Acceptance and Commitment Therapy (ACT) for long-term conditions (LTCs) and medically unexplained symptoms (MUS)

Living Well as the First Medicine – Training in ACT

Cognitive Behaviour Therapy (CBT) is a brilliant treatment for anxiety and depression, but many CBT therapists working in IAPT feel stuck when working with patients who have long-term conditions (LTCs).

This is not their fault. Many post-graduate training courses in CBT don’t equip trainees with the relevant knowledge and skills to treat long-term conditions.

It’s not the fault of universities and training providers either. PWP and HIPI courses are already packed full of essential teaching that course leaders would struggle to find more time to include physical health.

The integration of mental and physical health treatments within IAPT services is very young, which means that first and second wave IAPT implementation sites are only just beginning to develop these pathways.

How do IAPT services meet this challenge?

IAPT services do an amazing job and they are under extreme pressure to keep waiting lists down and reduce rates of anxiety and depression. Long-term health conditions or those with medically unexplained (MUS), are coming to terms with life changing events.

When patients have physical health problems, it can make it more challenging for HIPIs and PWPs to help them implement new CBT skills. This can be stressful for practitioners, because they saddle the burden of clients making slower progress.

Front-line staff working with long-terms conditions and medically unexplained symptoms (MUS) are exposed to a new context – instead of working to a framework built on moving towards full recovery, practitioners are helping patients adjust to the losses of health, mobility, energy, fitness, strength, days without physical pain, independence and freedom. This is a very different challenge and requires a broader set of skills.

I said earlier that CBT is brilliant for treating anxiety and depression. That is true, but when faced with helping people who have chronic physical health problems, traditional CBT can hit a brick wall.

What do you do with thoughts when they are true?

Second-wave ‘Beckian’ CBT is built on the philosophical assumptions that inaccurate or irrational thinking is a ‘broken cog in the machine’ that needs fixing. Thus, if these thoughts are ‘corrected’ or reconstructed that it will create a change in the emotions and coping behaviours that are better for the client.  Most practitioners know that teaching a patient to challenge a cognition that is unequivocally true, is just futile. What is the alternative?

This is where Acceptance and Commitment Therapy (ACT) offers some other ideas that can be easily added to the IAPT practitioner’s toolbox.  When someone who is trained in CBT learns about ACT, they discover that you can integrate some new interventions without having to abandon what you already know and do. ACT can be used alongside existing CBT evidence-based practices.

What is different about ACT?

Acceptance and Commitment Therapy (ACT) is a model that lets a therapist continue to use important behavioural methods like exposure and behavioural activation, whilst addressing cognitions in a different and more useful way to traditional CBT.

ACT targets cognitions, not by re-constructing them, but by altering the impact of them. When unhelpful thoughts are identified, ACT teaches you how to take a step back from them and leave them alone.

Although CBT has a way for examining the ‘helpfulness’ of thoughts, it tends to be of limited use to the patient.  Often, it’s over-thinking that maintains the problem. To treat over-thinking with a cognitive intervention i.e. more thinking, is like trying to put out a fire by putting more fuel on it.

Based on a behavioural analytic and scientific understanding of language, ACT deals with unhelpful thoughts using experiential methods instead of cognitive techniques. ACT teaches a person how to notice, disengage and be non-reactive to these thoughts. This is called Cognitive Defusion, and when you learn how to do this, it creates a powerful transformation.

Psychological Acceptance is another process that is central to ACT and different from traditional CBT. Acceptance is often misunderstood, because we tend to think of it as being like giving-in or putting up with. In ACT, acceptance is not like this.

Acceptance is a way that you can embody the painful emotions. It’s a way of making room for them, instead of trying to fix or minimise them. Research experiments into thought suppression have taught us that when you try not to think or feel something, you end up experiencing it more often. This is the struggle that we all get caught up in. And, when you have a long-term condition, its natural to want to push away the sadness, embarrassment, shame and anger of what has happened. But, when you do, it makes you suffer more. Acceptance is route out of the futility of trying to avoid painful emotions.

These two processes are just part of what make ACT different. To learn ACT in more depth and to acquire the necessary knowledge and skills to apply it correctly, practitioners can complete an introductory training course in ACT for long-term conditions and medically unexplained symptoms.

For more information and to discuss arranging training in ACT for LTCs for your team, get in touch by completing the form below.