University of Nevada, Reno Acceptance and Commitment Therapy with Dually Diagnosed ...

152 Pages·2008·0.98 MB·English

University of Nevada, Reno

Acceptance and Commitment Therapy with
Dually Diagnosed Individuals

A dissertation submitted in partial fulfillment of the
requirements for the Degree of Doctor of Philosophy in
Clinical Psychology

by

Julieann Pankey

Dr. Steven C. Hayes/Dissertation Advisor

December 2008
3339134

3339134
2009
THE GRADUATE SCHOOL

We recommend that the dissertation
prepared under our supervision by

JULIEANN PANKEY

entitled

Acceptance And Commitment Therapy With Dually Diagnosed Individuals

be accepted in partial fulfillment of the
requirements for the degree of

DOCTOR OF PHILOSOPHY

Dr. Steven C. Hayes, Advisor

Dr. Victoria Follette, Committee Member

Dr.Jacqueline Pistorello, Committee Member

Dr. Ramona Houmanfar, Committee Member

Dr. John Packham, Graduate School Representative

Marsha H. Read, Ph. D., Associate Dean, Graduate School

December, 2008
i
ABSTRACT
Developmentally disabled individuals presenting with psychopathological
symptoms present a challenge to service providers. It has been demonstrated that these
individuals suffer from the same mental health difficulties as the general population, and
that prevalence rates for Axis I disorders are slightly higher than the general population.
The developmentally disabled-dually diagnosed (DD/DD) population has been served
primarily pharmacologically rather than through psychotherapy. When intervention has
been attempted, it has manifested primarily in the form of behavior modification or other
structured behavioral intervention which seeks to change, control, eliminate, or modify
symptoms. Specifically, cognitively disabled individuals with mood, anxiety, or other
Axis I disorders have been taught to ignore or attempt to actively control negative or
anxious ideations rather than to embrace or accept them; and to curtail behaviors which
may arise surrounding negative evaluations or thoughts. The current study was a mini
randomized controlled study designed to investigate the influence of an acceptance-based
therapy, Acceptance and Commitment Therapy, (ACT), on the negative psychological
content induced by Axis I disorders in developmentally disabled individuals. Results
found that a brief group intervention for cognitively disabled individuals based on ACT
improved functioning, reduced psychopathology, increased psychological flexibility, and
increased time spent focused on the importance of values and living in line with one’s
values. This pattern of results suggest that the principles underlying ACT treatment
technology may assist individuals within the range of moderate mental retardation to
borderline intellectual functioning with issues related to mental health.
ii
Acknowledgements

Sincere gratitude to my mentor, Dr. Steve Hayes, for providing support and
guidance throughout the journey of graduate school. I am very appreciative of Dr. John
Packham, Dr. Jacqueline Pistorello, Dr. Victoria Follette, and Dr. Ramona Houmanfar for
being willing to serve on my dissertation committee and assisting me in helping this
project come to fruition. Thanks to Steve for standing up for me; and for encouraging me
to be creative and self-sufficient.
I have had a huge amount of support from my friends for my graduate endeavors
and this project in particular. I want to thank Lorri Tuomey, Holly Williams, Christine
Riley, Lora Olvera, Katie Brock, Shawn Taylor, and Marty Ross--you have all been
instrumental along this journey. My deepest thanks as well to Despina Hatton, Ernie
Neilson, Marcia Bennett, Judy Phoenix, Steven and Brenda, Rick and Sherilan, Aslan
Alton, Gil Greenberg, Ellen Brock, Bonnie Kirish, Dr. William Follette, Dr. Jim Comer;
and Dr. Patricia Haynes for their support and encouragement at differing critical
moments.
Deep love to my beautiful son, Gabriel Rowan, who blessed my life during the
process of graduate school. You are the shine. Love to my dogs, you have sustained me,
especially Telequa and Kuska for the hours lying beneath me as I typed.
Thanks and love to my mother for your support and pride in me. Thanks and love
to Benjamin, it’s been a long haul, thanks for adding to the equation. Oh Sherrie.
Thank you God, for watching over my family.
Most of all, this is for Marcella Parsell, my grandmother. You showed the way
and I followed.
iii
TABLE OF CONTENTS
Chapter One
Introduction and Literature Review
Population characteristics
Prevalence
Identification and diagnosis
Dual diagnosis
Continuum
Diagnostic overshadowing
Presentation for treatment
Treatment Intervention for the Developmentally Disabled
Introduction
Psychotherapy
Psychopharmacology
Acceptance and Commitment Therapy (ACT)
ACT model
DD/DD & ACT: Cognitive rigidity and the development of self stigma
DD/DD & ACT: The role of rule governance and avoidance
Research on ACT: Broad applicability
ACT and Brief Interventions
ACT and DD Evidence
Rationale and Purpose of the Study
Chapter Two
Method
Participant Recruitment
Table 2.1: Subject Characteristics
Characterization of Client Services and Informants
Table 2.2: Informant Characteristics
Treatment as Usual
Table 2.3: Treatment as Usual Nature of Contact/Frequencies
Intervention
Procedure
Session Structure
Table 2.4: Session Structure Outline
Measures
Inclusion Criteria and Demographic Measures
Primary Outcome Measures
Secondary Outcome Measures
Primary Process Measures
Secondary Process Measures
Adherence
Attrition
Hypotheses
Specific Hypothesis Testing
Chapter Three
Preliminary Investigation
Demographic Variables
Table 3.1 Demographic Information by Condition
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Primary Outcome Measures
Table 3.2 Primary Outcome Measures by Condition at Baseline Comparisons
Secondary Outcome Measures
Table 3.3 Secondary Outcome Measures by Condition at Baseline Comparisons
Primary Process Measures
Table 3.4 Primary Process Measures by Condition at Baseline Comparisons
Secondary Process Measures
Table 3.5 Secondary Process Measures by Condition at Baseline Comparisons
Data Analysis
Primary Outcome and Process Analyses Between Groups
Table 3.6 Means, Adjusted Means, Change Scores, Standard Deviations, Within and
Between Groups Cohen’s d on All Measures
Primary Outcome Measures Analyses
Table 3.7 Adjusted Means & Within Cohen’s d on Both Groups at Post & 30 Day
Follow-Up
Table 3.8 Between Group ANCOVAs for Primary Outcome Measures
Secondary Outcome Measure Analyses
Table 3.9 Between Group ANCOVAs for Secondary Outcome Measures
Primary Process Measures Analyses
Table 3.10 Between Group ANCOVAs for Primary Process Measures
Secondary Process Measures Analyses
Table 3.11 Adjusted Means and Standard Error for AFQ-Y Phases by Group
Table 3.12 Adjusted Means and Standard Error for MBEVI Phases by Group
Table 3.13 Between Group ANCOVAs for Secondary Process Measures
Table 3.14 Adjusted Means and Standard Error for ATQ-B Phases by Group
Mediational Analyses
Table 3.15 Mediation Using ATQ-Y Pre to 30 Day Outcome for the Vineland
Table 3.16 Mediation Using ATQ-Y Pre to 30 Day Outcome for the ADAMS
Life Coping Scale Item Analysis
Table 3.17 Life Coping Scale Inter-Item Correlation Matrix
Table 3.18 Differences Between Groups Life Coping Scale Item Scores at Pre, Post, and
30 Day Follow-Up
Verbal IQ
Adherence
Table 3.19 Adherence Ratings
Chapter Four
Discussion
Goals of the Study
Conceptual Framework
Results
Benefits of ACT for the DD Population
Considerations
Limitations of the Study and Recommendations for Future Research
Implications
Appendices
Appendix A: Consent to Participate in Research Study
Appendix B: ACT Treatment Manual for Dual Diagnosis
Appendix C: Assessment Instruments
Appendix D: Debriefing Form
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Appendix E: Recruitment Flyer
Appendix F: Evaluation for Understanding Informed Consent
Appendix G: Adherence Rater’s Checklist for ACT/DD Population Tx Protocol
References
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Acceptance and Commitment Therapy in the Treatment of Dually Diagnosed Individuals
Chapter One
Introduction and Literature Review
Diagnosing mental illness in the cognitively disabled population is a challenging
endeavor because of the difficulty in parsing features relevant to mental retardation
versus those related to co-morbid psychopathology. Although traditionally there exists a
bifurcation of service delivery between individuals with mental retardation and those
with mental illness, individuals who suffer from cognitive impairments may also have
difficulty coping with negative private emotional experiences and managing stressful life
events. By definition, persons with developmental disabilities seldom (if ever) are dealing
with one disability. The person may have communication deficits, perceptual problems,
motoric difficulties, general comprehension problems, and abstract reasoning difficulties
(Landsdell, 1990). Additionally, mentally handicapped individuals may suffer from the
full spectrum of psychopathological illnesses, yet there is a paucity of controlled research
investigating the efficacy of treatment interventions in this population. Unfortunately,
there is still a gap between the care needs and the services available for people with
intellectual disability (Raitasuo, Taiminem, & Salokangas, 1999).
A prevailing view is that people with intellectual disabilities and concomitant
psychiatric disorders have often been under-served or inappropriately treated (Moss,
Bouras, & Holt, 2000). Due to a number of clinical biases and misrepresentations about
the population, individuals with co-morbid mental retardation and psychopathology are
often mis-diagnosed and lack access to mental health services.
Developmentally disabled individuals with mental illness bear the double burden
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of experiencing negative private thoughts as well as an often crippling inability to cope
with these symptoms. Distress often manifests in multiple hospitalizations, creating a
drain on the health care industry. Although treatment programs are available, dually
diagnosed individuals often face recurrent and distressing symptoms, repeat
hospitalizations, and atypical responses to high doses of psychotropic medication that is
often used in this population to curtail “challenging behaviors,” despite the limited
evidence for their utility (Brylewski & Duggan, 2004).
Prout, Chard, Nowak-Drabik, and Johnson (2000) have advocated for the notion
that psychotherapy research with persons who have mental retardation needs to progress
toward more empirically based models of investigation. Others have suggested a need for
increased awareness among clinicians regarding the varying linguistic and symbolic
capacities among individuals with mental retardation (Butz, Bowling, & Bliss, 2000).
There have been very few methodologically sound investigations that adequately address
the gaps in empirical research (Nezu, Nezu, & Gill-Weiss, 1992). A recent meta-analysis
found that research in this area is dominated by case studies and single subject designs,
lacks traditional controlled comparison studies or clinical trials, does not demonstrate
interventions which have been clearly outlined and described, is not theoretically derived,
and is typified by vague descriptions of outcome data (Prout & Nowak-Drabik, 2003).
Population Characteristics: Until recently, mental health problems in people with
intellectual disabilities have been largely neglected by professionals and researchers,
resulting in the under-diagnosis of mental health problems (Charlot, Doucette, &
Hezzacappa, 1993). A national sample of professionals in community health centers
indicated that adults with mental retardation were significantly less likely to be offered