The Use of Acceptance and
Commitment Therapy with
Hemodialysis Patients
Mary Rzeszut, MSW, LCSW
Winthrop University Hospital
Mineola, New York
Can We Do Something Different?
60% of patients with chronic disorders adhere poorly to
treatment regimen*
Estimated that 50% of dialysis patients do not adhere to at
least part of their treatment**
Depressive symptoms are present in 30% of dialysis
patients***
Team’s or facility’s approach causing patient resistance?
*Journal of Clinical Epidemiology, 2001
**Seminars in Dialysis, 2001
***Nephrology Nursing Journal, 2010
Expectation of Medical Model
Educating patient increases understanding and
reduces anxiety
Health care team leads patient toward taking correct
action with regard to treatment and disease
management
Patient will want to take correct action in order to
produce good outcomes
Psychological factors and patient’s behavior are
important but secondary to primary task of dealing
with condition
Causes of Patient Resistance
Patient’s self-blame and guilt if belief illness was
self induced
Denial- talking about illness makes it real
“Expect to find a cure” “Receive a transplant soon”
Patient’s sense of being labeled or judged by team
(difficult, angry, non-compliant, depressed)
Clinical urges to “fix”, “to reassure" or “to advise”
patient
Feelings of anxiety, shame, and vulnerability
during every treatment (whether expressed or not)
What Can We Do?
Patient Centered Care
National Research Corporation
Psychosocial Interventions Maybe Helpful
Difficulty coping with adjustment to disease
Anger displayed through acting out behavior, self-
medication with drugs or alcohol, or
non-adherence
Tool to assist in breaking through resistance
To meet demands of CMS to regulate and control
hospitalizations and medical outcomes
Considerations When Applying Interventions
Patient should have a life goal
Proceed at patient’s pace, avoid persuasion.
Education of medical condition important but often
insufficient for behavioral change.
Need constant support due to complications from
illness
Expect relapse or setback
Overview of Case Study
Patient is a 49 year old single male
Abandoned by his biological mother at birth and
adopted at the age of 13
Never married and has limited support network
Suffered from two major losses, his father and
fiancé
Lives alone and works part time
History of drug and alcohol abuse and has been
incarcerated for dwi and assault
Still drinks occasionally and smokes marijuana
Overview of Case Study
Had an acute diagnosis of ESRD
From onset of hemodialysis treatment was non-
adherent
Missing on average 2-4 treatments a month, one
month missing 7 treatments
Displayed constant anger towards unit staff
Displayed feelings of hopelessness towards life
Therapeutic Goals
Desired therapeutic outcomes were:
1) to increase hemodialysis treatment adherence
to prescribed dialysis regimen
2) to increase patient’s quality of life and
achievement of life goals
Acceptance and Commitment Therapy (ACT)
Considered a third world modern
cognitive behavioral therapy(CBT)
Contrary to traditional CBT
Mindfulness-based, values-oriented
behavioral therapy
Acceptance and Commitment Therapy (ACT)
Teaches mindfulness skills to address
painful thoughts and feelings effectively
To have less impact and influence
Clarify what’s important and meaningful
To inspire and motivate to set goals
Take action that enriches life
Acceptance and Commitment Therapy (ACT)
ACT has two therapeutic goals:
Accept what
is out of our personal control
Commit to taking action that enriches life
Acceptance and Commitment Therapy (ACT)
ACT consists of six core processes that are
divided into two main components
Mindfulness and acceptance processes
Commitment and
behavior changes
Mindfulness and Acceptance Processes
Acceptance – willingness to experience any degree
of psychological distress
Cognitive defusion – techniques designed to alter the
context of one’s thoughts, especially those that
produce harm
Self-as-context – a person’s view of themselves based on
what they are currently thinking and feeling
These three processes help transform the cognitive and
emotional barriers that stand in the way of obtaining a
value driven life
Commitment and Behavior Changes
Contact with the present moment – closely monitoring
how one is effectively or ineffectively behaving in the
present moment
Values – verbal statements of what an individual
desires to experience throughout his life
Commitment - action towards achieving one’s chosen
values
How Was ACT Implementated
Assessment
Patient described problematic issues
Illness and hemodialysis treatment
Described feelings regarding issue
feelings of distress, frustration and anger
Discussed behaviors when experiencing these feelings
(avoidance behaviors)
Avoidant behaviors: excessive drinking, drug use, behaviors that
cause physical harm, procrastination and avoidance of conflict
Skips treatment
Drinks excessive fluids
Takes anger out on others
Interventions
Discussion if avoidant behaviors were adapted to avoid
distressful emotions
Patient explored present strategies/behaviors when dealing
with problematic issue and evaluated if they were effective
(anger, leaving dialysis unit and skipping treatment)
Patient reflection, no suggestions are given
May take more than one discussion for patient to see that
current avoidant strategies are problematic
Interventions Cont’d
Once patient saw avoidant strategies/behaviors as
problematic
Discussed what losses occur from this behavior in
terms of patient’s emotional energy, and health
Interventions Cont’d
Discussed how negative thoughts and feeling have
effect on living a more meaningful life.
nothing in life was worthwhile
Felt “less than””
Discussion on avoiding negative feelings creates
behavior that is detrimental to well-being and quality
of life.
Avoidance and control of these distressing emotions
are the problem not dialysis
Interventions Cont’d
Acceptance
The willingness to experience distressing emotions
To be mindful of emotions and choose the solution
that benefits his health
Exposure exercise – Patient asked to monitor behavior in
the present moment and choose alternative solution
(choose different approach if wait times are excessive at unit)
(to think about if skipping treatment will benefit long term
goals)
Interventions Cont’d
Established Life Goals
Discussed life goals
(kidney transplant, relationship, purchasing a car,
going on vacation)
Commitment/Maintenance
Develop plan of
action to reach life goals
Support when complications arose
(environmental stressors or medical complications)
Case Study Results
Treatment adherence improved after 15 sessions
Since July 2011, continues with 100% compliance or
missing only one treatment
Improvement in mood and affect
Self report of awareness of behavior
Responsibility for actions
Case Study Results
Decrease in hospitalizations
2011 - 8 admissions
2012 – 2 admissions
Improvement seen in KDQOL scores for mental
function and effect/burden of disease
Achieving life goals – presently in relationship, on
transplant list.
Other Uses for ACT
Adherence issues to diet and fluid restriction
Anxiety/Needle Phobia
Depression
How to Apply ACT
Have patient discuss problematic issue
Explore present coping strategies
What have you tried?
Reflect on outcome and create awareness of behavior
Do you feel this strategy is working?
Is it giving you the outcome you want in terms of
your health?
Is there something you can do differently in this
situation?
Explore the negative feelings/thoughts associated
with issue/problem
Have you thought about how this problem
makes you feel?
Is the thought true?
Replace “but” statements with “and” statements
“I would like to go to treatment but it makes me feel anxious”
“I would like to go to treatment and I am feeling anxious”
Explore life goals
What type of life would you like to have?
Goals should be specific
Measurable and include details
Within the patient’s ability
How do you know you are moving in the direction of
obtaining goal?
What’s getting in the way?
Can you try to work towards goals while still feeling
these distressful feelings?
Intervention Has Been Successful
Patient takes responsibility for behavior
Small behavioral change (adherence, diet or treatment)
Affect or mood change (less angry)
**Therapeutic interventions are not about what the
clinician values but what matters to the patient!!!
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