The systematic implementation of Acceptance & Commitment Therapy (ACT) in Dutch multidisciplinary chronic pain rehabilitation

Abstract

Objective

This study evaluates the implementation of Acceptance & Commitment Therapy (ACT) in Dutch chronic pain rehabilitation centers. Changes in multidisciplinary professionals’ self-perceived competencies in working with ACT were evaluated and corroborated with patients’ ratings of treatment adherence. To inform subsequent implementation efforts, relevant determinants of implementation success were monitored and the relationship with self-perceived competencies over time was explored.

Methods

Data was gathered from 111 professionals, 9 managers and 79 patients using questionnaires at the start (T0), halfway (T1) and end (T2) of implementation, and at the end of treatment.

Results

All professionals adhered to ACT, improved significantly in self-perceived competencies over time and rated competence in working with ACT ≥ adequate at T2. Determinants of success were evaluated extremely positive by professionals and management. Professionals’ self-perceived competencies at T2 were most strongly related to ratings of more workload (b = −.43), and experienced difficulties in working with ACT (b = −.38) at T0 and T1.

Conclusion

Multidisciplinary chronic pain rehabilitation professionals rated their improvement in working with ACT positively during the implementation period. Impeding and facilitating factors were explored successfully.

Practice implications

A multi-faceted, long-term, educational, train-the-trainer approach may help to guide systematic changes in multidisciplinary treatment.

Introduction

Chronic pain, defined as pain that lasts over three months that surpasses the normal healing time of tissue damage, is a highly prevalent and debilitating condition [1]. Physical, but also cognitive, emotional and social factors play a role in the understanding and treatment of chronic pain [2], [3], [4]. Since biomedical treatment modalities that focus on pain removal are not effective for everyone, psychological and multidisciplinary rehabilitation focuses on improvement of functioning in physical, psychological and social domains [5]. In multidisciplinary rehabilitation, different health-care providers work closely together to restore individual functioning of chronic pain patients. Most rehabilitation programs combine aspects as physical rehabilitation, exercise therapy, cognitive restructuring and behavioral treatment [5], [6]. Often, methods stemming from cognitive behavior therapy (CBT) are used to provide an underlying treatment framework [7]. Intensive multidisciplinary treatment is effective in improving functioning and quality of life [8], [9], [10], with effect sizes in both mono- and multidisciplinary treatment settings ranging from small to moderate [5], [11].

Recent developments in cognitive behavioral treatments introduced Acceptance & Commitment Therapy (ACT) [12], [13]. ACT is a form of CBT that targets acceptance of unavoidable aspects of chronic pain. Acceptance is an alternative to persistent, fruitless attempts to avoid or control the pain experience. By promoting acceptance and related processes such as present-moment awareness and values-based living, the goal of ACT is to increase psychological flexibility and take effective action in accordance with long-term meaningful values despite chronic pain [14]. By this focus, ACT offers an alternative to the paradoxical message of many rehabilitation programs that often implicitly focus on pain control. The inherent fit of the underpinnings of ACT to chronic pain treatment is reflected in outcomes of multiple studies showing that ACT is effective, both as a stand-alone psychological intervention and when interwoven in multidisciplinary rehabilitation [15], [16], [17], [18], [19], [20], [21], [22]. In general, effect sizes are small to moderate, which is similar to effect sizes of other CBT-interventions for chronic pain [21]. The American Psychological Association has recognized ACT as a clinical intervention for chronic pain with strong research support [23]. The above considerations resulted in consensus by collaborating professionals within a leading national consortium of chronic pain rehabilitation centers that ACT is the best practice for Dutch chronic pain rehabilitation [24]. The merit of ACT was reflected in a large, but diffuse, interest from health-care professionals as observed by the authors to receive training in ACT. To overcome the gap – or even ‘chasm’ – reported by the Institute of Medicine [25] between research findings and health-care practice and to prevent subsequent poor dissemination of ACT, we guided systematic implementation of ACT in Dutch chronic pain rehabilitation. In this paper, we describe the implementation and investigate factors related to successful implementation from start to post-implementation.

Multidisciplinary teams from nine Dutch rehabilitation centers offering individual and/or group-based treatment participated. All centers were self-referred to the authors and expressed a wish and readiness to adopt ACT [26]. Research indicates implementation requires considerable time and effort consisting of several recursive processes or stages of change [27], especially when teams are involved in the process [28]. Therefore implementation was designed to be rolled out over a relatively long period of time using multiple implementation and training strategies. In total, the implementation was designed to take 18 months. This trajectory consisted of a six-month pre-implementation phase followed by 12 months of implementation.

We adopted an effective implementation model developed by Grol and colleagues [29], taking into account the situation, setting, and our target of behavior change. In the planning phase, we developed academic partnerships, and visited all rehabilitation centers to communicate possible barriers and obtained formal commitments from each organization involved [26]. Materials to aid the implementation process were developed, among which a secured website containing a blueprint of the implementation, worksheets and contact information of participating professionals. An ACT therapist manual for interdisciplinary teams [30] was written to be used parallel to a patient self-help book ‘Living with Pain’ [31]. All planning and developmental strategies resulted in a formal implementation blueprint – containing information on ACT, the goals of implementation, all materials developed and an optimal timeline for training activities – that served as a guide for systematic implementation [26], [29].

ACT adheres to several factors that can help successful implementation, such as clear advantages of use, compatibility with existing procedures and values, and proven efficacy [32], [33], [34]. Nevertheless, ACT is a complex intervention asking for the use of new intervention techniques and long-term behavioral change of professionals. We therefore focused on educational strategies to heighten competencies in working with ACT [35]. Previous studies showed that didactics training alone do not create substantial change in therapy adherence and skills of professionals [36], [37]. Therefore, we applied a multifaceted, interactive training program using coaching sessions and feedback [27], [34], [38], [39], using a train-the-trainer approach. This approach included the assignment of individuals as ‘early adopters’ and ‘late adopters’ in each organization. Both groups received outreach visits from a trained supervisor and attended peer review meetings, while in the meantime applying ACT in their daily work. Early adopters received more educational opportunities for a longer period of time, most importantly a full six-day course ‘ACT for interdisciplinary teams’. Additionally, early adopters played a role in educational activities for late adopters in the second half of implementation. ACT was applied by both groups of adopters with selected patients, while other patients still received standard care. A schematic representation of the implementation process can be found in Fig. 1.

The overall goal of the implementation was to train rehabilitation professionals in multidisciplinary teams to apply ACT competently during treatment. Competence is an essential aspect of treatment integrity defined as the level or skill with which a professional delivers specified treatments [40], [41]. A related, prerequisite factor for competence is adherence, the actual application of treatment according to protocol [41]. We defined significant improvement in professionals’ self-perceived competencies in working with ACT as the most important proxy for implementation success. We hypothesized that, due to the train-the-trainer approach, early adopters would feel more competent in working with ACT at the start of the implementation and changes in competencies over time would be different for both groups. To corroborate data on changes in professionals’ competence from the perspective of patients, we performed a check on treatment adherence to the ACT protocol by using patient evaluations directly after they received multidisciplinary treatment.

A more theoretically oriented aim of our study was to monitor, describe and investigate the influence of theoretical determinants of innovation success within each health care setting [42]. The investigation of factors that actually impeded or facilitated implementation success, for example professionals’ attitude toward ACT or experienced capability of teams to implement ACT, can be helpful for future implementation efforts in selecting appropriate implementation strategies. We therefore asked professionals and management to rate possible determinants of implementation success. First, we described the ratings of these determinants and explored if any significant changes in ratings occurred over time for professionals. Furthermore, we explored which determinants as measured in early phases of the implementation were related to self-perceived competencies in working with ACT at the end of implementation.