Acceptance and Commitment Therapy (ACT) comes to high schools

 

  • A relatively large scale cluster-randomized controlled trial of acceptance and commitment therapy was implemented in Dutch high schools.
  • Across 11 outcome variables, there were no significant effects in main or subgroup analyses.
  • Transparent reporting of a thoroughly null trial was marred only by a non sequitur statement in the last sentence of the abstract suggesting trained mental health professionals would have obtained better results..
  • This study adds to the literature of the ineffectiveness of preventive interventions in classrooms.
  • Questions can be raised as to ‘why bother and why ACT?’

The study is unfortunately behind a pay wall but the abstract clearly conveys the null findings.

Van der Gucht K, Griffith JW, Hellemans R, Bockstaele M, Pascal-Claes F, Raes F. Acceptance and Commitment Therapy (ACT) for Adolescents: Outcomes of a Large-Sample, School-Based, Cluster-Randomized Controlled Trial. April 2017, Volume 8, Issue 2, pp 408–416

Abstract

The purpose of this study was to examine the efficacy of an abbreviated, classroom-based, teacher-taught Acceptance and Commitment Therapy (ACT) program as an intervention to improve mental health in adolescents. In a group-randomized controlled trial, students (N = 586, age 14–21) were nested within 34 classes, which were in turn nested within 14 schools. Individual classes were randomly assigned to either a four-session ACT program or a usual-curriculum control condition. Students were assessed using questionnaires at pre- and post-treatment, and a 12-month follow-up. Questionnaires assessed quality of life, internalizing and externalizing problems, thought and attention problems, and psychological inflexibility. Hierarchical linear modeling showed no significant improvements on any of the outcome measures compared with the control group. No substantive effect sizes for ACT across time were observed. These findings failed to support ACT in the format that was used in this current study, which was as an abbreviated, classroom-based, teacher-taught program to improve mental health for all students. We had a large sample and many outcome variables, but failed to find any statistically significant effects or substantive effect sizes. In this study, ACT was delivered by teachers as opposed to mental health professionals, so it is possible that professionally trained therapists are needed for ACT to be efficacious.

The control was students followed their regular school program. The 11 outcome variables were selected by the investigators because they would in theory be impacted by ACT. These variables included both traditional child behavior self-report mental health and behavior problem variables and variables related to the theory of ACT.

We hypothesized that participants in the ACT condition, relative to control participants, would show improvements on internalizing and externalizing problems, as well as thought and attention problems. We also hypothesized that ACT would increase quality of life and psychological flexibility.

ACT Intervention

A universal ACT prevention program developed by Fredrik Livheim and Francis De Groot (F. De Groot 2005; Livheim 2004) was adapted to the Flemish school context (Bockstaele 2012) for the current study. The program consisted of 4 weekly, 120-min classroom sessions. All sessions included a psycho-educational part focused on theory and background, as well as a practical part with experiential exercises and homework assignments. Participants were encouraged to apply the skills throughout their daily life. They received a workbook for reviewing the material at home and for making notes during their at-home practice (Bockstaele 2011).

In sessions one and two, the main focus was on values clarification, defusion, and self-as-context techniques to help students experience the difference between “experiencing something” and “the person having the experience.” The third session focused on stress and acceptance as an alternative for experiential avoidance. The “passenger on the bus” metaphor was used in the fourth and last session to link all the processes together. This metaphor describes the way internal experiences (thoughts, emotions, memories, etc.), represented as passengers on the bus, often seem to drive our lives. In these last two sessions, attention was given to planning and engaging in committed action. The program was intended to be applicable for all students and thus a universal prevention program.

The control group was students following their regular school program.

Results

For all 11 dependent variables  the critical tests for the ACT intervention were non-significant.

Because of the differences in baseline characteristics, we also performed an additional subgroup analysis on students with relatively high levels of externalizing problems because this group was more likely to drop from the study.

My interpretation

 This study introduces the distinct ACT brand into the competition for funds that are being made available for mental health programs in schools. The rationale for all such programs remains weak.

The rationale for an ACT-based program is only persuasive to someone already buying into its theory and weakly validated measures of process and mechanism. I wonder what the teens felt having to sit through the classes. Were they at least entertained?

In a nondistressed, general adolescent sample, we can’t really expect to such interventions will reduce the distress because of floor effects. The introduction of an ACT framework is novel, but the ACTvariables are mainly of interest to those who adhere to the model. The validity they have outside the model is in modest associations with measures of distress.

At least some of the impetus for such programs is the perception of professionals and parents that schools are stressful environments because of the heightened demands for achievement and the consequences of not performing well on tests and other evaluations.  Maybe these conditions exist, but these remedies are irrelevant and ineffective. I would suggest more directly addressing these environmental coinditions

Students actually in need of psychological intervention are ill-served by such interventions, which are too low in intensity and poorly focused. Moreover, the availability of such programs diverts resources from more proven interventions and discourages better focused efforts to increase the timely access to services because of the illusion

Questionable meta-messages

(1) Well-being takes focused practice, rather than emerges out of naturally occurring activities

(2)Schools are the most appropriate places to provide such learning, even at the sacrifice of other resources and time devoted to other activities.