Jeanie Stafford-Brown & Kenneth Pakenham
School of Psychology
The University of Queensland
Brisbane, Australia
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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)
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Excessive stress can negatively impact personal and
professional functioning and result in less than optimal
standards of care for clients
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Dearth of empirical studies on stress in trainee clinical
psychologists, and there is no published intervention research
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Mindfulness-based interventions have been efficacious in similar
populations e.g., med students, student counsellors
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To evaluate the efficacy of a group ACT
stress management intervention for postgraduate clinical psychology interns in:
◦ reducing stress and enhancing adjustment
◦ fostering therapist characteristics associated
with better therapy outcomes
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
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2.
acceptance and action
mindfulness
defusion
valued living
That changes in adjustment outcomes and therapist
qualities, would be mediated by changes in some or
all of the ACT processes
A non-randomised controlled trial with repeated measures
Condition
ACT
Intervention
Pre-treatment
assessment
Intervention
Post-treatment
assessment
10-week
follow-up
n = 28
n = 28
n = 27
n = 26
(2 universities)
Control
(2 universities)
n = 28
n = 28
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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:
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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
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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)
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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)
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ACT Processes
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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:
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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
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Aims to:
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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:
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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)

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
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Aims to:
◦ Broaden repertoire of mindfulness exercises
◦ build willingness/acceptance by defusing language
◦ foster contact with the “observing self” & undermine attachment to conceptualised self
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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)
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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
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Aims to:
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Strategies:
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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
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
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Aims to:
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Strategies:
◦ 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 selfcare and the ACT therapeutic stance
◦ bring it all together
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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)
Clinical background
%
n
Counselling/therapy exp
50
28
Meditation training
25
14
Current meditation practice
None
Very occasional
Once per week
63
31
6
34
17
3
Training in MBSR
21
12
Training in MBCT
6
3
Training in DBT
4
2
Training in ACT
9
5
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Satisfaction with clinical training (5-point response scale - 1
“totally dissatisfied” to 5 “totally satisfied”)
◦ Mean = 3.60 (SD = .80; range 1 - 5)
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At Pre-treatment ‘Caseness’ Levels using GHQ (cut-off
score of ≥ 5) = 73%
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)
ACT processes
Relative to the control group the intervention group
reported greater improvements in:
 Acceptance and action
◦ Willingness)
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Mindfulness
◦ Acting with awareness
◦ Non-judging
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Defusion
Valued living
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All treatment gains were maintained at the
10-week follow-up
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Bootstrapped nonparametric multiple mediator tests
showed that ACT processes mediated changes in:
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psychological distress
somatic symptoms
self-compassion (overidentification subscale)
self-efficacy (insight skills)
therapeutic alliance (bond subscale)
Key ACT mediators:
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present moment awareness
self-as-context
defusion
acceptance
values action
o
minimal attrition
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take up of options to join other group or 1:1 session
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on time and stayed until the end of each session
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high participation in discussions
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high participation in experiential exercises
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82 – 97% did some between session practice each week
◦ 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
Resilience for every Day
Nicola Burton, Ken Pakenham, Wendy Burton
23

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.
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Resilience is a dynamic process of adaptation to
stressful events that involves an interaction
between protective factors & stressors.
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Prior research focused on:
◦ children
◦ specific resilience-related intra-personal characteristics
◦ individuals in specific adverse circumstances (eg. chronic
physical illness, bereavement, divorce)
5 key resilience protective factors (Southwick, Vythilingam &
Charney, 2005)
1.
2.
3.
4.
5.
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Positive emotions
Cognitive flexibility
Meaning
Social support
Active coping strategies (eg. problem solving, positive
reappraisal, humour, acceptance, exercise)
Each protective factor shown to be related to:
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better mental health
lower risk of disease
better health outcomes for those already diagnosed with illness
neurobiological resilience factors (eg. a highly functional dopaminemediated reward system) (Ryff & Singer, 2003; Southwick et al., 2005)
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Resilience training targets protective factors that can be
modified, to increase an individual’s hardiness for
remaining healthy in the face of cumulative stress.
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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)
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CBT and ACT informed intervention
involved 11 x 2 hour group-based sessions over 14
weeks
Session format:
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discussion
experiential exercises
skills rehearsal and practice
didactic input
between session practice activities
review of between session practice
Resources:
◦ participant manual
◦ CD
◦ therapist manual
Session
Session 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
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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
Feeling
Positive
emotions
Doing
Coping
strategies
Resilience
Cognitive
flexibility
Social
support
Thinking
Meaning
Being
Relations
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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
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Session 3: Mindfulness
◦ Mindfulness of: eating sultana, environment, breath, body
◦ CD
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Session 4: Defusion I
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Session 5: Defusion II (including observer self)
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Session 6: Acceptance
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Session 7 : Review
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Session 8: Values
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Session 9: Social Support & Connectedness
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Session 10: Relaxation & Pleasurable Activities
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Session 11: Planning for the Future
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Pre-post single group design
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18 volunteers recruited from administrative staff at
University of Queensland
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15 women; 3 men
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mean age 36.5 years (SD 8.6) were
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2 drop-outs
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Psychological Well-being (Ryff, 1989)
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autonomy
environmental mastery
personal growth
positive relations
purpose in life
self-acceptance
Depression (CES-D; Radloff, 1977)
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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)
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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)
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BMI
Blood pressure (BP_Sys and BP_Dias)
Hematological data involved a fasting blood sample to
measure:
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blood glucose
total cholesterol
C-Reactive protein (CRP)
cortisol
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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:
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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)
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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
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Satisfaction: the mean rating 4.67
◦ (5-point scale; 5 excellent & 4 very good)
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Personal helpfulness: mean rating 4.44
◦ (5-point scale; 5 a lot & 4 moderately so)
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Workbook: mean rating 3.87
◦ (4-point scale; 4 very helpful & 3 moderately helpful),
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READY Personal Plan: mean rating 3.5
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75% agreed with weekly frequency
87% agreed with 2 hour session duration
56% agreed with overall program length (31% thought it was
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too short)
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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
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Both intervention conditions received a 10x2.5
hour group resilience training program (READY)
over 13 weeks.
Measures as per pilot
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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
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Coping with Chronic Illness
Carers