Monday 21st December 2015
Mac Voice, the magazine for Macmillan professionals: Winter 2015
In this third part of our Sharing Good Practice issue on psychological support, Claire Delduca examines how the Acceptance and Commitment Therapy (ACT) model can help people affected by cancer regain a sense of control.
A cancer diagnosis, and living with and beyond it, can elicit many distressing thoughts and feelings. People often describe that they feel as though they have ‘lost control’ and experience many frightening worries such as ‘What will happen to me and my family?’, ‘How will I cope?’, ‘Will the cancer come back?’ and ‘Will I die?’.
Adjusting to the impact on many areas of their life can be a difficult and ongoing task. Many people understandably feel that their survival is threatened, as well as their sense of normality and their predicted or expected future.As humans, our usual way to react to such a threat is with our innate ‘fight, flight or freeze’ survival response. We have evolved to try to get rid of threats. The example of being faced with a hungry tiger comes to mind – we automatically run away, fight or hide in order to stay safe. This system also then enables us to learn from past experiences and predict future ones, to prepare ourselves for what may come and plan how to avoid any potential threats. This mechanism helps the world to feel more predictable, which increases our sense of control and safety. Our minds have therefore evolved to think the way they do; to worry, plan, problem-solve and predict the negative.
Our bodies also respond by eliciting a range of feelings, such as anger, fear, sadness, guilt and insecurity – each telling us something important about the situation we are facing and the potential impact on the things which we value. Therefore, in essence our thoughts and feelings are understandable natural reactions and are not controllable.
Yet we are often caught up in an expectation that we ‘should’ be happy, think positively and be able to get rid of unpleasant thoughts and feelings.
When faced with the scary uncertainty of cancer, people understandably rely on these automatic reactions to try to protect themselves and those around them from distress. Ultimately, they can end up feeling very stuck when the thoughts and feelings do not go away in the long term. To try to cope, they may isolate themselves from the people and activities that they care about to avoid potential triggers for the distress.
They may keep busy so they don’t have time to think or feel. Or they may become caught up in the painful awareness that things have changed and they are now further away from their ideal reality. People often struggle and criticise themselves for not being happy or for feeling upset. In particular, this struggle often appears to be most prevalent after treatment has finished, when people often feel a sense of abandonment by the healthcare team, a heightened sense of responsibility over their own safety from cancer and an expectation that they should return to ‘life as normal’.
This is where the Acceptance and Commitment Therapy (ACT) model comes into its own.[1, 2, 3, 4]
The ACT model
The ACT model is not about challenging, changing or reducing distress; thoughts and feelings are not viewed as irrational or abnormal. ACT recognises that life is painful and suffering is universal.
It is based around six core therapeutic processes, which can be grouped into three areas (see Figure 1). Building on these processes enables people to increase their psychological resilience by dropping the struggle with their thoughts and feelings.
The emphasis instead lies on developing the ability to open up to and allow thoughts and feelings to be as they are. This frees up time, energy and mental space to enable the person to more consciously choose which action is most workable in that moment, helping them to connect with relevant and meaningful personal values.
Therefore, this can enhance their sense of well-being, vitality and quality of life in the face of distress. This model is becoming widely accepted as an effective psychological approach within health-care settings.[5,6]
Our Living with Uncertainty Group
Alongside other group interventions that our Psychology Within Cancer Services team has developed, including fatigue management, anxiety management and mindfulness, we were particularly interested in developing an ACT-based group. As well as the growing evidence base for the use of ACT in cancer settings specifically [6,7,8] the model seemed a good fit with the struggles associated with living with the impact of cancer. The process of sharing these experiences within a group intervention also helps to normalise difficult thoughts/feelings and offers a sense of feeling understood.
The group is spread over four two-hour sessions co-facilitated by two members of the Clinical Psychology and Counselling service and is held in a community setting, away from the hospital environment and ‘patient role’. Each session focuses on particular ACT concepts, which are explored using experiential exercises and reflection time throughout.
Underpinning each of the sessions is the emphasis on developing self-compassion and choosing workable actions (see figure 2). This involves a novel shift away from struggling to control the uncontrollable and exploring what is under our control or influence. This can sometimes mean choosing an action that involves sitting with, rather than avoiding, difficult thoughts and feelings in the service of working towards an important value, i.e. being the person they want to be. An example that often arises is the desire to be a loving and caring parent or grandparent. Spending time with children and grandchildren can be joyous, but can also elicit painful fears about not being around as they grow up. The automatic reaction may be to avoid playing with them to avoid the pain, whereas the meaningful action may be to make space for the pain in order to also experience the pleasure of sharing time with them. The importance of values related to self-care, compassion and savouring the present moment are most often realised during these poignant moments.
Outcomes of the group
The core intended outcome of ACT is not symptom reduction, but instead an increase in quality of life, meaningful actions and psychological flexibility. Symptom reduction can sometimes occur as a by-product of the intervention but is not expected. A small-scale preliminary analysis of this group programme as assessed by pre and post-scores for the Clinical Outcome in Routine Evaluation  (CORE), ACT-based Acceptance and Action Questionnaire  (AAQ) and the Functional Assessment of Cancer Therapy  (FACT) showed some interesting results. It was found that the group helped to improve participants’ reported level of anxiety, depression, general and social functioning as measured by the CORE and their emotional well-being as measured by the FACT. With the relatively small number of measures completed so far, there was not a significant difference found in the level of psychological flexibility as measured by the AAQ.
Verbal and written evaluations of the group provided by participants highlighted how it can be challenging to confront difficult thoughts and feelings in the short-term, but that the longer-term benefits of having the opportunity to feel understood, have their feelings validated and develop additional coping skills were valuable.
Upon reflection of the use of this approach so far within an oncology setting, an important element seems to be the process of validating that there is no right or wrong way to think, feel or act when living with the impact of cancer. In addition, this approach enables people to, in their own way, develop their sense of control over the actions they take.
For example, it may allow them to build their sense of fulfilment, savour small everyday moments and be kinder to themselves. It is this sense of control that appears to elicit an important shift in a person’s sense of resilience and ability to continue to live their life meaningfully in the moment, despite the cancer.
1 Harris R. The Happiness Trap. 2008. Constable & Robinson Ltd. London.
2 Hayes SC, Strosahl KD and Wilson K.G. Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. 2011. Guildford Press. New York, USA.
3 Harris R. ACT made simple. 2009. New Harbinger Publications. Oakland, CA.
4 Harris R. The Reality Slap. 2011. Constable & Robinson Ltd. London.
5 Barraca J. "Mental control" from a third-wave behavior therapy perspective. International Journal of Clinical and Health Psychology. 2012. 12(1):109-121.
6 Hulbert-Williams NJ, Storey L and Wilson KG. Psychological interventions for patients with cancer: psychological flexibility and the potential utility of Acceptance and Commitment Therapy. European Journal of Cancer Care. 2015. 24: 15-27.
7 Ciarrochi J, Fisher D and Lane L. The link between value motives, value success, and well-being among people diagnosed with cancer. Psycho-Oncology. 2011. 20(11):1184-92.
8 Rost AD, Wilson KG et al. Improving psychological adjustment among late-stage ovarian cancer patients: Examining the role of avoidance in treatment. Cognitive and Behavioral Practice. 2012. 19(4):508-517.
9 Connell J and Barkham M. CORE-10 user manual, Version 1.1. CORE System Trust & CORE Information Management Systems Ltd. 2007. 1-40.
10 Bond FW, Hayes SC et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire–II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy. 2011. 42: 676-688.
11 Cella DF, Tulsky DS et al. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. Journal of Clinical Oncology. 1993. 570-579.
Email Dr Claire Delduca, Macmillan Clinical Psychologist at the Velindre NHS Trust.
Continue reading Sharing Good Practice
Part 1: Psychological support - Dr Anne Johnson, Macmillan Consultant Clinical Psychologist, Velindre Cancer Centre.
Part 2: Evidence base - Janice Rees, Macmillan Consultant Clinical Psychologist, Cardiff and Vale University Health Board.
Part 3: Acceptance and Commitment Therapy - Dr Claire Delduca, Macmillan Clinical Psychologist, Velindre NHS Trust.
Part 4: Helping parents with cancer support their children - Dr Claire Delduca, Macmillan Clinical Psychologist, Velindre NHS Trust.
Part 5: How a clinical psychologist can support shared decision-making - Dr Rachel Criddle, Macmillan Clinical Psychologist, Cwm Taf University Health Board.
Part 6: Psychological supervision for staff - Dr Rachel Criddle, Macmillan Clinical Psychologist, Cwm Taf University Health Board.
Part 7: Extend your psychological support skills - Resources and training for professionals.