Brief Acceptance‑based Protocols Applied to the Work with Adolescents

Authors: M. Carmen Luciano, Sonsoles Valdivia Salas, Olga Gutiérrez Martínez, Francisco J. Ruiz, Marisa Páez Biarrina

Year: 2009

Source: International Journal of Psychology and Psychological Therapy, 9(2), 237-257

Type: EXPERIMENTAL

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Brief Acceptance-Based Protocols Applied to Work with Adolescents

Full reference: Luciano, M. C., Valdivia-Salas, S., Gutiérrez Martínez, O., Ruiz, F. J., & Páez Biarrina, M. (2009). Brief acceptance-based protocols applied to work with adolescents. International Journal of Psychology and Psychological Therapy, 9(2), 237-257.

Study type: Clinical studies with multiple brief ACT-based intervention protocols

CONTEXT AND OBJECTIVES

This article describes the implementation of three brief protocols based on Acceptance and Commitment Therapy (ACT) that were developed and applied to adolescents presenting different psychological barriers. The central objective was to demonstrate the utility of brief clinical methods based on ACT through their application to three specific contexts: (1) promotion of safe sexual behaviors in adolescents, (2) improvement of performance in elite young chess players, and (3) reduction of impulsive and antisocial behaviors in institutionalized adolescents.

The authors note that although ACT has growing empirical support, additional basic and applied research is still necessary to better isolate which specific components of the ACT process generate clinical change both within and outside of sessions. The conceptual framework of these protocols is grounded in Relational Frame Theory (RFT) and in the central components of psychological inflexibility: destructive experiential avoidance, cognitive defusion, acceptance, values clarification, and committed action.

METHOD

Participants

Protocol 1 (Safe sexual behavior): Two exploratory studies preceded a main study. The initial exploratory study (Gutiérrez Martínez et al., 2007) included secondary school adolescents. The second exploratory study (Gutiérrez Martínez et al., 2007) included 40 adolescents aged 14-17 years, randomly assigned to either an INFO (HIV/AIDS information) condition or an enhanced INFO/ACT condition. Participants were recruited from a secondary school in Spain. Self-report measures of sexual behaviors, HIV/AIDS knowledge, and risk attitudes were collected at baseline, post-intervention, and 6-month follow-up.

Protocol 2 (Chess - "Bright Young Hopes"): The study compared the effects of a brief ACT-based protocol versus a no-protocol control condition. Seven young Spanish chess players (ages 14-20 years) were assigned to the ACT condition, while seven matched European chess players served as the control group. Participants were selected by the Spanish Chess Federation to participate in the European Young Chess Championship. The protocol was implemented in group format during three sessions across five days of intensive chess training sessions. The main dependent variable was the ELO rating (chess performance score according to the International Chess Federation), as well as measures of avoidance and acceptance (AAQ-II) and a chess-specific questionnaire on reactive limitations (CLRQ).

Protocol 3 (Impulsive and antisocial behaviors): The protocol was implemented as part of a preliminary study with five adolescents (three boys and two girls, ages 15-17 years) presenting conduct disorder and behavioral problems. All participants grew up in low-income and dysfunctional families and were sentenced to mandatory community service and received psychological treatment. At the time of the study, they had been in psychological treatment for three years, including behavioral containment management training, behavioral contracts, and self-control and social skills training. Despite this, the adolescents showed limited improvement. Pre-treatment observation was collected from teacher's daily records, including frequent disruptive behaviors such as inappropriate classroom conduct, theft, questioning of teacher's rules, insults, threats to classmates, and low-frequency desirable behaviors. The protocol was implemented in 4 individual sessions, each approximately 1.5 hours, distributed over a 2-week period, delivered by the same psychologist who had provided previous treatment.

Design

Protocol 1: Quasi-experimental design with comparison group. The second sample of 40 adolescents was assigned to either INFO only or an enhanced INFO/ACT condition that included defusion and acceptance exercises.

Protocol 2: Matched control group design. The comparison was between participants who received the brief ACT protocol and matched European chess players who had no contact with the experimenters and served as a no-protocol control condition.

Protocol 3: Single-case design with multiple participants (N=5). The clinical impact of the protocol on in-class behaviors and in relevant areas such as family, social interactions, academic achievement, and occupational status was documented during one-year follow-up.

Materials and Procedure

Protocol 1 (Values-Acceptance for Safe Sexual Behaviors):

The protocol consisted of five main elements implemented within the context of a one-hour HIV workshop:

1. Identification of personal values: A "values compass" exercise adapted from Dahl et al. (2005) was used. Students identified ten value domains (including romantic/intimate relationships, friendships, work, recreation, spirituality, physical self-care). They were asked to imagine seeing themselves at age 25 and write down how they would see themselves behaving in each domain, to emphasize values they could be proud of. They were asked to rate the importance of each value on a 1-10 scale.

2. Introduction of HIV information-based contents: Information on HIV/AIDS transmission, diagnosis, symptoms, sexual transmission, HIV risk-reduction behaviors such as sexual abstinence and consistent condom use, and partner change was introduced.

3. Linking HIV risk-reduction actions with valued life areas: The connection was made between immediate actions (e.g., condom use) and remote and probabilistic positive consequences (valued goals) so that participants would maintain safe behavior now, which would likely provide positive reinforcement.

4. Practice of defusion from unpleasant thoughts and feelings: This exercise was based on Luciano (2005) and a compound of exercises typically used in ACT preparations. The aim was to generate conditions to experience the discomfort of an unpleasant thought and discriminate between the person having the thought or sensation and the contents of the thought and sensation. The exercises used multiple exemplar training.

5. Commitment exercise: Each student wrote in the compass worksheet what sexual practices they would adopt to be closer to the things they wanted for their life. Volunteers who wanted to speak aloud were encouraged to do so.

Protocol 2 (Acceptance-Defusion Applied to "Bright Young Hopes" Chess Players):

The protocol focused on teaching participants to react with flexibility to psychological barriers that interfered with their chess performance. It consisted of two parts:

First part: Defusion Protocol

Implemented on the second day of intensive chess sessions. Participants played a series of very rapid and difficult chess games against a computer while hearing loud noises. During the second day, participants were invited to say aloud the thoughts and sensations that arose during play and to perform multiple defusion exercises (as exemplar training). They were asked to practice the same when in real competitions.

The defusion exercises included three components:

1. Directing attention to situations in which participants did not experience thoughts or sensations (e.g., how their trousers or skirt felt on their skin, and simply noticing the sensation, and then responding to who was having the sensation: "then, responding to who was having the sensation, without noticing the sensation... and then... responding to who was having that sensation"). This was repeated with whatever thoughts and sensations they might be noticing at that moment.

2. Participants were invited to write on an individual card the thought they did not like while playing in competitions (e.g., "I am going to lose," "I am not sure what the best move is," "I have to win the game"). They were asked to look at what was written on the cards and not greet the thought. They were invited to do the same with any thought they were having at that moment.

3. Participants were invited to perform the "autumn and leaves exercise" (Pankey & Hayes, 2004, p. 320; Wilson & Luciano, 2002, p. 216). Participants were asked to close their eyes while imagining a birch tree by a river with leaves falling into the river. Then, they were asked to imagine a big hole beside a river with leaves falling into the river. Participants were asked to do the same with any thought or sensation that showed up during practice, and they were encouraged to practice the exercise again the next time they played computer chess games.

Second part: Creative Hopelessness, Acceptance, and Defusion Protocol

It focused, first, on the creative hopelessness experience and, second, on exercises to defuse from problematic thoughts or feelings. The following paragraphs illustrate these components.

4. Creative hopelessness experience: It was promoted (...) by asking what they usually did when a worry (e.g., "If I lose this game then I will not be able to play the next one") or a disturbing thought (e.g., "I have made a mistake, I should have played on the other side") arose. They reported that they generally did such things as spend time thinking about the moves until they felt confident, or playing defensively; that in the short run it made them feel control, but at the end of the game it did not translate into good results necessarily (e.g., "at the end of the day, I do not fear losing the game"). The metaphor of the man in the hole was used as an analogue of what they were doing. This metaphor established that if one falls in a deep hole and one believes one can climb, then although one believes one is doing the right thing to climb, finally the hole becomes deeper. The experimenter asked whether the hole would become deeper while attempting to climb, finally the hole becomes deeper, was it something similar to digging deeper and trying to get out by digging deeper.

5. When participants established the connections between their situation and the metaphor, the "lively metaphor was incorporated." To let participants experience that "...sometimes, it is necessary to go through a dirty swamp full of undesirable things to follow the path to things we care about most." Participants were asked to give some personal examples similar to that situation. They were asked to think about the "swamp": "What would you choose, the things you want or not having fear?" Upon answering "I would choose the things I want," and being asked "What would happen then, the others would have to change, not me," or "It is not my fault?" showed above. Then, they were asked whether this had something to do with playing randomly when fear of losing the game. Once again, the connections were made and the experimenter asked if they were willing to do something different with their fears and worries. To help participants cope with sensations (e.g., fear of losing the game), the experimenter invited them to practice the exercise they did during the first session, and introduced exercises again to physicalize the fear.

6. Physicalizing psychological barriers: (Wilson & Luciano, 2002, p. 240). To start, walking toward a corner in the room was made equivalent to making desired chess moves. Participants "asked to walk toward the corner." Each time the participant took a step in that direction, the experimenter signaled in the form of a stop sign to his fear of going the wrong way, etc. This was done with the subject taking the therapist by his hand and walking to the corner with the therapist by his side. This meant that one must do what one wanted to do (although not always meaning winning the game) carrying one's fear with them, instead of doing moves to conform or to eliminate the fear. Finally, the experimenter recommended participants practice the same when they were in real competitions, which were going to take place the following week.

7. Physicalizing the Bus Metaphor: The multiple exemplar defusion training was concluded with the physicalization of the bus metaphor (Hayes et al., 1999, p. 157; Wilson & Luciano, 2002, pp. 170, 240). Each participant was encouraged to be, first, the driver, then, a passenger. When a participant was the driver and drove the bus in the chosen direction, other participants asked the driver to change the direction of the bus, while passengers pressed the driver to change the direction of the bus. The driver's job was to keep the bus in the direction of playing the game instead of complying or reasoning with the passengers' arguments. Then, the role was reversed and other participants took the role of the driver. Finally, the experimenter recommended participants practice the same when they were in real competitions, which were going to take place the following week.

Analysis

The studies used basic statistical analysis of between-group comparisons and repeated measures. In the chess protocol, the established change criterion was used to detect significant changes in ELO between conditions. Differences in acceptance measures (AAQ-II) between ACT and control conditions were examined at baseline and follow-up.

RESULTS

Protocol 1 (Values-Acceptance for Safe Sexual Behaviors):

Results showed that both protocols (INFO and INFO/ACT) increased HIV/AIDS knowledge among adolescents. Participants who were fused with thoughts about the inconvenience of using condoms or other false beliefs about HIV infection (i.e., "condoms minimize pleasure") engaged in riskier sexual behaviors occasionally with occasional partners, with drugs and without condoms. At the second assessment, most participants in both conditions did not report unprotected penetrative sex practices, and consequently, acceptance of condom use intervals was not proven. However, those participants in the ACT condition who practiced sex without penetration reported significantly fewer sexual partners and less drug use before or during sex compared to the INFO condition. Although both protocols had a significant impact in increasing the perception of HIV risk when having unprotected sex with a steady partner. These preliminary results support the utility of ACT-based strategies as a component of HIV prevention interventions with adolescents engaging in sexual behavior exchange with occasional partners.

Protocol 2 (Chess - "Bright Young Hopes"):

Results showed that the brief ACT-based protocol improved chess performance in 5 of 7 participants in the ACT condition, and none reached the established change criterion (change criterion supported). The difference in ELO performance between conditions was statistically significant at follow-up but not at pre-intervention. Additionally, the correlation between experienced ACT increases (ELO) and changes in acceptance (AAQ-II) was strong. Furthermore, the increase in chess performance was stronger in those participants who showed, previously and during competition, more level of experiential avoidance. What follows is the description of the protocol (see details in Ruiz & Luciano, in press).

Protocol 3 (Impulsive and Antisocial Behaviors):

Results showed significant positive reduction of the clinical impact of the ACT protocol on in-class behaviors and in relevant areas such as family, social interactions, academic achievement, and occupational status. Relevant changes were reported at one-year follow-up (see details in Gómez Rodríguez et al., 2009).

DISCUSSION AND CONCLUSIONS

The authors argue that the implementation of the ACT protocols, in group or individual formats, produced clear differences in adolescents' behaviors. In the first study, adolescents who practiced unprotected penetrative sex reported significantly fewer sexual partners and less drug use before or during sex than adolescents who received only information. In the second study, the brief protocol with young chess players improved chess performance more than the control group. Finally, for the five adolescents presenting antisocial behavior, the ACT protocol showed positive clinical impact on their in-class behaviors and in other relevant areas.

The three protocols implemented performed the application of central ACT process components, although to different degrees according to the problem addressed: (a) functional experiential analysis which became the context to generate the creative hopelessness experience, as well as the appropriate context for therapy; (b) values clarification, which required multiple exercises both in contexts and in others; which was always the context for accepting discomfort and other problematic thoughts and feelings; and (c) many defusion interactions as multiple exemplar training for adolescents to be in a better position to experience and defuse from inevitable life events while being verbally competent. Regarding defusion practice, all three protocols involved, although to different degrees, mixed interactions to promote "experientiality" between the person having the thoughts and feelings, from the thoughts and feelings themselves. Of these, this is a socially constructed process (see details in Barnes-Holmes et al., 2001; Luciano, Valdivia Salas, et al., 2009; Skinner, 1945).

To summarize, the central point of this paper was to present a series of ACT applications to promote abstraction of relevant components and flexibility in applying acceptance methods. Throughout the three studies, we have described an example of establishing a useful therapeutic relationship, as well as several interactions to experience creative hopelessness, clarify values (e.g., with metaphors, with members and multiple exemplar exercises), and perform the necessary experiential interactions to differ from thoughts, memories, and feelings. As mentioned previously, these protocols were part of preliminary studies developed to better understand the conditions under which specific ACT components that work well, and to test the effects of implementing my interactions in the same exercises. Despite the fact that these brief protocols are only preliminary in their approach to these objectives, their comprehensive implementation has clarified the way for the design of basic studies in our laboratory concerning variables responsible for the transformation of function involved in different ACT methods. Undoubtedly, these scientific processes, sooner or later, will contribute to a better understanding and application of acceptance-based methods.

Significance and contribution

This article presents three brief ACT-based protocols applied to adolescents across multiple contexts, demonstrating the utility of acceptance and commitment-based approaches for addressing sexual risk behaviors, optimizing elite performance, and reducing problem behaviors. The protocols illustrate how core ACT components such as values clarification, creative hopelessness, cognitive defusion, and acceptance can be effectively applied in brief clinical formats. The findings contribute to the evidence base for ACT-based interventions in adolescent populations and demonstrate the feasibility of isolating and applying core ACT components without compromising effectiveness.