◦ Group sessions + 5 individual sessions with trainee psychologists  Coping with Chronic Illness  Carers