Psychological flexibility and the moderating role of the therapeutic working alliance in Acceptance and Commitment Therapy in Daily Life (ACT-DL) in an early psychosis sample

Abstract

Background: We investigated treatment effects of Acceptance and Commitment Therapy in Daily Life (ACT-DL) on psychological flexibility (PF) and the moderating role of the therapeutic working alliance on these effects in patients with early psychosis. Methods: ACT-DL is an ecological momentary intervention (EMI) combining face-to-face ACT with a smartphone app. In the multi-center INTERACT randomized controlled trial, n=148 early psychosis individuals were randomized to either treatment as usual (TAU as the control condition, n=77) or to ACT-DL in addition to TAU (ACT-DL + TAU as the experimental condition, n=71). We assessed global PF and the therapeutic alliance with self-report questionnaires. In addition, we used the experience sampling methodology (ESM) to assess PF with a momentary (in-the-moment and since-the-previous-beep openness) and an evening (daily PF) questionnaire. Assessments took place at baseline, post-intervention (POST), six (FU6), and twelve months (FU12) follow-up. Results: Global (B=19.49 to 33.14; all P-values<.001) and daily PF (B=0.68; P-value<.001) improved equally in both conditions at each time point. Individuals in the ACT-DL condition improved more than those in TAU on momentary openness (in-the-moment openness at POST (B=0.32; P-value=0.007) and since-the-previous-beep openness at POST (B=0.33; P<.001) and FU6 (B=0.23; P-value=0.025). Client-perceived working alliance moderated in-the-moment openness such that larger improvements in openness at POST (B=0.05; P-value<.001) were found in ACT-DL in individuals with higher working alliance scores. Conclusion: Our results provide partial support for the capability of ACT-DL to improve daily life measures of openness, and emphasize the importance of the therapeutic relationship in supporting processes of change.

Can digital tools improve clinical care in psychiatry?

“…In a randomized controlled trial, we found that ACT-DL was outperforming treatment-as-usual (including CBT) in improving negative symptoms and social functioning, two of the hardest-to-treat symptoms (12). Furthermore, we found that the intervention was feasible and accessible although it could further be optimized for use in this patient group (13).…”

Acceptance and commitment therapy for psychosis: Current status, lingering questions and future directions

“…This would avoid focusing on mechanisms that mirror the skills themselves, for example, acceptance and mindfulness exercises improving acceptance and mindfulness skills (Johannsen et al, 2022). The use of non‐self‐report measures can also help to understand how ACT skills lead to psychological flexibility, for example, experimental lab tasks, wearable devices and ecological momentary assessment across contexts of ACT skill use and time‐lagged physiological, cognitive and behavioural responses (e.g., Van Aubel et al, 2022; Van der Gucht et al, 2019).…”

“…Browne et al (2021) found that engagement (i.e., number of interactions) with an ACT smoking cessation smartphone app in people with severe mental illness including psychosis mediated the effect of the intervention on decreased number of cigarettes smoked per day compared with a non-ACT smoking cessation app. A recent multi-centre RCT of ACTp combined with ecological momentary intervention versus treatment as usual in people with early psychosis found that 'momentary openness' improved more in ACTp and higher client-rated working alliance moderated (improved) this outcome (Van Aubel et al, 2022).…”