Effect of acceptance and commitment therapy in improving interpersonal skills in adolescents: A randomized waitlist control trial

Authors: Koryn N. Bernal-Manrique, María B. García-Martín, Francisco J. Ruiz Year: 2020 Journal: Journal of Contextual Behavioral Science, 17, 86–94 DOI: https://doi.org/10.1016/j.jcbs.2020.06.008 Type: EMPIRICAL

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Context and objectives

Interpersonal skills are fundamental for adolescent social adaptation and psychological wellbeing. These skills encompass the ability to identify one's own and others' emotions, understand the causes of interpersonal conflicts, and generate alternative solutions. Although interpersonal skill training programs have demonstrated efficacy, they present limitations such as requiring a high number of sessions and difficulties in generalizing trained skills to other social contexts. An alternative hypothesis suggests that adolescents may possess developed interpersonal skills but fail to put them into practice due to cognitive overload, emotional dysregulation, or inflexible behavioral patterns. In this context, acceptance and commitment therapy (ACT) could facilitate adolescents putting their interpersonal skills into practice by promoting psychological flexibility. This randomized controlled trial evaluated the effect of a brief RNT-focused ACT protocol versus a waitlist control condition on improving interpersonal skills in adolescents with social and school adaptation problems.

Method

Participants

Forty-two adolescents (30 girls; age range = 11–17 years, M = 14.52, SD = 1.67) from a middle-class private school in Bogotá (Colombia) who displayed difficulties in social and school adaptation. Participants were identified by teachers and assessed by the school psychologist. Of the 56 adolescents initially assessed, 42 agreed to participate.

Design

Parallel two-arm randomized controlled trial with 1:1 simple randomization. Participants were randomly assigned to the RNT-focused ACT condition (n = 21) or the waitlist control condition (n = 21).

Intervention

The RNT-focused ACT protocol consisted of three group-based, 75-minute sessions delivered weekly in two groups of approximately 10 participants. The protocol was an adaptation of a protocol previously used for child depression. Sessions addressed: (1) differentiation between psychological inflexibility and flexibility, practice discriminating between both, and commitment to observe one's own reactions; (2) review of experience, promotion of a transcendental sense of self, exploration of values and goals, identification of counterproductive effects of RNT, and defusion practice; (3) review of inflexible and flexible reaction examples, development of defusion skills through multiple exemplar training, and practice differentiating between engaging in RNT or choosing to behave toward values.

Instruments

• Interpersonal Conflict Resolution Assessment (ESCI): Performance test of interpersonal problem-solving skills (16 exercises with three questions each). Total score and three subscales: Emotions, Causes, and Solutions. Primary outcome.
• DASS-21: Depression, Anxiety, and Stress Scales (secondary outcome).
• Valuing Questionnaire (VQ): Progress and Obstruction subscales (secondary outcome).
• PTQ-C: Perseverative Thinking Questionnaire – Children (process outcome).
• AFQ-Y-8: Avoidance and Fusion Questionnaire for Youth – 8 items (process outcome).

Analysis

Repeated measures ANOVAs with factors Time (pre and post) and Condition (ACT vs. waitlist). Bonferroni correction (adjusted alpha = .0056). F values were converted to Cohen's d. Additional analyses of reliable change (RCI) and clinically significant change (CSC) were conducted for participants with clinical scores on the DASS-Total.

Results

No statistically significant differences between conditions were found at pretreatment. Repeated measures ANOVAs showed statistically significant Time × Condition interaction effects for all primary outcomes and most secondary and process outcomes:

Primary outcomes (ESCI): ACT participants showed significantly greater increases in interpersonal skills with very large effect sizes: ESCI-Total (F(1, 40) = 68.71, p < .001, d = 2.62), ESCI-Emotions (F(1, 40) = 28.51, p < .001, d = 1.69), ESCI-Causes (F(1, 40) = 26.50, p < .001, d = 1.63), and ESCI-Solutions (F(1, 40) = 39.74, p < .001, d = 1.99).

Secondary outcomes: Significant interaction effects were found for DASS-Total (F(1, 40) = 9.71, p = .003, d = 0.98) and VQ-Progress (F(1, 40) = 15.04, p < .001, d = 1.23). No significant interaction was found for VQ-Obstruction (F(1, 40) = 2.11, p = .15, d = 0.46).

Process outcomes: Significant reductions in RNT (PTQ-C: F(1, 40) = 39.67, p < .001, d = 1.99) and psychological inflexibility (AFQ-Y-8: F(1, 40) = 12.22, p = .001, d = 1.11).

Analyses with clinical participants (DASS-Total ≥ 25): Results were replicated with similar effect sizes. 62.50% of ACT participants (vs. 15.39% in waitlist) showed reliable change, and 43.75% (vs. 7.69%) showed clinically significant change in emotional symptoms.

Discussion and conclusions

This study provides preliminary evidence that a brief RNT-focused ACT protocol can improve adolescents' interpersonal skills as measured by a performance test, without explicitly training those skills. Results suggest that psychological flexibility training could facilitate adolescents putting into practice interpersonal skills they already possess but do not use due to the interference of psychological inflexibility. The intervention also produced significant reductions in emotional symptoms, RNT, and psychological inflexibility, and improvements in valued living. Limitations include: a sample from a single middle-class private school, no long-term follow-up, a single therapist delivered the intervention, no ecological data on interpersonal skills, and use of waitlist as the control condition.

Significance and contribution

This study is the first randomized controlled trial evaluating the effect of an ACT intervention on improving interpersonal skills in adolescents, measured through a performance test (not self-reports). It demonstrates that a very brief (3-session) RNT-focused ACT intervention can produce very significant improvements in interpersonal skills without directly training them, suggesting that psychological flexibility facilitates the deployment of already existing skills. This finding has important implications for integrating psychological flexibility training within interpersonal skills training programs for adolescents.