Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Dissociative identity disorder wikipedia , lookup
Drug rehabilitation wikipedia , lookup
Psychological trauma wikipedia , lookup
Combat stress reaction wikipedia , lookup
Posttraumatic stress disorder wikipedia , lookup
Veterans benefits for post-traumatic stress disorder in the United States wikipedia , lookup
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