Acceptance and commitment therapy for the treatment of stress among social workers: A randomized controlled trial

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Abstract

Chronic stress increases the risk of health problems and absenteeism, with negative consequences for individuals, organizations and society. The aim of the present study was to examine the effect of a brief stress management intervention based on the principles of Acceptance and Commitment Therapy (ACT) on stress and general mental health for Swedish social workers (n = 106) in a randomized, controlled trial. Participants were stratified according to stress level at baseline in order to examine whether initial stress level moderated the effect of the intervention. Two thirds of the participants had high stress levels at baseline (Perceived Stress Scale; score of ≥25). The results showed that the intervention significantly decreased levels of stress and burnout, and increased general mental health compared to a waiting list control. No statistically significant effects were, however, found for those with low levels of stress at baseline. Among participants with high stress, a substantial proportion (42%) reached criteria for clinically significant change. We concluded that the intervention successfully decreased stress and symptoms of burnout, and increased general mental health. Evidence is, thus, provided supporting ACT as brief, stress management intervention for social workers.

Highlights

► We examined the effects of a brief stress management intervention for social workers. ► We stratified participants according to stress level at baseline. ► The intervention decreased levels of stress and burnouts and increased general health. ► No significant effects were found for those with low stress levels at baseline. ► A brief acceptance-based intervention may positively influence health among social workers.

Introduction

Every fifth employee in Sweden has experienced some form of work-related health problem during the last year, where stress and psychological distress were the most common causes (Swedish Work Environment Authority, 2008). The socio-economic costs of stress-related health problems, related to working life, was estimated at 8 billion SEK (approx. 1.1 billion USD) in terms of production loss in one year (Swedish Government Offices, 2001). Studies conducted in other countries, including the United Kingdom and the United States, have reported similar consequences of work-related stress (Hardy et al., 2003, Kessler and Frank, 1997, Kessler et al., 2008). In the worst scenario, prolonged, unresolved stress at the workplace can lead to burnout, which is characterized by physical, mental and emotional exhaustion, and discomfort and loss of empathy (Maslach & Jackson, 1981). Thus, burnout is a serious feature of stress, one which can have substantial impact on general health and productivity of employees.

Social workers are at risk of developing stress-related health problems. Often working under difficult occupational circumstances with high work demands and limited support and resources, social workers are, to a large extent, faced with the psychological effects of stress and burnout (Lloyd, King, & Chenoweth, 2002). In fact, high levels of stress and psychiatric symptoms, emotional exhaustion, and low levels of job satisfaction have repeatedly been observed in the group (e.g., Bride, 2007, Coyle et al., 2005, Evans et al., 2006, Lloyd et al., 2002, Tham and Meagher, 2009). These negative consequences are often related to feeling undervalued at work, high work demands and low control (Evans et al., 2006, Lloyd et al., 2002, Tham and Meagher, 2009). Social workers within the public sector have shown to have higher levels of psychological stress compared to those working in other areas, regarding symptoms of burnout, anxiety, depression and irritation, as well as significantly more somatic complaints, such as tiredness, dizziness and muscle tension (Himle, Jayaratne, & Thyness, 1993). In Sweden, social workers have been found to report high workload (Tham & Meagher, 2009), high staff turnover (Tham, 2007) and long-term sick leave with stress-related health problems as the main cause (Swedish Work Environment Authority, 2008).

Stress management interventions, mainly based on behavioural and cognitive methods, have been developed with the aim of increasing the individual’s psychological resources and ability to effectively cope with occupational strains (Barkham and Shapiro, 1990, Murphy, 1996). Reviews have provided support for their use in increasing health and well-being in employees (Murphy, 1996, Van der Klink et al., 2001). Yet, room for improvement in outcomes exists (Van der Klink et al., 2001) and, thus, further development of effective procedures in the treatment of work-related stress is needed.

Acceptance and Commitment Therapy (ACT) is a modern form of behaviour therapy and is based on behavioural principles formalized in Relational Frame Theory (Hayes, Strosahl, & Wilson, 1999). The overall aim of ACT is to increase psychological flexibility through the six core processes of acceptance, defusion, self as context, committed action, values, and contact with the present moment (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Psychological flexibility is defined as “the ability to contact the present moment more fully as a conscious human being and to change, or persist in, behaviour when doing so serves valued ends” (Hayes et al., 2006, p. 7). Through the means of psychological flexibility the therapy seeks to reduce experiential avoidance, which is described as process involving any behaviour that functions to avoid or control internal experiences, such as thoughts, feelings, or physiological sensations (Hayes, Strosahl et al., 2004). The idea is that experiential avoidance over time will increase the intensity, frequency or duration of the very same experience that one is trying to avoid or control. There is some support for this notion in the literature (see, Chawla & Ostafin, 2007, for an empirical review of experiential avoidance).

Research on ACT has provided promising results for various psychological problems, with effect size estimates in the moderate range (Hayes et al., 2006, Öst, 2008). There are, however, still only a few studies on ACT within each specific area or diagnosis (Hayes, Masuda, Bisset, Luoma, & Guerrero, 2004). Studies on ACT have also been criticized for not having the same research methodology standard as studies on “traditional” CBT (Öst, 2008). Thus, further controlled trials of high methodological rigour are needed.

As ACT’s primary aim is to increase flexibility rather than to eliminate pathology, it has been argued that the treatment can be especially useful when the goal is to prevent future health issues (Biglan, Hayes, & Pistorello, 2008). Biglan et al. (2008) considers the possibility that experiential avoidance may serve as meditator of the impact of stressful events on pathology. Individuals who are high on experiential avoidance may lock into a self-amplifying process by avoiding the experience that goes along with stressful events, thereby increasing the risk for prolonged stress reactions and for the development of negative effects over time. Thus, as ACT explicitly targets experiential avoidance, the therapy may help to prevent some of the harmful consequences of stress. ACT has, in fact, been modified as a preventive stress management intervention (ACT–SMI; Bond & Hayes, 2002). The intervention focuses on acceptance of unpleasant internal events rather than on changing or eliminating stressors that give rise to such events (Bond, 2004, Bond and Hayes, 2002). The intervention is given to groups and consists of three 3-h sessions: two on consecutive weeks, and the third after three months. Studies on ACT–SMI in organizational settings have provided evidence for its usefulness, showing that the intervention can have a beneficial effect on depression, general mental health, dysfunctional cognitions, occupational constraints, learning at work and propensity to innovate (Bond and Bunce, 2000, Flaxman and Bond, 2010). Furthermore, preliminary findings support that the effects of the intervention were mediated by the proposed processes of the therapy (i.e., psychological flexibility; Bond and Bunce, 2000, Flaxman and Bond, 2010).

Despite these encouraging findings, further studies on ACT–SMI in different settings and cultural contexts are warranted. In fact, studies on ACT–SMI and on key processes related to the intervention have almost exclusively been conducted in the United Kingdom and they have been limited to the private sector of working life (Bond and Bunce, 2000, Bond and Bunce, 2003, Bond et al., 2008, Flaxman and Bond, 2010). Specifically, to our knowledge, no study has to date tested whether the intervention also can be beneficial for social workers who experience occupational strains in the public sector.

A modified version of the ACT–SMI has been developed in Sweden (Livheim, 2008). This version of ACT–SMI has a slightly different structure compared to the original version. It includes one more session with a total of four sessions of 3 h each, provided every other week. Although similar exercises are used to promote psychological flexibility, more time is devoted to homework assignments and daily practice between sessions in this version of the intervention. To our knowledge, two randomized controlled trials of the protocol have been conducted in school settings in Sweden, providing preliminary evidence for beneficial consequences for teachers (Altbo & Nordin, 2007) and youths (Livheim, 2004).

To summarize, social workers have reported high levels of stress and stress-related health problems and can therefore be assumed to benefit from a stress management intervention. The aim of the present study was to examine the effect of an ACT–SMI on stress and general mental health for Swedish social workers compared to a waiting list control in a randomized, controlled trial. Although ACT–SMI’s primary aim is not to reduce pathology, stress and general mental health were chosen as primary outcomes given that these outcomes are often targeted in traditional CBT-based SMIs (e.g., Murphy, 1996). Thus, this will allow comparison of efficacy within the established research tradition. Furthermore, experiential avoidance may decrease an individual’s ability to cope with stressors (see, Biglan et al., 2008, for a review on the diathesis-stress model of experiential avoidance), making stress an adequate target even from ACT perspective. In addition, general mental health has been used as primary outcome in previous studies on ACT–SMI (e.g., Flaxman & Bond, 2010). Secondary outcome variables in our trial were burnout, performance-based self-esteem, and job demand and control, as these outcomes are of importance from a work-related perspective, in particular the work of social workers (Evans et al., 2006). We also investigated the effect of the ACT–SMI on the purported process of change in the treatment, i.e., psychological flexibility. Moreover, as perceived level of stress might affect the need for improved stress management, we examined whether initial level of stress moderated the effects of the intervention. In addition, we explored whether therapist effects were present in the trial by randomizing and comparing experienced therapists with less experienced therapists. Finally, we conducted exploratory correlation analyses to examine the association between the proposed process in ACT–SMI (i.e., psychological flexibility) and the outcome.

The present study was designed to address the above stated aims. First, we predicted that the ACT–SMI would produce significant improvements on the outcome and process variables in comparison with the control condition for the entire sample of participants (Hypothesis 1). Second, we expected to observe larger effects of ACT–SMI on stress in a subgroup of participants with high stress levels at baseline in comparison with the effects seen in a subgroup of participants with low initial stress levels (Hypothesis 2). That is, effects would be significant for those with high stress levels but not for those with low stress levels. In line with this, we assumed that a greater proportion among participants with high initial stress levels would experience clinically significant improvements than participants with low initial stress levels. Third, we expected that more experienced therapists would produce greater improvements in outcomes than less experienced therapists (Hypothesis 3). Fourth, we hypothesised that psychological flexibility would be correlated with the outcomes, such that higher increase in flexibility would be associated with greater improvements (Hypothesis 4).

Section snippets

Participants

All social workers employed by the City of Stockholm, Sweden (N = 1228) were offered to participate in the study and were invited to an information meeting. A total of 108 social workers attended the meeting, making them eligible for participation in the study. Of these, 106 participants were enrolled in the study, providing informed consent and self-assessments. There were no exclusion criteria. The participants did not receive any compensation for participation. This sample of participants

Attrition

Dropout occurred when participants did not complete the intervention (which required presence at a minimum of three out of four sessions) or did not complete the post-intervention measures. Ninety-four participated in the post-intervention measures, which brought the number of participants that dropped out to twelve. Five of these never started the intervention, a further two did not finish it and the remaining five finished the intervention but did not complete the post-intervention measures.

Discussion

This study examined the effect of a brief, stress management intervention based on the behavioural principles of ACT for social workers. The study had four specific hypotheses. In support of Hypothesis 1, the results suggest that the intervention had an effect on primary outcome of stress and general mental health as well as secondary outcome of burnout and its subscales emotional exhaustion, depersonalization and personal accomplishments for the sample as a whole. A substantial proportion

Acknowledgements

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article. The authors received no financial support for the research and/or authorship of this article. The authors wish to thank Fredrik Livheim for helping with education and training throughout the study. They are also grateful to psychologists, Maria Lalouni and Erik Hellman, who participated in the study.

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