Download Acceptance and Commitment Therapy: An example of third

Acceptance and Commitment Therapy: An example of third-wave therapy as a
treatment for Australian Vietnam War veterans with Posttraumatic Stress Disorder
By
Lynn Marie Williams
Bachelor of Arts, Graduate Diploma of Psychology, Post Graduate Diploma of Psychology
Dissertation
(for submission to journal Behavior Modification)
In partial fulfilment of the requirements for the degree
Master of Clinical Psychology
in the
Faculty of Arts
At Charles Sturt University
September, 2007
Vietnam veterans and ACT
Page 2
Certificate of Authorship
I hereby declare that this submission is my own work and that, to the best of my knowledge and
belief, it contains no material previously published or written by another person nor material which
to a substantial extent has been accepted for the award of any other degree or diploma at Charles
Sturt University or any other educational institution, except where due acknowledgement is made in
the dissertation. Any contribution made to the research by colleagues with whom I have worked at
Charles Sturt University or elsewhere during my candidature is fully acknowledged.
Signed:
Lynn Marie Williams
Registered Psychologist
PS0067890
Vietnam veterans and ACT
Page 3
ACKNOWLEDGMENTS
I would like to thank my husband, Peter, for his unfailing encouragement and genuine interest in
this project. He has been my most steadfast fan over a very long journey which has resulted in this
dissertation. Appreciation goes to Dr David Mallard for initial assistance. Thanks to Elizabeth
Murrell and Associate Professor Michael Kiernan for advice and supervision. Thanks to Georgina
Luscombe for being there. Special thanks to Dr Robyn Walser, National Center for Posttraumatic
Stress Disorder, California, United States of America. Thanks for her skill as a trainer,
encouragement when this project was only an initial thought, then for her feedback and provision of
the preliminary protocol for Acceptance and Commitment Therapy. Robyn was a positive influence
in many ways. Thanks to Dr Ruth Baer, University of Kentucky, for permission to use the Kentucky
Inventory of Mindfulness Skills. Finally, thanks to the Vietnam veterans. To Darrell Ford and
Graham Oldfield for advice on the recruitment of veterans – the bond remains strong. Most of all,
thanks to the Vietnam War veterans who participated in the groups. They gave me their trust and
participated with courage and humour. They demonstrated not only their commitment to the
research but commitment to each other and to all the veterans who follow them.
Vietnam veterans and ACT
Page 4
Acceptance and Commitment Therapy: An example of third-wave therapy as a
treatment for Australian Vietnam War veterans with Posttraumatic Stress Disorder
Lynn M. Williams
Acceptance and Commitment Therapy (ACT) was applied as an outpatient group treatment
programme for Australian Vietnam War veterans with Posttraumatic Stress Disorder (PTSD). To
better understand the processes of ACT, 16 veterans were divided into two therapy groups. One
group received all phases of ACT (ACTFULL) and one group received ACT without the
‘discovering the self’ phase (ACTDIS). Following treatment, both groups showed a reduction in
scores for PTSD, psychiatric and non-psychiatric symptoms, conscious suppression of disturbing
thoughts and an increase in scores for mindfulness skills. The expected outcome that the ACTFULL
group would demonstrate greater levels of symptom reduction and a greater increase in mindfulness
skills than the ACTDIS group was only supported on one outcome measure. A three-month followup was conducted and most changes were maintained. Clinical implications and suggestions for
future studies are discussed.
Key words: posttraumatic stress disorder, acceptance and commitment therapy, mindfulness,
avoidance, exposure, Vietnam veterans
Vietnam veterans and ACT
Page 5
When asked what thoughts sprang to mind when hearing the words, ‘the Vietnam War’, the
Australian Vietnam veterans participating in this study responded, ‘adventure’, ‘sheer horror’,
‘killing of innocent people caught up in combat situations’, ‘smelling of death’, ‘thought that I
would never live again’, ‘my life is still suffering’, ‘being treated like a criminal when I got back’.
Clearly, more than thirty years after the war ended in 1975, the trauma may still be only 30 seconds
away. Recent reviews have found that 80 percent of American Vietnam veterans and 31 percent of
Australian Vietnam veterans still have Posttraumatic Stress Disorder (PTSD) (Commonwealth
Department of Veterans’ Affairs [DVA], 1998; Price, 2005). This chronicity, plus currently serving
defence force personnel who have developed PTSD, shows we have more to learn about the course
and treatment of PTSD (Hoge et al., 2004; Koenen, Stellman, Stellman & Sommer, 2003). This
study examines the history of PTSD, existing treatments and limitations, and the application of
ACT with Australian Vietnam veterans. The research question investigated is ‘Does the inclusion of
the ‘discovering the self’ phase of Acceptance and Commitment Therapy (ACT) lead to outcomes
that are significantly more positive than ACT without this phase?’
THE NATURE AND CAUSES OF PTSD
Hyams, Wignall and Rosewell (1996) found literature on war-related illnesses going back to
1863. Physical symptoms reported included fatigue, shortness of breath, headache, sleep
disturbance, impaired concentration, nightmares and infectious diseases. These were referred to as
‘irritable heart’, soldier’s heart’, ‘the effort syndrome’, ‘Agent Orange syndrome’ and ‘Gulf War
syndrome’. Psychological symptoms were called ‘shell shock’, ‘nostalgia’, ‘trench neurosis’, ‘battle
fatigue’, ‘combat exhaustion’, ‘post-Vietnam syndrome’ and ‘posttraumatic stress disorder’.
Current literature advises that PTSD may develop following a traumatic event(s), such as
physical or sexual assault, torture, natural disasters or military combat (Yehuda, 2004). The
Vietnam veterans and ACT
Page 6
Diagnostic and Statistical Manual (DSM-IV; APA, 1994) details symptom clusters: re-experiencing
(e.g., flashbacks); avoidance (e.g., emotional detachment); and arousal (e.g., hypervigilance).
However, the meaning of the event, whether the trauma was man-made or a natural disaster, and
comorbid symptoms (e.g., depression) contribute to the lack of a stereotypical pattern of PTSD
behaviour (McNally, 2003; Orsillo & Batten, 2005). Therefore, recent research has begun to
investigate issues beyond DSM-IV symptoms.
Quality of life, defined by Mendlowicz and Stein (2000) as a subjective evaluation of life
not only expressed in quantifiable terms, was analysed by Zatzick et al. (1997) from data in the US
National Vietnam Veterans’ Readjustment Study (NVVRS). They found that veterans suffered
impairments in physical health, employment, and social and emotional well-being. Furthermore,
Jordan et al. (1992) interviewed veterans from the NVVRS and found more marital violence, family
adjustment problems, and more behavioural problems in the children of veterans with PTSD than
those without PTSD.
Various theories are proposed as to the etiology of PTSD. There is some evidence that
individuals with lower levels of the stress hormone cortisol may develop PTSD (Yehuda &
McFarlane, 1995). Others found that individuals with negative attitudes towards emotional
expression are more likely to develop PTSD (Nightingale & Williams 2000). Ozer, Best, Kipsey
and Weiss (2003) examined seven predictors of PTSD: prior trauma; prior psychological
adjustment, family history of psychopathology, perceived life threat during the event; post-trauma
social support, high levels of emotion during or immediately after the trauma; and dissociative
responses during or immediately after the trauma. They found that high levels of emotion and
dissociation during the event, not prior characteristics, were the strongest predictors of PTSD. In the
first longitudinal study examining risk factors for combat-related PTSD, Koenen et al. (2003) found
that intensity of combat exposure, discomfort in disclosing Vietnam experiences, negative attitudes
Vietnam veterans and ACT
Page 7
by the community on homecoming, and anger predicted the development and or chronic course of
PTSD. Therefore, Yehuda and McFarlane (1995) argue that it is incorrect to attribute the event as
the primary cause of PTSD.
AUSTRALIAN VIETNAM VETERANS
From 1962 to 1973, Australia sent 58,721 personnel to serve in Vietnam, half of which were
conscripts (DVA, 1998; Marshall, Jorm, Grayson & O’Toole, 1998). Of these, 500 were killed and
3,131 were wounded (Wilson & Horsley, 2003). Australian studies found statistically significant
elevated levels in mortality (e.g., lung cancer) and morbidity in veterans compared to similarly aged
male Australians (Australian Institute of Health and Welfare, 1999; Crane, Barnard, Horsley &
Adena, 1997). O’Toole et al. (1996) found that compared to US studies, Australian findings
reported less antisocial personality disorder and less drug abuse, but more phobias. Alcohol abuse
was high for both groups. Interestingly, Tennant, Streimer and Temperley (1990) found no
significant psychiatric differences between conscripts and regular defence force veterans.
Of the risk factors previously described, the intensity of combat exposure made the largest
contribution to the development of PTSD in an Australian sample (Tennant et al., 1990).
Additionally, Marshall et al. (1998) found that veterans feel that they have been discriminated
against and feel anger at the lack of welcome upon returning home. Many still bear psychological
scars from being called ‘baby killers’, ‘bullies’ and ‘butchers’ (Cochrane, 1990; Pigot, 2000). Many
feel that they have never been de-briefed while others denied their symptoms, often not seeking
help until their mid 40s when they could not maintain employment (Martin, 2001). With over
31,000 PTSD articles tracked by the US National Center for PTSD (NCPTSD; 2007), it is important
to outline the most significant symptoms that research has found that contributes to the maintenance
of PTSD.
Vietnam veterans and ACT
Page 8
SUPPRESSION, AVOIDANCE AND PTSD
Individuals often dwell on thoughts and sometimes this is helpful as it keeps us focused.
However, when thoughts are disturbing and intrusive, usually on past events that cannot be
changed, it is argued by Gold and Wegner (1995) that individuals engage in thought suppression
(conscious desire to suppress thoughts). Empirical literature consistently demonstrates that the more
individuals suppress unwanted thoughts, the more they intrude (Roemer & Borkovec, 1994; Wegner
& Zanakos, 1994). Further, Gold and Wegner argue that a rebound effect occurs because
individuals use distraction during suppression efforts. The rebound occurs because distraction
creates implicit associations with the unwanted thoughts which then serve as bidirectional cues to
remind individuals of the other during suppression attempts. This may explain why verbally
describing a trauma can be just as painful as the original experience (Orsillo & Batten, 2005).
Hayes, Strosahl and Wilson (1999) have extended thought suppression theories and use the
term ‘experiential avoidance’ (EA). Hayes et al. (1999) define EA as occurring when an individual
is unwilling to remain in contact with bodily sensations, memories, emotions, thoughts and
behaviours and takes conscious steps to avoid them. Examples of EA include alcohol or drug abuse
and sabotaging intimate relationships. Furthermore, Hayes et al. (1999) argue that when the focus is
not on EA, that is, symptom avoidance, but on healthy living, the distress is moderated. As PTSD is
acknowledged to be a treatable condition (Foa, Riggs, Massie & Yarczower, 1995) it is appropriate
to look at how existing treatments target avoidance.
Vietnam veterans and ACT
Page 9
EXISTING TREATMENTS FOR PTSD
Although Summerfield (2001) argues that PTSD is the diagnosis of an ‘age of
disenchantment’ and that it legitimises ‘victim-hood’, most individuals recover from initial trauma
reactions without professional assistance (Australian Centre for Posttraumatic Mental Health
[ACPMH], 2005; Flouri, 2005). Early veteran treatment models were inpatient programmes,
however, research revealed that inpatient and outpatient models showed no difference in outcomes
(Creamer, Forbes, Biddle & Elliott, 2002). Treatment format is individual, small groups or a
combination of both varying from three to 52 hours over three to six months (Bradley, Green, Russ,
Dutra & Westen, 2005; Jaycox, Foa & Morral, 1998; Turner, Beidel & Frueh, 2005). The major
treatments for PTSD include psychopharmacology (Friedman, 1997), psychotherapy (Van Etten &
Taylor, 1998) and hypnosis (Evans, 2003).
There are accredited guidelines that have been developed for treatment for PTSD (APA,
2004; Foa, Davidson & Frances, 1999). Foa et al. (1999) recommend psychotherapy or combined
medication and psychotherapy as first-line treatment. They do not rate Eye-Movement
Desensitisation and Reprocessing, hypnosis, or psychodynamic models as highly effective for
PTSD. However, although Bradley et al. (2005) did not find one treatment more effective than
another, cognitive-behaviour therapy (CBT) is the most empirically studied model (Creamer,
Forbes, Phelps & Humphreys, 2004). Interestingly, Tarrier and Sommerfield (2004) found that
eradication of avoidance appeared to improve outcomes more than exposure work and a study by
Jakupcak et al. (2006) on Behavioural Activation, focused on reducing avoidance behaviour without
exposure work. However, exposure is an intervention considered to be a key treatment component
for PTSD (Keane, 1995; Orsillo & Batten, 2005).
Vietnam veterans and ACT
Page 10
Indeed, exposure work may be the first opportunity veterans have to work through complex
emotions (e.g., fear, guilt, shame) and Creamer and Forbes (2004) argue that the opportunity to heal
shattered beliefs about ‘self’ may be a treatment turning point. One explanation is that exposure
helps individuals to differentiate between remembering and re-experiencing their trauma (Jaycox et
al., 1998). Using a range of techniques (Creamer et al., 2004), therapists guide individuals through
their trauma under in vivo (in real life) or in vitro (imaginal) conditions where they are presented
with real-life or imagined cues related to their trauma(s) (e.g., verbalising the event), while
experiencing the emotions associated with the trauma(s) until habituation (Keane, 1995). Given the
empirical support for the effectiveness of existing treatments, why change from existing
approaches?
LIMITATIONS OF EXISTING TREATMENTS
Barlow, Allen and Choate (2004) argue that ongoing research has resulted in complex
protocols that make implementation difficult with most treatment manuals for PTSD recommending
exposure interventions. It is also acknowledged that there is a high drop-out rate by individuals who
cannot emotionally engage, or who resist participating in exposure work (Eifert & Forsyth, 2005;
Keane, 1995; Orsillo & Batten, 2005). Furthermore, exposure work is not recommended for
individuals who are abusing substances, are in crisis, are non-compliant, are unable to tolerate
intense arousal, and those with psychoses (ACPMH, 2005). Additionally, some evidence exists that
exposure work is less effective with individuals who have high levels of anger or guilt (Foa et al.,
1995). These mixed results may also be associated with therapists. For example, some do not use
exposure because they are inexperienced with the techniques or because they become distressed
listening to traumatic experiences (Marks, Lovell, Noshirvani, Livanou & Thrasher, 1998).
Vietnam veterans and ACT
Page 11
Additional factors are specific to Vietnam veterans. Most veteran studies report poorer
outcomes than studies with non-veteran PTSD populations (Bradley et al., 2005; Creamer &
Forbes, 2004). Possible explanations for poorer outcomes are: severity of pathology in veterans;
limited disclosure after homecoming; military training and personality style may make therapeutic
engagement difficult; military operations may have resulted in biological changes, such as
hyperarousal, which are difficult to reverse; and veterans have high levels of comorbidity (Creamer
& Forbes, 2004). Further, Creamer and Forbes (2004) argue that a treatment goal of having a
veteran return to pre-trauma levels of functioning is probably unrealistic. With the limitations of
complex protocols, high drop-out rates, and lack of therapist implementation of exposure work,
there is a place for a fresh approach to treating veterans.
AN ALTERNATIVE TO TARGETTING SYMPTOMS
Following the call to look beyond PTSD symptoms to address psychosocial issues, such as
impaired relationships (APA, 2004; Turner, Beidel & Frueh, 2005), Lombardo and Gray (2005)
reviewed PTSD treatments that go beyond the use of exposure strategies to counteract avoidance.
They state that Acceptance and Commitment Therapy (ACT) has the broadest scope in terms of a
‘third-wave’ therapy. Third-wave therapies are described as more experiential than didactic, their
philosophies more contexualistic than mechanistic (Hayes, 2004a), whilst some argue that they
extend traditional CBT interventions (Hayes, Masuda, Bissett, Luoma & Guerrero, 2004b).
Specifically, Lombardo and Gray (2005) observe that ACT differentiates itself from first-wave
(behaviour therapy) and second-wave (CBT) therapies because ACT focuses on life values rather
than primarily focusing on exposure work. This focus may be important in retaining individuals in
therapy.
Vietnam veterans and ACT
Page 12
There are several reasons why ACT may reduce drop-out rates. Firstly, ACT is flexible
because it is ‘principles’ rather than ‘procedures’ driven (Hayes et al., 1999). Secondly, it can be
applied in outpatient settings, which is recommended by the APA (2004) as appropriate for most
PTSD clients. Thirdly, ACT is suitable for groups because it utilises interactive processes (Walser
& Pistorello, 2004). Fourthly, it is particularly suitable for individuals who demonstrate high levels
of experiential avoidance (Hayes et al., 1999). Therefore, ACT provides a way for individuals to
safely experience a full range of emotions with the overall goal of increasing quality of life. One
way that ACT makes these changes operational is through mindfulness.
THE EAST-WEST BRIDGE IN TREATING PTSD
Mindfulness is not a new concept, and although some attribute its origin to Buddhist and
other ancient traditions (Brown & Ryan, 2003; Chan, 1963), Kabat-Zinn (2003) argues that
mindfulness is a universal capability. It is variously described as a set of techniques to encourage
deliberate, nonevaluative contact with events that are here and now (Hayes & Wilson, 2003), being
non-judgmental to the moment-by-moment experience (Krasner, 2004), and having a heightened
sense of involvement in the present (Brown & Ryan, 2003). It is not a cold, cognitive process
(Langer & Moldoveanu, 2000).
The range of definitions and mindfulness techniques make its empirical study difficult.
However, Baer (2003) found 18 empirical studies on mindfulness which showed statistical
improvements in ratings of pain, other medical symptoms and general psychological symptoms.
Many benefits from mindfulness practice are promoted. For example, mindfulness leads to: greater
sensitivity to your environment, more openness to new information; increased life satisfaction; less
anxiety, depression and negative affect, increased perspectives on problem-solving; and the ability
Vietnam veterans and ACT
Page 13
to experience physical pain without overwhelming emotion (Brown & Ryan, 2003; Langer &
Moldoveanu, 2000).
Mindfulness is not about specifically fixing anything but it is about allowing yourself to be
where you already are (e.g., breathing, walking) (Baer & Allen, 2004). This emphasis on lack of
attachment to an outcome is a radical departure from current clinical interventions (Kabat-Zinn,
2003; Krasner, 2004). Importantly, the concept of mindfulness aligns well with ACT philosophy,
theory and practice (Ciarrochi & Robb, 2005).
ACCEPTANCE AND COMMITMENT THERAPY
According to its originators, ACT aims not to change or eliminate the form or frequency of
an individual’s private events (negative sensations, thoughts, emotions and memories) but to change
the way individuals relate to these experiences (Blackledge & Hayes, 2001).
The philosophical basis of ACT is functional contextualism. Here psychological events are
viewed as a whole interacting with events from the past (historical context) and the present
(situation context) (Hayes et al., 1999). For example, having the thought ‘I must never fail’ would
be viewed in terms of what function does this thought have in your life rather than assuming this
thought is harmful (Ciarrochi, Robb & Godsell, 2005). ACT targets the influence of verbal rules
(verbal formulations of events and relationships between events) on behaviour (Hayes et al., 1999).
This philosophy integrates into a new theory of language and cognition called Relational Frame
Theory (RFT) which underpins ACT (Hayes, Luoma, Bond, Masuda & Lillis, 2006).
It is beyond the scope of this study to give more than a brief RFT overview. RFT argues that
cognitions and behaviours are based on verbal relations[ships], which are learned directly, indirectly
Vietnam veterans and ACT
Page 14
or through observation, and that relations[ships] or ‘frames’ given to one event can transfer to other
events (Blackledge, 2003). Thus, when we think, reason, or speak we do so by deriving
relations[ships] between events, between words and events, words and words and events and events
(Hayes, Masuda & De Mey, 2004c). For example, a child hears she is going on a ‘boat’ and on the
boat experiences sea-sickness, if the child subsequently learns that a ‘car ferry’ is a type of boat,
later when the child hears she is going on a car ferry the child may experience anxiety despite
having no direct experience with car ferries (National University of Ireland, 2005). Therefore, ACT
argues that much psychopathology results from human language and subsequently RFT targets
language processes (Hayes et al., 1999).
The larger goal of ACT is not the same as mainstream interventions which seek to eliminate
or change unwanted thoughts, feelings, sensations or behaviours (Hayes & Wilson, 2003).
Essentially, ACT works on redefining the problem and the solution. This means that the problem is
not the unwanted private events – it is the restriction of life – and the solution is not the elimination
of unwanted private events – it is the living of a valued life (Hayes & Wilson, 2003). Acceptance is
the process which breaks the link between struggling against private events and trying to control
them (Eifert & Forsyth, 2005). ACT argues that stepping out of this struggle enables the individual
to then focus on what works in the long-term (a valued life) rather than feeling good in the shortterm (symptom reduction) (Hayes et al., 1999).
ACT is an experiential treatment model (Elliott, Greenberg, & Lietaer, 2004) and as such it
is a process not an outcome (Eifert & Forsyth, 2005). Importantly, Hayes et al. (2006) argue that
acceptance must be learned experientially rather than merely following instructions. Although its
roots are in the behaviourist tradition, ACT shares much with cognitive-behaviour, gestalt,
humanistic and emotion-focused models of therapy (Hayes et al., 1999). However, since therapy
Vietnam veterans and ACT
Page 15
involves language, Hayes et al. (1999) argue that you also have to work outside the language
system.
Techniques such as mindfulness, confusion, use of metaphors and paradoxes are used to
help individuals disentangle from their mind (Hayes et al., 1999) thereby allowing them to increase
their psychological flexibility. Confusion is used to prevent individuals from intellectualising
problems into the same solutions that have already failed (Hayes et al., 1999). The use of
mindfulness and metaphors contributes to learning acceptance. Metaphors are a figure of speech
where a word or phrase denoting one kind of object is used in place of another by suggesting a
likeness between them (McCurry & Hayes, 1992). For example, the metaphor of a scar, which
remains as a reminder, but is no longer painful, may be used to communicate acceptance ideas to
individuals with PTSD. The use of paradoxes helps to highlight that language is useful in some
contexts but not in others (Hayes et al., 1999). The most important paradox used in ACT is a rule
about private events, which is ‘if you aren’t willing to have it [thoughts, memories, feelings, bodily
sensations] you’ve got it’ (Hayes et al., 1999, p. 121).
Although there are specific phases of ACT, the sequence is not rigid (Hayes et al., 1999).
The first phase is Creative Hopelessness. Here, individuals identify what strategies they have used
to fix their problems and identify their success rate (Hayes et al., 2004c). Creative Hopelessness is
not feeling hopeless it is feeling hopeful that alternative strategies are available (Wilson, Follette,
Hayes & Batten, 1996).
The second phase is Control is the Problem – Not the Solution. The goal here is to
destabilise confidence in using the control-based strategies of removing, suppressing or distraction
to control private events (Hayes et al., 1999). Clients are not being asked to ‘give in’, ‘give up’ or
Vietnam veterans and ACT
Page 16
endure their pain, rather to paradoxically be willing to embrace the things that they dread at the
same time as they pursue valued life directions (Blackledge & Hayes, 2001).
The third phase is Building Acceptance by Defusing Language. Through cognitive defusion
techniques individuals learn that cognitions can become fused with identity, for example who you
are is what a thought says you are, such as ‘I am worthless’ (Hayes et al., 2004c). ACT uses
mindfulness exercises to help individuals realise that often thoughts are not their actual experience
and they become aware of the process of thinking not just the content (Ciarrochi & Robb, 2005).
The fourth phase is Discovering the Self. Here individuals experience the distinction
between a self that is constant and a self which undergoes an experience, that is, to distinguish
between self-as-context and self-as-content (Wilson et al., 1996). This self-as-context, provides
stability when individuals are being asked to experience what they have strenuously avoided
(Hayes, 1984) and the aim is to demonstrate that they will not be threatened by allowing themselves
to feel, think or experience whatever is present for them (Orsillo & Batten, 2005).
The fifth phase is Valuing. Here individuals decide what they want their life to stand for
(e.g., family, health) and goals are set, actions listed and psychological barriers to performing
actions identified (Hayes et al., 2004a). Orsillo and Batten (2005) state that this area is especially
critical to individuals with PTSD and argue that acceptance and cognitive defusion alone will not be
enough to motivate change with chronic PTSD sufferers.
The final phase of ACT is Willingness and Commitment – Putting ACT into Action. Here
individuals take action toward their valued life directions. Metaphors and experiential exercises
demonstrate the need to be open to all experiences, positive and negative, if individuals want to
fully live their life (Orsillo & Batten, 2005).
Vietnam veterans and ACT
Page 17
Positive outcomes have been reported using ACT with Generalised Anxiety Disorder
(Roemer & Orsillo, 2002), Panic Disorder (Levitt, Brown, Orsillo & Barlow, 2004), PTSD (Orsillo
& Batten, 2005), positive psychosis symptoms (Bach & Hayes, 2002), polysubstance abusing opiate
addicts on methadone (Hayes et al., 2004d), smoking cessation (Gifford et al., 2004), pain tolerance
(Gutiérrez, Luiciano, Rodríguez & Fink (2004) and workplace stress (Bond & Bunce 2004; Dahl,
Wilson & Nilsson, 2004).
These studies demonstrate that ACT is a comprehensive, yet flexible, treatment that is
underpinned by empirical research (Hayes et al., 2006). Additionally, it has been used with different
ethnic groups in a variety of formats, settings and time frames (Hayes et al., 2004b). However, there
appear to be common processes contributing to therapeutic outcomes. Although the actual
mechanisms of change remain unclear (Dahl, Wilson & Nilsson, 2004) positive changes appear to
be the result of some key processes which are different to those of traditional mainstream therapies
(Hayes et al., 2006). Namely, the reduction of experiential avoidance by increasing client
acceptance of experiencing negative sensations, thoughts, feelings and memories, while taking
action towards valued life directions.
A search of MEDLINE and PsychINFO revealed no published studies on the use of
Acceptance and Commitment Therapy (ACT) with Australian Vietnam veterans with PTSD.
Therefore, the rationale for this study is as follows: there is a need for further investigation of what
works for treating Vietnam veterans given that 31 percent of Australian Vietnam veterans originally
diagnosed with PTSD still have PTSD (DVA, 2004); it has been argued by some that there is a lack
of empirical support for one treatment producing superior outcomes to any other treatment for
PTSD (e.g., Bradley et al., 2005); some authors have pointed out that there is a high drop-out rate in
programmes which utilise exposure work (e.g., Orsillo & Batten, 2005); there is a need to look
Vietnam veterans and ACT
Page 18
beyond symptom reduction to broader psychosocial issues in PTSD programmes (APA, 2004), and
there is a call for dismantling studies of treatments for PTSD (Baer, 2003). ACT originators argue
that contact with the ‘observing’ self [experienced as part of the ‘discovering the self’ phase in
ACT] ‘… is critical to acceptance work … that kind of stability and constancy makes it less
threatening for a client to enter into the pain and travails of life’ (Hayes et al., 1999, p.186).
However, anecdotal experience by clinicians suggests that the ‘discovering the self’ phase may not
be essential for positive change (J. Kendall, personal communication, 14 July, 2006). Therefore, to
better understand the processes of ACT, the research question investigated in this study is ‘Does the
inclusion of the ‘discovering the self’ phase of ACT lead to outcomes that are significantly more
positive than ACT without this phase? In other words, in the application of Acceptance and
Commitment Therapy how important is it to ‘discover the self’ in order to live a good life and
reduce the symptoms of PTSD?
There are several hypotheses for the following study:
1.
General health
It is hypothesised that there will be an increase in general health and well-being scores for all
groups post-treatment.
2.
Psychological symptoms
It is hypothesised that there will be a decrease in scores for psychological symptoms,
including the severity of PTSD symptoms, for all groups post-treatment.
3.
Suppression of thoughts.
It is hypothesised that there will be a decrease in scores related to the suppression of
disturbing thoughts for all groups post-treatment.
4.
Mindfulness skills.
It is hypothesised that there will be an increase in mindfulness scores for all groups posttreatment.
Vietnam veterans and ACT
5.
Page 19
The importance of ‘discovering the self’.
It is hypothesised that the ACTFULL condition (the therapy programme that includes the
‘discovering the self’ phase) will show higher scores at the end of treatment on general health
and well-being and mindfulness skills and lower scores on measures of symptom severity and
thought suppression than the ACTDIS condition (the therapy programme that does not include
the ‘discover the self’ phase).
METHOD
Participants
Participants were 16 male Vietnam veterans all of Australian birth. Data for one veteran was
excluded from analysis as his self-report scores, structured interview scores and information the
researcher obtained from other sources failed to support an independent psychiatric diagnosis of
PTSD. The average age was 59.9 years (SD = 3.93, range = 56 to 67 years). Eighty percent had
secondary level education and 20% completed tertiary level. Twenty percent had never married
with 73.3% currently married and 6.7% were divorced. Although no veteran was in paid
employment, 33.3% did voluntary work. Table 1 Appendix E shows how demographics were
distributed between the two group conditions. Regarding psychiatric history, Table 3 Appendix G
shows the demographic distribution between the two groups and that 13.3% had been an inpatient
and 40.0% had received outpatient treatment for PTSD. Notably, 46.7% had never received hospital
treatment for PTSD. At the time of the study, 66.7% were currently taking psychotropic medication.
Current contact with a health professional was that 20.0% had their primary contact with a general
practitioner, 66.7% with a psychiatrist and 13.3% with a counsellor from the Vietnam Veterans’
Counselling Service. All veterans completed all sessions (i.e., each veteran attended 30 hours of
group therapy). Additionally, 15 of the 16 completed their group’s three-hour follow-up session
three months after their initial programme.
Vietnam veterans and ACT
Page 20
Design
The design of the study was a 2 x (3) mixed factorial, with one between-participants
comparison and one within-participants comparison (i.e., repeated measures). A dismantling
strategy with regard to treatment evaluation was utilised. One treatment approach (ACT) was used
in an outpatient group treatment format. For one treatment condition, the phase of ACT
‘discovering the self’, was omitted from the programme. The other treatment condition received the
full ACT programme. Two therapy groups each of 4 participants received the full ACT programme
(ACTFULL) and two therapy groups each of 4 participants received the ACT programme with the
‘discovering the self’ phase omitted (ACTDIS). Both treatment groups received an equal amount of
time (66 hours each group for a total of 132 treatment hours for the study) with the ACTDIS group
participating in a ‘free form discussion’ (topic of their choice) as a substitute for the ‘discovering
the self’ phase. All participants completed a variety of self-report measures of problem severity at
pre-treatment, post-treatment and after three months. Additionally, the constructs of thought
suppression (avoidance) and mindfulness were measured at pre-treatment, post-treatment, and after
three months. The follow-up session consisted of a review of goals committed to by each veteran
for the month and three months following their initial programme. It also consisted of open
discussion on which parts of ACT had worked well, any difficulties experienced in implementing
ACT, and the overall influence the veterans felt that ACT had had on their quality of life.
Measures
(i)
The Combat Exposure Scale (CES: Keane et al. 1989).
The CES is a self-report measure of the severity of a veteran’s experience with seven
wartime stressors measured on a Likert scale. Responses are weighted according to severity, for
example ‘seeing someone hit by incoming enemy rounds’ is weighted more than ‘firing rounds at
the enemy’. Total scores range from 0 to 41 and are classified as light – heavy levels of exposure.
The National Center for PTSD (NCPTSD) PILOTS Database (2007) has recorded that the CES has
Vietnam veterans and ACT
Page 21
been used in 399 published works. Keane et al. (1989) reported the CES shows sound
psychometrics with coefficient alpha of 0.85 for internal consistency and test-retest reliability of
0.97. The CES was used for matching for group allocation and cross-sectional analysis with PTSD
severity.
(ii)
The Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990).
The CAPS is a structured interview which assesses the 17 DSM-IV (APA, 1994) symptoms
of PTSD. The 2001 update used in this study also assesses life-time traumatic events, guilt,
dissociation, derealisation, depersonalisation and reduction in awareness of surroundings. It
measures symptom frequency and severity over the past week, month and lifetime diagnosis of
PTSD. Symptoms are measured on a five-point (0-4) rating scale and ratings can be summed to
create a 9-point (0-8) severity score for each symptom. Weathers, Keane and Davidson (2001)
found the CAPS has excellent reliability with alpha coefficients for internal consistency ranging
from 0.80 to 0.90 for all symptom clusters and the PTSD syndrome. According to Weathers et al.
(2001), the CAPS has been used in more than 200 empirical studies on PTSD either as the primary
diagnostic or outcome measure (e.g., Lubin, Loris, Burt & Johnson, 1998; Tarrier et al., 1999). In
this study, the CAPS was used to confirm a PTSD diagnosis assessing symptoms over the past
month and the 1-2 scoring rule was used (i.e., clinical threshold is a minimum frequency score of 1
and a minimum intensity score of 2). Combined with the CES, the CAPS provided a clearer
understanding of the specific nature of each veteran’s lifetime and war-related traumatic event(s).
(iii)
The Posttraumatic Stress Disorder Checklist – Military Version (PCL-M; Weathers, Litz,
Herman, Huska, & Keane, 1993).
The PCL-M is a self-report measure where respondents are asked how the 17 DSM-IV
symptoms have bothered them over the past month on a 5-point Likert scale ranging from ‘not at
all’ to ‘extremely’. The NCPTSD (2007) has recorded that the PCL-M has been used in 87
Vietnam veterans and ACT
Page 22
published works. According to Weathers et al. (1993), the PCL shows excellent psychometrics with
coefficient alpha of 0.97 for internal consistency for the total scale and 0.93 for Cluster B
symptoms, 0.92 for Cluster C symptoms and 0 .92 for Cluster D symptoms. It has excellent
diagnostic utility with a cut-off score of 50 indicating PTSD for military personnel. In this study,
the PCL-M was used to measure pre and post-treatment scores and at three months post-treatment
follow-up.
(iv)
The Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1994).
The SCL-90-R is a 90-item self-report questionnaire and is a useful screening device and
outcome measure (Ambrose, Button & Ormrod, 1998). Respondents mark answers to symptoms on
a 5-point Likert scale (0-4) ranging from ‘not at all’ to ‘extremely’ for the past week. It has nine
scales: somatisation; obsessive-compulsive; interpersonal sensitivity; depression; anxiety; hostility;
phobic anxiety; paranoid ideation and psychoticism. The NCPTSD (2007) has recorded that the
SCL-90-R has been used in 117 published works. The SCL-90-R shows good to excellent construct
validity with three global scores, the Global Severity Index (GSI), Positive Symptom Distress Index
(symptom intensity), and Positive Symptom Total (symptom breadth) (Derogatis & Cleary, 1977).
According to Derogatis and Cleary (1994) the GSI is the best single indicator where a summary
score is called for as it combines the number of symptoms reported with the intensity of perceived
distress. The GSI is the summary score used in this study. The SCL-90-R has adequate to good
reliability with alpha coefficients for individual scales ranging from .70 for Psychoticism to .90 for
Depression (Derogatis, 1994). Additionally, the SCL-90-R shows good test-retest reliability and
very high convergent validity (Derogatis, Rickels & Rock, 1976). In the current study, the SCL-90R was used to measure pre and post-treatment scores and at three months follow-up.
Vietnam veterans and ACT
(v)
Page 23
The General Health Questionnaire 28 (GHQ-28; Goldberg & Williams, 1988).
The GHQ is a self-administered tool which detects common non-psychotic psychiatric
symptoms experienced in the past few weeks. It is an indication of state rather than trait
characteristics. It provides a measure of total distress (0-28) and four scaled scores: somatic
symptoms; anxiety and insomnia; social dysfunction and depression. Participants respond on a 4point Likert scale, ranging from ‘better than usual’ to ‘much worse than usual’. Binary scoring
(0011) of the GHQ is used for case identification. Subscale scores are obtained using a Likert
(0123) method. A summary score of 5 indicates that the respondent is likely to suffer from
psychological distress and to have a psychiatric diagnosis (Rabinowitz, Shayevitz, Hornik &
Feldman, 2005). The NCPTSD (2007) has recorded that the GHQ-28 has been used in 538
published works. In the current study, the GHQ was used to measure pre and post-treatment scores
and at three months follow-up.
(vi)
The White Bear Suppression Inventory (WBSI; Wegner & Zanakos, 1994).
The WBSI is a self-report measure of the conscious desire to suppress thoughts. There are
15 questions, for example ‘there are things I prefer not to think about’ with responses ranging from
‘strongly disagree’ (1) to ‘strongly agree’ (5) with higher scores indicating chronic thought
suppression. Over five studies (N=2746), Wegner and Zanakos (1994) found that the mean WBSI
score for women was 47.7 and 45.8 for men. The NCPTSD (2007) has recorded that the WBSI has
been used in 18 published works. According to Wegner and Zanakos (1994), it is a reliable measure
with good internal consistency of 0.87 with undergraduate samples and test-retest reliability ranging
from 0.69 to 0.92. The WBSI has been reported to be positively correlated with emotional
vulnerability and psychopathological symptoms (Merckelbach & Horselenberg, 1996). In this
study, the WBSI was used to measure pre and post-treatment scores and at three months follow-up.
Vietnam veterans and ACT
(vii)
Page 24
The Kentucky Inventory of Mindfulness Skills (KIMS; Baer & Allen, 2004).
Measures of mindfulness are relatively new. The KIMS is a self-report inventory designed
to assess an individual’s general tendency to be mindful in daily life. It is used in general and
clinical populations including respondents with no meditation experience. Respondents rate 39
items on a 5-point Likert scale ranging from 1 (never or very rarely true) to 5 (almost always or
always true). The KIMS measures four mindfulness skills: observing (e.g., I pay attention to
whether my muscles are tense or relaxed); describing (e.g., I’m good at finding the words to
describe my feelings); acting with awareness (e.g., When I’m doing something, I’m only focused on
what I’m doing and nothing else) and accepting or allowing without judgment (e.g., I tend to
evaluate whether my perceptions are right or wrong). According to Baer, Smith, Hopkins,
Krietemeyer and Toney (2006) an undergraduate sample showed internal consistency of 0.87 for the
total scale with internal consistencies for the four subscales ranging from 0.76 to 0.91. Baer et al.
(2004) found that scores were significantly lower in a sample of individuals with borderline
personality disorder than in a student sample for all scales except the ‘observe’ subscale. In this
study, the KIMS was used as a pre and post-treatment measure and at three months follow-up.
Procedure
Approval to undertake this study was gained through Charles Sturt University’s Ethics in
Human Research Committee.
Veterans were recruited using a variety of methods: flyer mailed to random postcodes by the
Vietnam Veterans’ Federation (VVF); flyer inserted into a VVF magazine, advertisement placed in
the Totally and Permanently Incapacitated Association and Vietnam Veterans’ Association
magazines, flyer posted on the VVF website; flyer given to two general practitioners, three
psychiatrists, and word-of-mouth from other veterans.
Vietnam veterans and ACT
Page 25
McNally (2003) recommends that researchers verify combat experience by consulting
military records. In this study, when veterans volunteered to participate their service was verified by
consulting The Nominal Roll (DVA, 1997).
Veterans attended an Orientation Session conducted by the researcher. This covered an
outline of the study, the researcher’s experience working with PTSD and Vietnam veterans in an
outpatient hospital setting, knowledge of the Vietnam War and Vietnamese culture, and experience
with Acceptance and Commitment Therapy. A condition of participation was that veterans cease
any counselling while they were taking part in the study. However, those on medication would
continue that regime. Following informed consent, veterans completed the CES and PCL-M.
Veterans were then individually assessed using the CAPS to confirm PTSD and the specific nature
of their war-related traumatic event(s). A final decision on eligibility to participate was based on
accepted guidelines (ACPMH, 2005; Keane, 1995; Walhberg, 1997) as follows:
Inclusion criteria –

Veterans diagnosed with PTSD.

Veterans assessed as cognitively suitable (e.g., able to sustain attention) as observed during their
CAPS interview.
Exclusion criteria –

Veterans currently abusing drugs or alcohol.

Veterans exhibiting psychotic, suicidal, self-mutilating behaviour.

Veterans requiring nursing attention.
Veterans were allocated to one of the two treatment conditions by a matching process. The
matching criteria were severity of PTSD symptoms, level of combat exposure, and defence force
Vietnam veterans and ACT
Page 26
status (i.e., conscript or regular). Treatment condition 1 (ACTFULL) was experienced by two
therapy groups of 4 participants each. Treatment condition 2 (ACTDIS) was experienced by two
therapy groups of 4 participants each. Therapy groups were conducted one day a week for six
weeks from 9.30am to 3.00pm. The researcher received initial ACT training from a recognised
expert in ACT (Dr R. Walser) and adapted a preliminary protocol in use with inpatient Vietnam
veterans with PTSD at the VA Medical Center in California. The basic session outline was
maintained in order to maintain the integrity of ACT processes. Changes made by the researcher in
this study related to some differences in pre and post-treatment measurement instruments, selection
of daily centering/mindfulness exercises (details not specified in protocol), the addition of daily
summary charts of ACT material, and the addition of the ‘free form discussion’ for the ACTDIS
group to replace the ‘discovering the self’ phase received by the ACTFULL group. Additionally,
the researcher introduced the Values and Goals component of the Valuing phase on the first day of
the programme because the researcher considered this critical groundwork for the whole ACT
programme.
RESULTS
Statistical Analysis
Data were analysed using the Statistical Package for the Social Sciences (V14.0). Reliability
analyses were conducted for this study. Results showed that the CES showed an internal
consistency of 0.83, the PCL-M showed internal consistency of 0.92 for the total scale, 0.89 for
Cluster B, 0.82 for Cluster C, and 0.68 for Cluster D. While the GHQ-28 showed an internal
consistency of 0.90 for the total scale, results of 0.68 for somatic and 0.71 for anxiety/insomnia
subscales were low but acceptable, 0.87 for social dysfunction, and 0.85 for depression. The WBSI
showed an internal consistency of 0.74. Finally, the KIMS showed internal consistency of 0.84 for
the total scale, 0.93 for observe, 0.89 for act with awareness 0.89, and 0.82 for accept or allow
Vietnam veterans and ACT
Page 27
without judgment subscale. The describe subscale is below acceptable levels at 0.59. Whether this
is related to the Vietnam veteran population is unknown. At the time of this study, previous research
using the KIMS reported findings using two undergraduate samples and one borderline personality
sample. Alternatively, it may be a function of sample size (R. Baer, personal communication, 30
July, 2007).
Means and standard deviations (SD) are reported. As detailed in the Procedures section,
groups were compared on age, PSTD scores, combat exposure level severity and status which
showed that matching was successful. For normally distributed continuous variables, independent
samples t-tests were used to compare groups, and for categorical variables, chi-square analyses
were used. As recommended by Cook and Campbell (1979) for this type of quasi-experimental
analysis, repeated measures analyses of covariance (ANCOVA) were used to examine the effect of
time on the repeated outcome measures (e.g., PCL-M), and to explore whether there was a group by
time interaction (i.e., whether the two intervention groups differed in how their scores changed over
time). Pre-intervention scores were used as a covariate, and the post-intervention scores were used
as repeated measures. In the absence of random allocation, this analysis allows variance due to preintervention differences to be removed from the comparison of the post-test and follow-up scores,
while at the same time allowing the pre-test to be compared to the post-intervention tests.
Significance level was set at 0.05.
The research question investigated was ‘Does the inclusion of the ‘discovering the self’
phase of ACT lead to outcomes that are significantly more positive than ACT without this phase?’
It was hypothesised that both treatment groups would show a reduction in PTSD, psychiatric and
non-psychiatric symptoms and avoidance scores. Additionally, it was hypothesised that both groups
would show an increase in mindfulness scores. Finally it was hypothesised that the ACTFULL
Vietnam veterans and ACT
Page 28
group’s scores would show greater score changes than those of the ACTDIS group over the study
period.
Demographic data in Table 2 Appendix F shows the distribution between the two conditions
on characteristics of wartime service. Light intensity of combat was experienced by 13.3% and
light-moderate by 13.3%. Most experienced moderate (26.7%) to moderate-heavy (26.7%) intensity
of combat with heavy exposure experienced by 20%. Most veterans served in the army (86.7%)
with 6.7% each in the navy and air force. One veteran volunteered to serve in Vietnam and for
statistical analysis his data was included with regulars in the army (40.0%) while 53.3% were
conscripts. Rank was mainly private (66.7%) with rank of corporal (13.3%) and 6.7% each for
sergeant, captain and Major Lt-Commander.
Prior to ANCOVA analysis regarding the two levels of ACT intervention, cross-sectional
analysis was conducted using the total sample in order to identify potential influences on PTSD
symptoms (i.e., PCL-M). Results showed no significant differences in PTSD scores between
regulars or conscripts at pre-treatment, post-treatment or follow-up time points. There was a
significant difference in PTSD scores at the end of the treatment programme (six weeks) showing
that officers had higher PTSD scores than those of lower rank t(13) = -2.53, p = 0.025.
Additionally, veterans who had received previous treatment (inpatient or outpatient) for PTSD
showed higher PTSD scores at pre-treatment t(13) = -2.29, p = 0.039 and at follow-up t(13) = -2.50,
p = 0.028 than veterans who had not had any previous treatment for PTSD. Finally, there was a
significant association between the intensity of combat exposure and higher pre-treatment PTSD
scores r(15) = 0.546, p = 0.04 indicating that veterans who reported having experienced higher
levels of combat intensity had higher PTSD scores at the beginning of treatment.
Vietnam veterans and ACT
Page 29
Table 4 shows the means and standard deviations on outcome measures at pre-treatment,
post-treatment and three-month follow-up averaged across the total sample. The analysis of
covariance (ANCOVA) for the PCL-M total score approached a significant covariate main effect of
pre-test F(1,11) = 4.46, p = 0.058, with partial 2 = 0.29 and observed power of 48.7%. As shown
in Figure 1 there is an evident difference and this result may be a Type II error failing to detect that
the pre-test score was significantly different from the averaged post-test and follow-up scores for
the total sample (see Table 4). Neither the group main effect F(1,11) = 1.09, p = 0.320, nor the time
main effect F(1,11) = 0.35, p = 0.565 were significant. The interaction between the covariate and
the time main effect was not significant F(1,11) = 0.70, p = 0.419. However, there was a significant
interaction between group and the time main effect F(1,11) = 4.83, p = 0.050, with partial 2 = 0.31,
indicating that 31% of the variance in the time main effect on PCL-M score was accounted for by
group. This result suggests that the ACTFULL group had a significantly greater decrease in PCL-M
scores from post to follow-up than the ACTDIS group (see Figure 1).
The ANCOVA for the SCL-90-R indicated a significant covariate main effect of pre-test
F(1,11) = 32.19, p = 0.001, that is, the pre-test score was significantly different from the averaged
post-test and follow-up scores for the total sample (see Table 4). Neither the group main effect
F(1,11) = 0.53, p = 0.483, nor the time main effect F(1,11) = 0.24, p = 0.631 were significant. The
interaction between the covariate and the time main effect was not significant F(1,11) = 0.42, p =
0.533. There was also no significant interaction between group and the time main effect F(1,11) =
4.55, p = 0.056.
The ANCOVA for the GHQ-28 total score indicated a significant covariate main effect of
pre-test F(1,11) = 12.06, p = 0.005, indicating that the pre-test score was significantly different
from the averaged post-test and follow-up scores for the total sample (see Table 4). Neither the
group main effect F(1,11) = 0.53, p = 0.483, nor the time main effect F(1,11) = 0.11, p = 0.742
Vietnam veterans and ACT
Page 30
were significant. The interaction between the covariate and the time main effect was not significant
F(1,11) = 0.18, p = 0.684. There was also no significant interaction between group and the time
main effect F(1,11) = 1.39, p = 0.264.
The ANCOVA for the WBSI indicated no significant covariate main effect of pre-test
F(1,11) = 4.26, p = 0.063. Neither the group main effect F(1,11) = 4.65, p = 0.054, nor the time
main effect F(1,11) = 0.19, p = 0.674 were significant. The interaction between the covariate and
the time main effect was not significant F(1,11) = 0.05, p = 0.824. There was also no significant
interaction between group and the time main effect F(1,11) = 1.07, p = 0.322.
The ANCOVA for the KIMS total score indicated a significant covariate main effect of pretest F(1,11) = 59.76, p = 0.001, indicating that the pre-test score was significantly different from the
averaged post-test and follow-up scores for the total sample (see Table 4). Neither the group main
effect F(1,11) = 0.22, p = 0.650, nor the time main effect F(1,11) = 0.54, p = 0.476 were significant.
The interaction between the covariate and the time main effect was not significant F(1,11) = 0.73, p
= 0.410. There was also no significant interaction between group and the time main effect F(1,11) =
0.35, p = 0.568.
Vietnam veterans and ACT
PCL-M PreTreatment total
score
PCL-M PostTreatment total
score
PCL-M 3-Month
Follow-up total
score
65
60
Mean PCL-M total score
Page 31
55
50
45
40
35
30
ACTFULL
ACTDIS
ACTFULL or ACTDIS
Figure 1 Means for PCL-M at pre, post and follow-up time points
Vietnam veterans and ACT
Page 32
Table 4.
Means and Standard Deviations on Outcome Measures at Pre-Treatment, Post-Treatment and
3-Month Follow-Up (N=14)
Pre-Treatment
Outcome Measure
Post-Treatment
3-Month F/Up
M
SD
M
SD
M
SD
Re-experiencing
14.21
4.49
13.57
4.91
11.43
4.11
Avoidance
24.43
5.52
16.86
5.75
17.36
4.97
Hyperarousal
18.43
3.39
14.64
3.39
14.07
3.50
Total Score
56.86
12.30
44.36
11.02
41.64
12.50
1.63
0.70
1.14
0.52
1.11
0.48
9.31
4.61
6.92
4.17
6.77
2.74
Anxiety/Insomnia
10.38
4.25
7.15
3.29
6.46
2.33
Social dysfunction
10.38
4.41
6.38
2.99
5.77
3.37
Depression
6.31
4.07
4.00
2.80
3.46
3.73
Total Score
34.54
11.60
24.46
9.55
22.77
9.14
WBSI Total
64.36
5.50
55.00
7.20
59.86
5.76
Observing
35.79
10.91
38.07
8.81
38.14
8.67
Describing
17.93
3.25
21.64
4.72
23.07
5.80
Acting with awareness
27.00
7.85
27.64
5.80
28.43
6.39
Accept/allow without
23.00
6.02
25.29
5.08
24.79
13.41
103.71
14.45
112.64
11.68
114.43
13.33
PCL-M
SCL-90-R
GSI Total Score
GHQ-28
Somatic
KIMS
judgment
Total Score
Note. PCL-M = Posttraumatic Stress Disorder Scale – Military version; SCL-90-R = Symptom Checklist 90Revised; GHQ-28 = General Health Questionnaire-28, WBSI = White Bear Suppression Inventory; KIMS =
Kentucky Inventory of Mindfulness Skills.
Vietnam veterans and ACT
Page 33
DISCUSSION
This study examined two versions of Acceptance and Commitment Therapy. The hypothesis
that all veterans would show a decrease in total scores for PTSD symptoms, psychiatric and nonpsychiatric symptoms was supported and maintained at follow-up. The expected result that there
would be a decrease in conscious suppression of disturbing thoughts was not supported. Although
there was a decrease in scores for the total sample from pre-treatment to post-treatment this was not
maintained at follow-up. Additionally, the hypothesis that all veterans would show an increase in
total mindfulness scores was also supported and maintained at follow-up. The final hypothesis that
the ACTFULL group would show greater score changes than the ACTDIS group was only
supported for the PCL-M where the ACTFULL group showed a significantly greater decrease in
PTSD scores from post-treatment to follow-up time points than the ACTDIS group. Therefore, in
relation to the research question it is difficult to conclude that veterans need to ‘discover the self’ in
order to live a good life and reduce PTSD symptoms.
Overall, the current study supports previous recommendations that ACT can be effective as
a group programme (Walser & Pistorellio, 2004) and is suitable for individuals with high levels of
experiential avoidance (Hayes et al., 1999). It offers continued support to the APA (2004)
recommendation that outpatient treatment is appropriate for most individuals with PTSD and that
outpatient treatment for veterans can be as effective as inpatient treatment (Creamer et al., 2002).
Importantly, the study shows that the application of ACT phases is flexible and therefore it is not
constrained by a manualised approach (Barlow, Allen & Choate, 2004).
An interesting finding was that at pre-treatment and three-month follow-up veterans who
had not had previous treatment for PTSD had lower PTSD scores than those who had previously
had inpatient or outpatient hospital treatment. On one hand, this may be because they did not have
Vietnam veterans and ACT
Page 34
to contend with the possible cognitive confusion of previously learnt therapeutic strategies or that
their symptoms were less severe overall. On the other hand, some veterans who had completed the
CBT accredited model (Creamer & Forbes, 2004) reported that they did not find a CBT model
helpful and found ACT more suitable for their needs. One promising implication of this finding
may be that it suggests that it is not too late for Vietnam veterans with PTSD to learn new skills
which can lead to positive life changes. Considering current military conflicts (Hoge et al., 2004) it
is critical that clinicians maintain research into alternative treatments for veterans with PTSD.
Continued research will also assist with institutional financial planning as veterans are major
consumers of health care services as noted by O’Toole et al. (1996).
Clinical implications of this study need to be considered in terms of how ACT moves
beyond traditional treatment models (APA, 2004; Beidel & Frueh, 2005) theoretically and
operationally. As Lombardo and Gray (2005) observe, the focus on life values in ACT is a critical
differentiator from other models. To this end, the researcher in the current study introduced the
Valuing phase on the first day of the programme and every component of the ACT model, on every
treatment day, was linked back to the values and goals that veterans were defining in various life
areas. Values are the ‘glue’ that binds the ACT programme together. In reality, this was not an easy
task. For example, some veterans struggled with the potential risk of failure if values, goals and
psychological barriers to the achievement of goals were documented. It is significant, therefore, that
all veterans completed their one-month and three-month goals that they had set for themselves at
the end of the programme.
Although Tarrier and Sommerfield (2004) found that the eradication of avoidance achieved
better outcomes than exposure it is difficult to say whether this is an either or argument. Indeed, the
current study offers continued support for the benefits of exposure work and avoidance reduction.
Related to exposure work Orsillo and Batten (2005) found that the ‘observer exercise’ [part of the
Vietnam veterans and ACT
Page 35
‘discovering the self’ phase] was so powerful that it enabled their composite case study Vietnam
veteran to work directly on previously avoided trauma memories. In the current study, veterans
were told that they would not be expected to do exposure work as an essential part of the ACT
programme, but could do so if they chose to. The ACTDIS group on Day 3 was given a substitute
session instead of the ‘discovering the self’ phase. They had a ‘free form discussion’, for example
discuss: topic of their choice; would you rather drive a Harley Davidson motorcycle or a Triumph;
would you drink recycled water? It was noteworthy that they talked about traumatic Vietnam War
memories. Topics discussed included: decisions that resulted in the death and or injury of a fellow
soldier; survivor guilt; guilt at taking the opportunity to return home early or early repatriation due
to illness; guilt relating to their contribution to the ravaging of the Vietnamese country and innocent
people; and the burden of enemy contact, either not knowing if they had personally killed someone,
or feeling that they did not have enough contact with the enemy. Indeed, every veteran discussed
either personal or war-related traumatic memories at some stage throughout the programme. This is
important because rather than confirming or disconfirming the critical nature of the ‘discovering the
self’ phase, this result seems to indicate the significance of the other ACT phases of Valuing,
Creative Hopelessness, Control is the Problem – Not the Solution, and Willingness as an
Alternative, which were completed by all veterans, prior to the ‘discovering the self’ phase.
Related to the reduction of avoidance, another factor that differentiates ACT from other
models is that ACT often works outside the language system (Hayes et al., 1999). The use of
experiential exercises, metaphors and confusion seemed to increase veterans’ willingness to reduce
avoidance of disturbing thoughts, emotions, memories and or bodily sensations. This contrasts with
the outcome from the Jakupcak et al. (2006) study with Vietnam veterans using Behavioural
Activation which did not include exposure to traumatic memories. Their study showed no
significant changes in PCL-M scores for the sample, no changes in depression scores, and in some
cases, depression worsened. By contrast, in the current study, a surprising outcome resulted from an
Vietnam veterans and ACT
Page 36
experiential exercise on Day 6 called ‘What Does the Little Kid Want?’ It was compelling that all
veterans talked about severe negative emotional experiences that for some took place as early as
five years of age. Therefore, with all veterans reducing their total scores on psychiatric and nonpsychiatric symptoms and reducing avoidance of painful memories, thoughts, emotions and bodily
sensations this adds support to the findings by Elliott et al. (2004) that experiential processes
increase access to emotions and emotional processing which are associated with better treatment
outcomes.
It is relatively new to incorporate the concept of mindfulness into mainstream therapies.
ACT includes mindfulness as a way of reducing avoidance and daily practice gave veterans the
experience of noticing whatever was happening at the moment without striving to relax, reduce
their pain or change their thoughts or emotions. Additionally, the lack of attachment to an outcome
(i.e., reducing symptoms) while focusing on living a valued life is a marked departure from more
common interventions such as CBT (Krasner, 2004). Mindfulness seemed to work in a synergistic
fashion with the Willingness phase of ACT to reduce avoidance and move towards goals. Although
there are no norms for mindfulness, veteran scores were compared to two student samples and a
borderline personality disorder sample (R. Baer, personal communication, 15 December, 2005). At
pre-treatment, total mindfulness scores for the total veteran sample were lower than the three Baer
and Allen (2004) samples mentioned. At post-treatment and follow-up, veteran scores had increased
but were lower than the two student samples and higher than the borderline personality sample. The
current study found that although mindfulness skills are not difficult to learn they are more difficult
to implement. That is, being mindful is the opposite to what many veterans have been trained to do,
that is to be disciplined about an outcome, be alert, and be able to juggle many tasks
simultaneously. However, it was seen that mindfulness skills can develop over time and, as
recommended by Kabat-Zinn (2003), ideally daily practice, both formally and informally, results in
greater benefits. Although the increase in veterans’ scores was small, these results add support to
Vietnam veterans and ACT
Page 37
Baer’s (2003) findings that mindfulness-based interventions may help reduce physical and
psychological symptoms.
Other interesting results came from cross-sectional analysis. Firstly, there was an association
between high levels of combat exposure and higher PTSD scores than those exposed to low or
moderate levels of combat. This supports the finding by Tennant and Streimer (1990) who found
that Australian Vietnam veterans with PTSD had experienced substantially higher levels of combat
stress than veterans hospitalised with anxiety, dysthymic, somatoform, dissociative and adjustment
disorders. The current study also found, as did Tennant and Streimer, that there was no difference
between PTSD scores for regulars or conscripts. It was notable that the current study showed that at
the end of the six-week programme, that although officers had reduced their PTSD scores, their
scores were higher than PTSD scores for enlisted men. This may be an area that merits further
exploration. However, in this study the researcher found that officers are extremely reluctant to
present for treatment due to perceived stigma of having PTSD.
At a qualitative level there were some important changes as veterans started to practice their
ACT skills. For example, some told how their relationships with their children had improved, some
contacted specific people or did things that they had avoided or feared for years, some had better
sleep and all drank less alcohol. It was significant that the 40th anniversary of the Battle of Long
Tan, which was Australia’s most intense battle during the Vietnam War, occurred during the course
of this study. This could potentially have been a trigger for veterans to lapse into avoidance or old
maladaptive ways. This did not occur however, and veterans reported that they attended previously
avoided commemorative functions, drank less alcohol, and experienced less depressive mood and
less anger.
Vietnam veterans and ACT
Page 38
A final point worthy of comment is that there were no dropouts and only one veteran failed
to attend his three-month follow-up. One possible explanation may be attributed to the
characteristics of the veterans themselves and the discipline of their defence force training. Another
contributing factor could be that the researcher regularly maintained contact with all veterans
through a series of letters, including updating the groups who were waiting to start their
programme.
The main limitation of this study is the size of the sample. The relatively small sample size
means that not all significant analyses had adequate power (Wilson Van Hoorhis & Morgan, 2007).
Larger sample sizes in future studies, due to the availability of co-therapists, will go some way in
addressing this point. However, it needs to be noted that small group sizes (i.e., 5 – 10 maximum)
are recommended for combat veterans and other trauma populations (Walhberg, 1997). McNally
(2003) cites problems with research into Vietnam veterans and others with PTSD. He questions the
accuracy of self-reports, and potential faking of symptoms to avoid the risk of losing financial
incentives (e.g., disability payments). However, the researcher in this study used extensive
structured and unstructured methods to establish PTSD diagnoses. Additionally, this study had no
association with the Department of Veteran Affairs and therefore pension payments were never at
risk. A common criticism with this type of research is that the sample may not be representative
because veterans who participated were motivated to make changes. Although this criticism may be
valid the nature of the study was that participation was voluntary. However, given that it is well
known that combat veterans are reluctant to access mental health services due to potential
stigmatisation (Hoge et al., 2004; Martin, 2001) it is argued that the benefits to veterans outweigh
this methodological limitation.
Vietnam veterans and ACT
Page 39
This was an intense programme and in a group format the researcher suggests some changes
if implementing ACT in future studies. Firstly, it is suggested that more mindfulness practice is
included. This study had one session each treatment day and veterans were encouraged to practice
daily and were given examples of how to do so. Secondly, if conducting groups in a closed format
have fortnightly rather than weekly sessions to enable more time for assimilation and practice of
skills. Thirdly, include family sessions as there is a need to consider significant others affected by
interactions with veterans. Fourthly, include individual sessions for veterans that could cater for
individual management, such as exposure work or documenting specific steps to achieve defined
goals.
CONCLUSION
Although this study did not show conclusively that it is critical to ‘discover the self’ in order
to live a good life and reduce PTSD symptoms, it does offer support for ACT to be considered as a
viable therapeutic model. It adds to past studies which show that ACT offers a flexible approach to
treatment that goes beyond symptom reduction as the primary treatment goal. It appears that ACT is
operating in a different way to traditional models. It differentiates itself by adopting an experiential
and mindfulness approach, often non-language based, to reduce avoidance on the journey towards
acceptance with the aim of achieving goals in accordance with individual values. The study
demonstrates that ACT can be effective as an outpatient group programme for veterans and shows
that ACT methods may help to reduce drop-out rates and provide a safe pathway to exposure work.
This paper began with the voices of the veterans and it seems appropriate to end it with their
voices. At the follow-up session, each was asked the question ‘Overall, what comment would you
like to make about the ACT tools and the general effect it has had on your life?’ Their responses
Vietnam veterans and ACT
Page 40
included: ‘I have never previously attempted to deal with my PTSD symptoms. Since attending this
course I have stopped avoiding everything to do with my Vietnam experience and started applying
some of the skills learned to enhancing my enjoyment of life; it has empowered me with the
approach of acceptance of uncomfortable feelings; it really liberates the mind and gives you the
ability to put things in perspective and work out what is important and what isn’t; [ACT has]
enhanced my family relationships, more at peace with myself, life and fellow humans’.
Vietnam veterans and ACT
Page 41
References
Ambrose, L., Button, E., & Ormrod, J. (1998). A long-term follow-up study of a cohort of referrals
to an adult mental health clinical psychology department. British Journal of Clinical
Psychology, 37, 113-115.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
American Psychiatric Association (2004). Practice guidelines for the treatment of patients with
acute stress disorder and posttraumatic stress disorder. Washington. Author.
Australian Centre for Posttraumatic Mental Health (2005). PTSD review – prevalence, prediction
and psychological treatment. Retrieved October 25, 2005 from
http://www/acpmh.unimelb.edu.au/research/ptsdReview.html
Australian Institute of Health and Welfare (1999). Morbidity of Vietnam veterans: A study of the
health of Australia’s Vietnam veteran community. Vol 3: Validation study. Canberra: AIHW.
Bach, P., & Hayes, S.C. (2002). The use of Acceptance and Commitment Therapy to prevent the
rehospitalisation of psychotic patients: A randomised controlled trial. Journal of Consulting
and Clinical Psychology, 7, 1129-1139.
Baer, R. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review.
Clinical Psychology: Science and Practice, 10, 125-143.
Vietnam veterans and ACT
Page 42
Baer, R., & Allen, K. (2004). Assessment of mindfulness by self-report: The Kentucky Inventory of
Mindfulness skills. Assessment, 11, 191-206.
Baer, R., Smith, G., Hopkins, J., Krietemeyer, J. & Toney, L. (2006). Using self-report assessment
methods to explore facets of mindfulness. Assessment, 13, 27-45.
Barlow, D., Allen, L., & Choate, M. (2004). Toward a unified treatment for emotional disorders.
Behavior Therapy, 35, 205-230.
Blackledge, J.T. (2003). An introduction to Relational Frame Theory: Basics and applications. The
Behavior Analyst Today, 3, 421-433.
Blackledge, J., & Hayes, S. (2001). Emotion regulation in acceptance and commitment therapy.
Psychotherapy in Practice, 57, 243-255.
Blake, D., Weathers, F., Nagy, L., Kaloupek, D., Klauminzer, G., Charney, D., & Keane, T. (1990).
A clinician rating scale for assessing current and lifetime PTSD: the CAPS-1. Behavior
Therapy, 13, 187-188.
Bond, F., & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused
worksite stress management interventions. Journal of Occupational Health Psychology, 5,
156-163.
Bradley, R., Green, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis
of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214-227.
Vietnam veterans and ACT
Page 43
Brown, K., & Ryan, R. (2003). The benefits of being present: Mindfulness and its role in
psychological well-being. Journal of Personality and Social Psychology, 84, 822-848.
Chan, W. (1963). A source book in Chinese philosophy. New Jersey: Princeton.
Ciarrochi, J., Robb, H., & Godsell, C. (2005). Letting a little nonverbal air into the room: Insights
from acceptance and commitment therapy part 1: Philosophical and theoretical underpinnings.
Journal of Rational-Emotive & Cognitive Behavior Therapy, 23, 79-106.
Ciarrochi, J., Robb, H. (2005). Letting a little nonverbal air into the room: Insights from acceptance
and commitment therapy part 2: Applications. Journal of Rational-Emotive & Cognitive
Behavior Therapy, 23, 107-130.
Cochrane . P. (1990). At war at home. In G. Pemberton (Ed), Vietnam Remembered (pp. 164-185).
Sydney: Weldon Publishing.
Commonwealth Department of Veterans’ Affairs (1998). Morbidity of Vietnam veterans: A study of
the health of Australia’s Vietnam veteran community. Vol 1: Male Vietnam veterans survey
and community comparison outcomes. Canberra: Department of Veterans’ Affairs.
Commonwealth Department of Veterans’Affairs (1997). The Nominal Roll of Vietnam Veterans.
Canberra: Author.
Cook, T., & Campbell, D. (1979). Quasi-experimentation: Design and analysis for field settings.
Chicago: Rand McNally.
Vietnam veterans and ACT
Page 44
Crane, P., Barnard, D., Horsley, K., & Adena, M. (1997). Mortality of national service Vietnam
veterans. A report of the 1996 retrospective cohort study of Australian Vietnam veterans.
Canberra: Department of Veterans’ Affairs.
Creamer, M., & Forbes, D. (2004). Treatment of posttraumatic stress disorder in military and
veteran populations. Psychotherapy: Theory, Research, Practice, Training, 41, 388-398.
Creamer, M., Forbes, D., Biddle, D., & Elliott, P. (2002). Inpatient versus day hospital treatment for
chronic combat-related posttraumatic stress disorder: A naturalistic comparison. The Journal
of Nervous and Mental Disease, 190, 183-189.
Creamer, M., Forbes, D., Phelps, A., & Humphreys, L. (2004). Treating traumatic stress:
Conducting imaginal exposure in PTSD. Heidelberg: Australian Centre for Posttraumatic
Mental Health Inc.
Dahl, J., Wilson, K., & Nilsson, A. (2004). Acceptance and Commitment Therapy and the treatment
of persons at risk for long-term disability resulting from stress and pain symptoms: A
preliminary randomised trial. Behavior Therapy, 35, 785-801.
Derogatis, L. (1994). SCL-90-R administration, scoring and procedures manual (3rd ed.).
Minneapolis: National Computer Systems.
Derogatis, L., & Cleary, P. (1977). Confirmation of the dimensional structure of the SCL-90: A
study in construct validation. Journal of Clinical Psychology, 33, 981-989.
Vietnam veterans and ACT
Page 45
Derogatis, L., Rickels, K., & Rock, A. (1976). The SCL-90 and the MMPI: A step in the validation
of a new self-report scale. British Journal of Psychiatry, 128, 280-289.
Eifert, G., & Forsyth, J. (2005). Acceptance & Commitment Therapy for Anxiety Disorders: A
practitioner’s guide to using mindfulness, acceptance and values-based behaviour change
strategies. Oakland, CA: New Harbinger.
Elliott, R., Greenberg, L., & Lietaer, G. (2004). Research on experiential psychotherapies. In M.
Lambert, A. Bergin & S. Garfield (Eds), Handbook of psychotherapy and behaviour change
(5th ed.), pp. 493-541. New York: Wiley.
Evans, B. (2003). Hypnosis for post-traumatic stress disorders. Australian Journal of Clinical and
Experimental Hypnosis, 31 (1), 54-73.
Flouri, E. (2005). Post-traumatic stress disorder (PTSD): What we have learned and what we still
have not found out. Journal of Interpersonal Violence, 20, 373-379.
Foa, E., Davidson, J., & Frances, A. (1999). The expert consensus guidelines series: Treatment of
posttraumatic stress disorder. Journal of Clinical Psychiatry, 60, 1-76.
Foa, E., Riggs, D., Massie, E., & Yarczower, M. (1995). The impact of fear activation and anger on
the efficacy of exposure treatment for posttraumatic stress disorder. Behavior Therapy, 26,
478-499.
Friedman, M. (1997). Pharmacotherapy for PTSD: a status report. NCP Clinical Quarterly, 7 (4),
1-5.
Vietnam veterans and ACT
Page 46
Gifford, E.V., Kohlenberg, B.S., Hayes, S.C., Antonuccio, D.O., Piasecki, M.M., Rasmussen-Hall,
M.L., & Palm, K. (2004). Acceptance-based treatment for smoking cessation. Behavior
Therapy, 35, 689-7065.
Gold, D., & Wegner, D. (1995). Origins of ruminative thought: Trauma, incompleteness,
nondisclosure, and suppression. Journal of Applied Social Psychology, 25, 1245-1261.
Goldberg, D., & Williams, P. (1988). A user’s guide to the general health questionnaire. Berkshire:
NFER-Nelson.
Gutiérrez, O., Luciano, C., Rodríguez, M., & Fink, B. (2004). Comparison between an acceptancebased and a cognitive-control based protocol for coping with pain. Behavior Therapy, 35, 767783.
Hayes, S.C. (1984). Making sense of spirituality. Behaviorism, 12, 99-110.
Hayes, S.C. (2004a). Acceptance and commitment therapy, relational frame theory and the third
wave of behavioral and cognitive therapies. Behavior Therapy, 35, 639-665.
Hayes, S., Luoma, J., Bond, F., Masuda, A., & Lillis, J. (2006). Acceptance and commitment
therapy: Model, processes and outcomes. Behaviour Research & Therapy, 44, 1-25.
Hayes, S.C., Masuda, A., Bissett, R., Luoma, J., & Guerrero, L.F. (2004b). DBT, FAP, and ACT:
How empirically oriented are the new behaviour therapy technologies? Behavior Therapy.
Vietnam veterans and ACT
Page 47
Retrieved February 14, 2005 from
http://www.personal.kent.edu/~dfresco/CBT_Readings/ACT_FAP_&_DBT_review.pdf
Hayes, S.C., Masuda, A., & De Mey, H. (2004c). Acceptance and Commitment Therapy and the
third wave of behaviour therapy. Behavior Therapy, 35, 639-664.
Hayes, S.C., Strosahl, K., & Wilson, K. (1999). Acceptance and Commitment Therapy: An
experiential approach to behavior change. New York: Guilford Press.
Hayes, S., & Wilson, K. (2003). Mindfulness: Method and process. Clinical Psychology: Science
and Practice, 10, 161-165.
Hayes, S.C., Wilson, K., Gifford, E.V., Bissett, R., Piasecki, M., Batten, S., Byrd, M., & Gregg, J.
(2004d). A preliminary trial of Twelve-Step Facilitation and Acceptance and Commitment
Therapy with polysubstance-abusing Methadone-maintained Opiate addicts. Behavior
Therapy, 35, 667-688.
Hoge, C., Castro, C., Messer, S., McGurk, Cotting, D., & Koffman, R. (2004). Combat duty in Iraq
and Afghanistan, mental health problems, and barriers to care. New England Journal of
Medicine, 351, 13-22.
Hyams, K., Wignall, S., & Roswell, R. (1996). War syndromes and their evaluation: From the Civil
War to the Persian Gulf War. Annals of Internal Medicine, 125, 398-405.
Vietnam veterans and ACT
Page 48
Jakupcak, M., Roberts, L., Martell, C., Mulick, P., Scott, M., Reed, R., Balsam, K., Yoshimoto, D.
& McFall, M. (2006). A pilot study of behavioural activation for veterans with posttraumatic
stress disorder. Journal of Traumatic Stress, 19, 387-391.
Jaycox, L., Foa, E., & Morral, A. (1998). Influence of emotional engagement and habituation on
exposure therapy for PTSD. Journal of Consulting and Clinical Psychology, 66 (1) 185-192.
Jordan, K., Marmar, D., Fairbank, J., Schlenger, W., Kulka, R., Hough, R., & Weiss, D. (1992).
Problems in families of male Vietnam veterans with posttraumatic stress disorder. Journal of
Consulting and Clinical Psychology, 60, 916-926.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future.
Clinical Psychology: Science and Practice, 10, 144-156.
Keane, T. (1995). The role of exposure therapy in the psychological treatment of PTSD. NCP
Clinical Quarterly, 5, 1-17.
Keane, T., Fairbank, J., Caddell, J., Zimering, R., Taylor, K., & Mora, A. (1989). Clinical valuation
of a measure to assess combat exposure. Psychological Assessment, 1, 53-55.
Koenen, K., Stellman, J., Stellman, S., & Sommer. J. (2003). Risk factors for course of
posttraumatic stress disorder among Vietnam veterans: A 14-year follow-up of American
legionnaires. Journal of Consulting and Clinical Psychology, 71, 980-986.
Krasner, M. (2004). Mindfulness-based interventions: A coming of age. Families, Systems &
Health, 22, 207-212.
Vietnam veterans and ACT
Page 49
Langer, E., & Moldoveanu, M. (2000). The construct of mindfulness. Journal of Social Issues, 56,
1-9.
Levitt, J., Brown, T.A., Orsillo, S.M., & Barlow, D. (2004). The effects of acceptance versus
suppression of emotion on subjective and psychophysiological response to Carbon Dioxide
challenge to patients with Panic Disorder. Behavior Therapy, 35, 747-766.
Lombardo, T., & Gray, M. (2005). Beyond exposure for posttraumatic stress disorder (PTSD)
symptoms. Broad-spectrum PTSD treatment strategies. Behavior Modification, 29, 3-9.
Lubin, H. Loris, Burt, J., & Johnson, D. (1998). Efficacy of psychoeducational group therapy in
reducing symptoms of posttraumatic stress disorder among multiply traumatized women.
American Journal of Psychiatry, 155, 1172-1177.
McCurry, S., & Hayes, S. (1992). Clinical and experimental perspectives on metaphorical talk.
Clinical Psychology Review, 12, 763-785.
McNally, R. (2003). Progress and controversy in the study of posttraumatic stress disorder. Annual
Review of Psychology, 54, 229-252.
Marks, I., Lovell, K. Noshirvani, H., Livanou, M., & Thrasher, S. (1998). Treatment of
posttraumatic stress disorder by exposure and/or cognitive restructuring. Archives of General
Psychiatry, 55, 317-325.
Vietnam veterans and ACT
Page 50
Marshall, R., Jorm, A., Grayson, D., & O’Toole, B. (1998). Posttraumatic stress disorder and other
predictors of health care consumption by Vietnam veterans. Psychiatric Services, 49, 16091611.
Martin, G. (2001). Post traumatic stress disorder (PTSD): An Australian Vietnam veteran’s
experience. Retrieved July 3, 2005 from http://www.vvaa.org/au.experience.html
Mendlowicz, M., & Stein, M. (2000). Quality of life in individuals with anxiety disorders. The
American Journal of Psychiatry, 157, 669-682.
Merckelbach, M., & Horselenberg, R. (1996). Individual differences in thought suppression. The
White Bear Suppression Inventory: factor structure, reliability, validity and correlates.
Behaviour Research & Therapy, 34, 501-13.
National Center for PTSD (2007). The PILOTS Database. Retrieved April 24, 2007 from
http://www.ncptsd.va.gov/ncmain/publications/pilots/index.html
National University of Ireland (2005). Relational Frame Theory. Retrieved February 18, 2005 from
http://www.nuim.ie/academic/psychology/RFT.shtml
Nightingale, J., & Williams, R. (2000). Attitudes to emotional expression and personality in
predicting post-traumatic stress disorder. The British Journal of Clinical Psychology, 39, 243254.
Orsillo, S., & Batten, S. (2005). Acceptance and commitment therapy in the treatment of
posttraumatic stress disorder. Behavior Modification, 29, 95-129.
Vietnam veterans and ACT
Page 51
O’Toole, B., Marshall, R., Grayson, D., Schureck, R., Dobson, M., Ffrench, G., Pulvertaft, B.,
Meldrum, L., Bolton, J., & Vennard, J. (1996). The Australian Vietnam Veterans Health
Study: III. psychological health of Australian Vietnam veterans and its relationship to combat.
International Journal of Epidemiology, 25, 331-340.
Ozer, E., Best, S., Lipsey, T., & Weiss, D. (2003). Predictors of posttraumatic stress disorder and
symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52-73.
Pigot, J. (2000). Leather Bred Heroes. Victoria: Arts Victoria.
Price, J. (2005). Findings from the National Vietnam Veterans’ Readjustment Study. Retrieved
December 21, 2005 from http://www.ncptsd.va.gov/facts/veterans/fs_NVVRS.html
Rabinowitz, J., Shayevitz, D., Hornik, T., & Feldman, D. (2005). Primary care physicians’ detection
of psychological distress among elderly patients. The American Journal of Geriatric
Psychiatry, 13, 773-780.
Roemer, L., & Borkovec, T. (1994). Effects of suppressing thoughts about emotional material.
Journal of Abnormal Psychology, 103, 467-474.
Roemer, L., & Orsillo, S. (2002). Expanding our conceptualisation of treatment for Generalised
Anxiety Disorder: Integrating mindfulness/acceptance-based approaches with existing
cognitive-behavioral models. Clinical Psychology: Science and Practice, 9, 54-58.
Vietnam veterans and ACT
Page 52
Summerfield, D. (2001). The invention of post-traumatic stress disorder and the social usefulness of
a psychiatric category. British Medical Journal, 322, 95-98.
Tarrier, N., Pilgrim, H., Sommerfield, C., Faragher, B., Reynolds, M., Graham, E., &
Barrowclough, C. (1999). A randomized trial of cognitive therapy and imaginal exposure in
the treatment of chronic posttraumatic stress disorder. Journal of Consulting and Clinical
Psychology, 67, 13-18.
Tarrier, N., & Sommerfield, C. (2004). Treatment of chronic PTSD by cognitive therapy and
Exposure: 5-year follow-up. Behavior Therapy, 35, 231-246.
Tennant, C., Streimer, J., & Temperly, H. (1990). Memories of Vietnam: Post-traumatic stress
disorders in Australian veterans. Australian and New Zealand Journal of Psychiatry, 24, 2936.
Turner, S., Beidel, D., & Frueh, C. (2005). Multicomponent behavioural treatment for chronic
combat-related Posttraumatic Stress Disorder. Behavior Modification, 29, 39-69.
Van Etten, M., & Taylor, S. (1998). Comparative efficacy of treatments for post-traumatic stress
disorder: A meta-analysis. Clinical Psychology and Psychotherapy, 5, 126-144.
Walhberg, L. (1997). Selecting patients for trauma focus group therapy. Retrieved August 20, 2005
from http://www.ncptsd.va.gov/publications/cq/v7/n1/walhberg.html
Walser, R., & Pistorello, J. (2004). Acceptance and commitment therapy in group format. Retrieved
November 20, 2005 from http://therapist-training.com.au/Walser%20ACT%20in%groups.pdf
Vietnam veterans and ACT
Page 53
Weathers, F., Keane, T., & Davidson, J. (2001). Clinician-administered PTSD scale: A review of
the first ten years of research. Depression and Anxiety, 13, 132-156.
Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (1993). The PTSD Checklist (PCL):
Reliability, validity, and diagnostic utility. Paper presented at the 9th Annual Meeting of the
International Society for Traumatic Stress Studies. Texas.
Wegner, D., & Zanakos, S. (1994). Chronic thought suppression. Journal of Personality, 62, 615640.
Wilson, K., Follette, V.M., Hayes, S.C., & Batten, S. (1996). Acceptance Theory and the treatment
of abuse survivors: Implications of Acceptance Theory for the treatment of survivors of
childhood sexual abuse. PTSD Clinical Quarterly, 6, 34-37.
Wilson, E., & Horsley, K. (2003). Health effects of Vietnam service. ADF Health, 4, 59-65.
Wilson Van Voorhis, C., & Morgan, B. Statistical rules of thumb: What we don’t want to forget
about sample sizes. Retrieved February 8, 2007 from
http://www.psichi.org/pubs/articles/article_182.asp
Yehuda, R. (2004). Risk and resilience in posttraumatic stress disorder. Journal of Clinical
Psychiatry, 65, 29-36.
Vietnam veterans and ACT
Page 54
Yehuda, R., & McFarlane, A. (1995). Conflict between current knowledge about posttraumatic
stress disorder and its original conceptual basis. The American Journal of Psychiatry, 152,
1705-1718.
Zatzick, D., Marmar, C., Browner, W., Metzler, T., Golding, J., Stewart, A., Schlenger, W., &
Wells, K. (1997). Posttraumatic stress disorder and functioning and quality of life outcomes in
a nationally representative sample of male Vietnam veterans. The American Journal of
Psychiatry, 154, 1690-1695.
Vietnam veterans and ACT
APPENDIX A
BEHAVIOR MODIFICATION
SPECIFICATIONS FOR SUBMISSION
Page 55
Vietnam veterans and ACT
Page 56
APPENDIX B
Flyer Mailed to Random Post Codes, Advertisement in Veteran Magazines,
Veteran Website, Psychiatrists, General Practitioners
VIETNAM VETERANS
INVITATION
As a result of your Vietnam War service and a particular event(s) that occurred in Vietnam have
you been diagnosed with Posttraumatic Stress Disorder or do you have any of the following
symptoms:

Experience distress when sights, sounds or smells remind you of the event

Feel as though the event is happening again

Avoid people, situations or places which remind you of the event

Have difficulty putting thoughts of the event out of your mind

Have sleep difficulties

Feel emotionally detached from friends/family

Feel panicky, anxious, on-edge and are easily startled

Feel depressed and/or angry
If so, you are eligible to be assessed for a research study using a new group therapy treatment aimed
at helping you live a better life. A limited number of groups will be conducted. There will be 4
groups to receive the treatment. There will be 4 veterans in each group. Groups will be 1 day a
week for 6 weeks in the Sydney CBD and will be conducted by a registered psychologist
experienced in working with Vietnam Veterans.
The study is part of a requirement that I am completing as part of my Masters Degree in Clinical
Psychology. Other than your travel to the Sydney CBD, there is no cost to you to receive the
treatment.
No information will be passed on to the Department of Veteran Affairs and they have no
association with this study or the psychologist. This study will have no influence on your
current pension rates.
You are invited to register your interest to attend an Orientation Session. As the numbers are strictly
limited, please telephone Lynn Williams on xxxx xxx xxx to ensure your place.
Vietnam veterans and ACT
Page 57
APPENDIX C
Consent Form to Participate in Study
Consent Form to Liaise with General Practitioner and or Psychiatrist if Required
CONSENT FORM
Acceptance and Commitment Therapy:
An example of third-wave therapy as a treatment for Australian Vietnam War
Veterans with Posttraumatic Stress Disorder (PTSD)
Principal Researcher
Lynn Williams
Supervisor
Dr David Mallard
School or Research Centre
School of Social Sciences and Liberal Studies
School or Research Centre
School of Social Sciences and Liberal Studies
Telephone
(m) xxxx xxx xxx
Telephone
(02) 63384485
I agree to participate in a study that is investigating the treatment of Australian Vietnam War
Veterans with Posttraumatic Stress Disorder (PTSD). I have read and understood the information
sheet given to me. I have been given the opportunity to ask questions about the research and
received satisfactory answers.
I understand the following:

The purpose of this study is to look at the effectiveness and mechanisms of change of two
versions of Acceptance and Commitment Therapy. To participate in the study I must not be
currently receiving therapy in another group or individually. If I am currently taking medication,
this will remain unchanged.

Potential benefits of the treatment are (a) an improved quality of life, (b) improved interpersonal
relationships, (c) reduction in intensity and frequency of PTSD symptoms (d) an increased
willingness to be open to experiencing emotions.

The procedure will be as follows: I will be invited to attend an Orientation Session where I will
be asked to complete some brief questionnaires asking about my general health and my PTSD
symptoms. If selected as eligible for the study I will then attend a more detailed Assessment
Session. Then, I will be allocated to one of two treatment groups and attend group therapy
sessions in the Sydney CBD one day a week for six weeks from 10.30am until 3.30pm. Sessions
will be free of charge and I will not be paid to participate in this study. At the end of the study I
will be asked to complete some questionnaires so that the researcher can monitor changes in my
symptoms and quality of life.

I may experience an increase in feelings of anxiety or discomfort if I choose to access
previously avoided painful thoughts and memories of a traumatic event. Reduction of avoidance
is a goal of the therapy and increases in arousal will be managed in the group sessions or
individually by the researcher, and if appropriate, with my psychiatrist or general practitioner
(see attached).
Vietnam veterans and ACT
Page 58

I am free to withdraw my participation in the research at any time, and if I do, I will not be
subjected to any penalty or discriminatory treatment.

The researcher may decide to take me off the study if I abuse medications, illegal drugs or
alcohol or if my behaviour places myself, other participants or the researcher at risk.

The information that I give during the study is strictly confidential and only the researcher will
have access to any data. I will be given an identification number so that no participant can be
identified. No information will be passed on to the Department of Veteran Affairs and they
have no association with this study or the researcher. This study will have no influence on
my current pension rates. Sessions will not be audio or video taped.
Charles Sturt University’s Ethics in Human Research Committee has approved this study.
I understand that if I have any complaints or concerns about this research I can contact:
Executive Officer
Ethics in Human Research Committee
Academic Secretariat
Charles Sturt University
Private Mail Bag 29
Bathurst NSW 2795
Phone: (02) 6338 4628
Fax:
(02) 6338 4194
Signed By:
……………………………………………. (PRINT NAME)
……………………………………………. (SIGNATURE)
………………………………………….…. DATE
Vietnam veterans and ACT
Page 59
PERMISSION TO CONSULT/RELEASE OF INFORMATION
I ______________________________________ (client name) hereby give my
permission for _____Lynn Williams____to consult with, or to release information to:
General Practitioner & Address:
Psychiatrist Name & Address:
regarding the following matters:
To discuss my symptoms and medication relating to matters that have arisen during my
participation in the research study titled ‘Acceptance and Commitment Therapy: An example of
third-wave therapy as a treatment for Australian Vietnam War Veterans with Posttraumatic Stress
Disorder’.
Signature of client:
______________________________
Date:
______________________________
Vietnam veterans and ACT
Page 60
APPENDIX D
Information Sheet Given to Participants at Orientation Session
INFORMATION SHEET
Acceptance and Commitment Therapy:
An example of third-wave therapy as a treatment for Australian Vietnam War
Veterans with Posttraumatic Stress Disorder (PTSD)
We are inviting you to take part in a research study. You may ask questions about what we will ask
you to do, the risks, the benefits, your rights as a volunteer, or anything else about the research or
this form that is not clear. When we have answered all of your questions, you can decide if you
want to participate. This process is called ‘informed consent’. We will give you a copy of this form
for your records.
The principal investigator for this study is Lynn Williams who is completing a Masters Degree in
Clinical Psychology through Charles Sturt University. The principal investigator is a registered
psychologist with approximately 10 years counselling experience which includes six years
experience as a crisis telephone and face-to-face counsellor for Lifeline Australia. The principal
investigator worked for three years at a private psychiatric hospital as a co-therapist and then
coordinator and lead therapist on an accredited PTSD programme for Vietnam Veterans with PTSD.
The Vietnam Veteran programme was accredited annually by the Australian Centre for
Posttraumatic Mental Health. Additionally, the principal investigator has 6 years experience
working with non-defence force clients with PTSD, such as police and civilians and is a currently
accredited Victims of Crime Counsellor who also works with family members of homicide victims.
Furthermore, the principal investigator has over 25 years corporate experience including conducting
group training programmes with adults.
The principal investigator will be supervised during the study by Dr David Mallard, School of
Social Sciences and Liberal Studies. He can be contacted on (02) 63384485. Lynn Williams, School
of Social Sciences and Liberal Studies can be contacted on xxxx xxx xxx.
What is the purpose of this study?
We are looking at the effectiveness and mechanisms of change of two versions of Acceptance and
Commitment Therapy in the treatment of Australian Vietnam War Veterans with Posttraumatic
Stress Disorder (PTSD). Different versions of this therapy have been found to be effective in
decreasing distress and associated problems in the areas of anxiety, work stress, psychosis, panic
attacks, substance abuse, smoking cessation, pain tolerance and workplace stress. This study will
compare the two versions and will be administered by a registered psychologist who has personally
experienced the treatment phases that you will go through. To participate in the research you must
not be currently receiving therapy in another group or individually. If you are currently taking
medication, this will remain unchanged.
Vietnam veterans and ACT
Page 61
What steps are involved before treatment?
If you are in interested in being in the study, you will be invited to attend an Orientation Session
where you will be asked to complete some brief questionnaires asking about your general health
and your PTSD symptoms. If selected as eligible for the study, you will then attend a more detailed
Assessment Session. This will allow us to see whether the treatment offered through this study will
be appropriate and beneficial for you. If it is not appropriate, we will discuss other options available
to you. If you have PTSD and you agree to take part in the study, you will be randomly allocated to
one of two treatment groups. There will be four Vietnam Veterans in each group
When and where will the therapy take place?
Group sessions will be in the Sydney CBD one day a week for six weeks from 9.30am until 3.00pm
during which time you will be treated with regard to the past traumatic event(s). Sessions will be
free of charge and you will not be paid to participate in this study. You will be asked to complete
some questionnaires at the beginning and end of the therapy so that we can monitor changes in your
symptoms and quality of life. Sessions will not be audio or video taped.
What are the risks and benefits of the study?
Participants may experience an increase in feelings of anxiety or discomfort if they choose to access
previously avoided painful thoughts or memories of a traumatic event. Reduction of avoidance is a
goal of the therapy. Increases in arousal will be managed by talking through the anxiety,
maximising support from other group members and if necessary the researcher will provide
individual counselling. If necessary, and with your consent (see attached), contact will be made
with your psychiatrist or general practitioner. You can leave the study at any time. However, if you
decide to leave, we encourage you to talk to the researcher and your psychiatrist or general
practitioner first. The researcher may decide to take you off the study if you abuse medications,
illegal drugs or alcohol or if your behaviour places yourself, other participants or the researcher at
risk.
Potential benefits from this therapy are improved quality of life, improved interpersonal
relationships, reduction in intensity and frequency of PTSD symptoms and an increased willingness
to be open to experiencing emotions. You will be making a contribution to the psychological
profession as presently there is no published or known research using Acceptance & Commitment
Therapy with Australian Vietnam Veterans. Finally, this research may contribute to early
intervention with veterans or peacekeepers that follow you. This treatment may help others in
minimising the risk of PTSD symptoms becoming chronic problems.
Is the study confidential?
The information that you give during the study is strictly confidential and only the researcher will
have access to any data. Individuals will be given an identification number so that no individual will
be able to be identified. No information will be passed on to the Department of Veteran Affairs
and they have no association with this study or the researcher. This study will have no
influence on your current pension rates. Analysis of data will be for the purpose of improving
understanding of PTSD in Australian Vietnam Veterans and their treatment.
I understand that am free to withdraw my participation in the research at any time, and that if I do, I
will not be subjected to any penalty or discriminatory treatment.
Vietnam veterans and ACT
Charles Sturt University’s Ethics in Human Research Committee has approved this study.
I understand that if I have any complaints or concerns about this research I can contact:
Executive Officer
Ethics in Human Research Committee
Academic Secretariat
Charles Sturt University
Private Mail Bag 29
Bathurst NSW 2795
Phone: (02) 6338 4628
Fax:
(02) 6338 4194
Your contribution and participation are important to this study and to the health of Vietnam
Veterans. We hope you will agree to take part and I look forward to working with you.
Yours Sincerely,
Lynn Williams
Principal Researcher
Dr David Mallard
Supervisor
Page 62
Vietnam veterans and ACT
APPENDIX E
Group Demographics
Table 1.
Demographic Characteristics
Total
ACTFULL
ACTDIS
15
7
8
59.9 (3.9)
59.9 (4.1)
59.9 (3.9)
56 - 67
56 - 67
56 - 67
12 (80.0)
4 (57.1)
8 (100.0)
3 (20.0)
3 (42.9)
0 ( 0.0)
Single (never married)
3 (20.0)
2 (28.6)
1 (12.5)
Married
11 (73.3)
4 (57.1)
7 (87.5)
Divorced
1 ( 6.7)
1 (14.3)
0 ( 0.0)
5 (33.3)
3 (42.9)
2 (25.0)
N
Age years, mean (SD)
range
Education, n (%)
Secondary
Tertiary
Marital status, n (%)
Voluntary work, n (%)
Page 63
Vietnam veterans and ACT
APPENDIX F
Group Service Characteristics
Table 2.
Characteristics of service
Total
ACTFULL
ACTDIS
15
7
8
Army
13 (86.7)
6 (85.7)
7 (87.5)
Navy
1 ( 6.7)
0 ( 0.0)
1 (12.5)
Air Force
1 ( 6.7)
1 (14.3)
0 ( 0.0)
Regular
6 (40.0)
2 (28.6)
4 (50.0)
Conscript
8 (53.3)
4 (57.1)
4 (50.0)
Volunteer
1 ( 6.7)
1 (14.3)
0 ( 0.0)
10 (66.7)
5 (71.4)
5 (62.5)
Corporal
2 (13.3)
1 (14.3)
1 (12.5)
Sergeant
1 ( 6.7)
1 (14.3)
0 ( 0.0)
Captain
1 ( 6.7)
0 ( 0.0)
1 (12.5)
Major Lt-Commander
1 ( 6.7)
0 ( 0.0)
1 (12.5)
Light (0-8)
2 (13.3)
2 (28.6)
0 ( 0.0)
Light-moderate (9-16)
2 (13.3)
0 (0.0)
2 (25.0)
Moderate (17-24)
4 (26.7)
2 (28.6)
2 (25.0)
Moderate-heavy (25-32)
4 (26.7)
1 (14.3)
3 (37.5)
Heavy (33-41)
3 (20.0)
2 (28.6)
1 (12.5)
21.4 (9.5)
19.9 (12.2)
22.8 (6.8)
2 - 35
2 - 34
13 - 35
N
Service branch, n (%)
Status, n (%)
Rank, n (%)
Private
Combat Exposure Scale
category, n (%)
Combat Exposure Scale
score, mean (SD)
range
Page 64
Vietnam veterans and ACT
APPENDIX G
Group Psychiatric History
Table 3.
Nature of Treatment Received
Total
ACTFULL
ACTDIS
15
7
8
Inpatient
2 (13.3)
2 (28.6)
0 ( 0.0)
Outpatient
6 (40.0)
0 ( 0.0)
6 (75.0)
Never received treatment
7 (46.7)
5 (71.4)
2 (25.0)
10 (66.7)
5 (71.4)
5 (62.5)
General Practitioner
3 (20.0)
1 (14.3)
2 (25.0)
Psychiatrist
10 (66.7)
5 (71.4)
5 (62.5)
Vietnam Veterans Counselling Service
2 (13.3)
1 (14.3)
1 (12.5)
N
Treatment, n (%)
Currently taking prescribed psychotropic
medication, n (%)
Current contact with health professional
(primary contact), n (%)
Page 65