Acceptance and Commitment Therapy for the Treatment of Posttraumatic Stress Among Adolescents

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    • 00:00

      [Michelle Woidneck Kieffe, Licensed Psychologist,Boys Town Center for Behavioral Health][Acceptance and Commitment Therapy for the Treatmentof post traumatic Stress Among Adolescents]

    • 00:07

      MICHELLE WOIDNECK KIEFFE: Hello.My name is Dr. Michelle Woidneck.I'm a licensed psychologist.And I currently work at the outpatient clinichere at the Boys Town Center for Behavioral Health near Omaha,Nebraska.I was asked to participate in the Sage video initiativeto discuss the article, "Acceptance and Commitment

    • 00:30

      MICHELLE WOIDNECK KIEFFE [continued]: Therapy for the Treatment of Post-Traumatic StressAmong Adolescents," which was published in BehaviorModification in 2014 by myself and two of my colleagues, MikeTwohig and Kate Morrison.I completed this project while I was at Utah State University.

    • 00:51

      MICHELLE WOIDNECK KIEFFE [continued]: And I was initially exposed to ACT through my workwith Mike Twohig, who is also a co-author on this article.And ACT was a treatment model that just really resonatedwith me on a personal level, and I found myselfbecoming increasingly interested in ACTas more and more research came outshowing its effectiveness with a variety of populations

    • 01:14

      MICHELLE WOIDNECK KIEFFE [continued]: and presentations.So as I was becoming more and more interested in ACT,at the same time, I was also doing a fair amount of workwith adolescents, and becoming increasinglyinterested in working with post-traumatic stresssymptomology the more I got exposed to this population.

    • 01:37

      MICHELLE WOIDNECK KIEFFE [continued]: So to me, it just seemed that given that avoidanceis central to PTSD and post-traumatic stress,it seemed like ACT would be a natural fit for this condition.And so this project was born.So prior to this study, a few case studies

    • 01:57

      MICHELLE WOIDNECK KIEFFE [continued]: with adults with post-traumatic stresshad been done, looking at the effectiveness of ACTto treat this population.And those case studies showed promising results,but there was no research at the time lookingat ACT to treat younger populationswith post-traumatic stress.

    • 02:19

      MICHELLE WOIDNECK KIEFFE [continued]: And like I said, given the role of avoidancein post-traumatic stress, and giventhat ACT, one of its primary targets is experientialand behavioral avoidance that interferes with an individual'sability to live full and meaningful lives,we thought that this would be a natural treatment approach.And we hypothesized that not only would adolescents

    • 02:45

      MICHELLE WOIDNECK KIEFFE [continued]: find ACT to be an acceptable treatmentapproach for their condition, but we alsoanticipated that we would see a decreaseof post-traumatic stress symptomologyand an increase in overall quality of lifeas a result of participation in ACT.We also hypothesized that the processes underlying

    • 03:07

      MICHELLE WOIDNECK KIEFFE [continued]: ACT would mediate the changes, or at least changealongside with the changes in post-traumatic stresssymptomology.So to investigate this, we used a multiple baseline studyto explore the effectiveness of a 10-week ACT protocol

    • 03:28

      MICHELLE WOIDNECK KIEFFE [continued]: to treat post-traumatic stress in adolescentsbetween the ages of 12 and 17.So given that many youth who do notmeet the full diagnostic criteria for PTSDcontinue to experience problematic post-traumaticstress symptomology, a full diagnosis of PTSD

    • 03:49

      MICHELLE WOIDNECK KIEFFE [continued]: was not an eligibility requirementfor participation in this study.Rather, individuals who experiencedclinically significant post-traumatic stress symptomswere eligible for participation, evenif they didn't meet full diagnostic criteria for PTSD.And so we used the Clinician-Administered PTSD

    • 04:09

      MICHELLE WOIDNECK KIEFFE [continued]: Scale for Children and Adolescents,or the CAPSCA, which was the gold standard assessmentfor post-traumatic stress at the time.We used this to assess for severityof post-traumatic stress symptoms.So individuals who scored a global severity rating of twoor moderate PTSD symptomology, which

    • 04:29

      MICHELLE WOIDNECK KIEFFE [continued]: was defined as definitive distress or functionalimpairment, but able to function satisfactorily with effortwere eligible for the study.Potential participants were initiallyrecruited from the community.And we ended up having a much more difficult timewith recruitment than we had anticipated.

    • 04:50

      MICHELLE WOIDNECK KIEFFE [continued]: And so we ended up extending our recruitment effortsto a residential population in the nearby community.As a result, we ended up with seven total participantsfrom two separate samples, four youth from a community sample,and three youth from a residential sample.So in the community sample, there

    • 05:12

      MICHELLE WOIDNECK KIEFFE [continued]: were two males and two females between the ages of 12 and 17,and all of the residential samplehappened to be 15-year-old females with co-morbid eatingdisorders, which is what they werereceiving residential treatment for, for the eating disorder.The trauma exposure ranged from a single incident

    • 05:32

      MICHELLE WOIDNECK KIEFFE [continued]: of physical abuse to a single incidentof sexual abuse, sudden death of a primary caregiver,to a natural disaster, to repeatedsexual and physical abuse.So a wide range of trauma exposure.So parents and youth interested in the studywere initially screened by phone.Potential participants who contacted the clinic

    • 05:55

      MICHELLE WOIDNECK KIEFFE [continued]: and met the preliminary eligibility requirements--so they were between the ages of 12 and 17,they had experienced a traumatic event,and they were seeking treatment for symptoms that developedafter exposure to that traumatic event--were eligible to move forward in the study.

    • 06:16

      MICHELLE WOIDNECK KIEFFE [continued]: Potential participants were ineligible for the studyif they were experiencing ongoing trauma,if they had been diagnosed with a developmental disability,if parental consent could not be attained,or if the individual was currentlyreceiving trauma-related treatment elsewhere.And if needed, we of course gave them

    • 06:37

      MICHELLE WOIDNECK KIEFFE [continued]: referral information to other providerswho might be able to meet their needs.So parents and youth then attendeda two-hour pre-treatment assessmentwhich consisted of attaining informed consent and assent,and completing the CAPSCA, the Clinician-Administered PTSD

    • 06:58

      MICHELLE WOIDNECK KIEFFE [continued]: scale that I had mentioned.So if the participants met the criteria based on the CAPSCA,then they completed some additional self-reportmeasures, including the Child PTSD Symptom Scale,or the CPSS, the Comprehensive Quality of Life Scale,and the Avoidance and Fusion Questionnaire for Youth,

    • 07:19

      MICHELLE WOIDNECK KIEFFE [continued]: or the AFQY, which is a process measure thatassesses ACT processes of experiential avoidanceand cognitive fusion.So after completion of the intake,participants also began to engagein daily self-monitoring.So they completed a five-question survey every day

    • 07:44

      MICHELLE WOIDNECK KIEFFE [continued]: after the pre-treatment questionnairethrough the completion of this study.And the five questions, they were asked to rateon a scale from zero to 10 the frequencyof the re-experiencing symptoms, frequency of daily avoidance,and frequency of hyper-arousal symptoms,as well as the level of distress associated with those symptoms,

    • 08:06

      MICHELLE WOIDNECK KIEFFE [continued]: and how much those symptoms interferedwith their daily functioning.So the responses of these five questionswere totaled to provide an overall post-traumatic stressscore.And this score was used as the primary outcomevariable for the study.After completion of the initial intake,participants then began the baseline phase of treatment

    • 08:29

      MICHELLE WOIDNECK KIEFFE [continued]: where they completed the daily self-monitoring questionnaire.And baseline phase ranged from sevento 66 days following the pre-treatment assessment.And in order to move on to the treatment phase of the study,a minimum of five stable post-traumatic stress baselinedata points were needed.

    • 08:49

      MICHELLE WOIDNECK KIEFFE [continued]: And for participants two, three, or four,we also had to see a reduction in the previous participant'spost-traumatic stress symptoms before the next participantcould begin.So the treatment phase consisted of 10 one-hour therapysessions.And the protocol used in this study

    • 09:10

      MICHELLE WOIDNECK KIEFFE [continued]: was a modified protocol created from a preexisting ACTtreatment manual used with adolescents for another anxietydisorder and supplemented with exercises from a manual,specifically developed for PTSD in adults.

    • 09:31

      MICHELLE WOIDNECK KIEFFE [continued]: The goals of the treatment protocolwere to, one, decrease the use of experiential avoidancestrategies.Two, help the client determine effective strategiesfor responding to trauma-related symptoms.Three, practice using these strategies outside of session.Four, gradually decrease distress

    • 09:51

      MICHELLE WOIDNECK KIEFFE [continued]: associated with the trauma-related symptoms.And five, to increase the occurrence ofidentified meaningful life activity.So participants continued to completethe daily self-monitoring questionnairethroughout the treatment phase, and they alsocompleted the Child PTSD Symptom Scale and the AFQY, the process

    • 10:14

      MICHELLE WOIDNECK KIEFFE [continued]: measure, at each session.So one week after completion of the 10th session,participants completed a post-assessment, whichconsisted of all the same assessments at pre-treatment,plus one additional measure that asked them to ratethe acceptability of the treatment.

    • 10:36

      MICHELLE WOIDNECK KIEFFE [continued]: Three months later, participants completed a follow-upassessment.So one week prior to follow-up assessment,they completed the daily self-monitoring form online,and then the follow-up assessmentthat was the same as pre and post.

    • 10:56

      MICHELLE WOIDNECK KIEFFE [continued]: So the results repealed a decreasein post-traumatic stress symptoms across both samples.So the mean reduction in post-traumatic stress symptoms,according to the self-report scale at post-treatmentwas a 69% average reduction among the community sample,

    • 11:20

      MICHELLE WOIDNECK KIEFFE [continued]: and an 81% average reduction in post-traumatic stress symptomsamong the residential sample.And these results were maintained at follow-upwith an overall reduction of 68% in post-traumatic stresssymptoms for the community sample,and an overall reduction of 84% for the residential sample.

    • 11:42

      MICHELLE WOIDNECK KIEFFE [continued]: Reductions in the clinician-rated measure PTSD,were observed for all participantswith mean reductions at 57% for the community sampleand 61% in the residential sample.At follow-up these results also were

    • 12:02

      MICHELLE WOIDNECK KIEFFE [continued]: maintained with a 71% overall reduction for the communitysample, and 60% overall reductionfor the residential sample.Slight increases in quality of lifewere seen among all participants.And six of the seven total participantsshowed positive changes in psychological flexibility,

    • 12:25

      MICHELLE WOIDNECK KIEFFE [continued]: according to the AFQY, the process measure between pre-and post-treatment.And all the participants completing follow-upshowed a positive increase in psychological flexibilityon that process measure.So overall, this study provides preliminary support

    • 12:49

      MICHELLE WOIDNECK KIEFFE [continued]: for the effectiveness of the 10-week ACT protocolto treat post-traumatic stress in adolescents.At the time, this study represented the firstin its area of ACT for anxiety generallyand post-traumatic stress specifically.

    • 13:11

      MICHELLE WOIDNECK KIEFFE [continued]: Additionally, ACT was effective for individualswho experienced different types of traumatic events,as well as for individuals who experienced a single traumaor multiple traumas.Also notable in this study was the high rateof treatment acceptability.So treatment acceptability is an important issue

    • 13:32

      MICHELLE WOIDNECK KIEFFE [continued]: for alternate approaches with you, and perhaps even more sowith post-traumatic stress.And given that exposure to traumais related to a number of negative outcomesthat can persist into early adulthood and beyond,early intervention may be essential in helpingto prevent these long-term negative outcomes.

    • 13:56

      MICHELLE WOIDNECK KIEFFE [continued]: The treatment refusal and treatment dropouthave been problematic among youth getting treatmentfor post-traumatic stress.And in this study, possibly the exclusionof trauma narratives or repeated retellings of the trauma

    • 14:17

      MICHELLE WOIDNECK KIEFFE [continued]: may have influenced the positive acceptability ratings fact.It should be noted that trauma narratives or retellingor exposure in session or outside of sessionis not necessarily inconsistent with an ACT approach at all.From an ACT perspective, these activitieswould function as a way to practice mindful acceptance

    • 14:41

      MICHELLE WOIDNECK KIEFFE [continued]: of the distress that you're experiencingwhile simultaneously responding in a different waythan you have in the past in orderto provide new learning opportunities that will allowthe individual to incorporate additional, moreflexible behavioral responses into his or her repertoire.

    • 15:04

      MICHELLE WOIDNECK KIEFFE [continued]: And this will ultimately assist in promotingvalues-driven behavior.So in ACT, the goal is always increasingbehavioral and psychological flexibilityin order to have a fuller and more meaningful life.So in addition to the positive contributions of this study,there are number of limitations that must be addressed.

    • 15:27

      MICHELLE WOIDNECK KIEFFE [continued]: So first, although ACT received favorable acceptabilityratings, difficulty recruiting interested participantsand treatment dropout in this studywere comparable with those among existing treatment.So I didn't mention it earlier in this video,but I do go into more depth in the article.

    • 15:48

      MICHELLE WOIDNECK KIEFFE [continued]: And you can also see more informationabout the results and specific trends in the article.But there were three community participantswho were considered treatment dropouts,and were therefore not included in the data analysis.And they completed the pre-treatment assessment

    • 16:08

      MICHELLE WOIDNECK KIEFFE [continued]: and I think one session.And the other two, I believe, completed two sessions.But all three of these participantsexperienced chronic, severe sexual abuse historiesand exhibited complex trauma symptomology.So this may suggest that modifications

    • 16:29

      MICHELLE WOIDNECK KIEFFE [continued]: are needed to the protocol for adolescents with historywith this kind of history and presentation.It also may be indicative of the needof additional interventions that target treatment engagementor treatment-interfering behaviorsamong adolescents with complex trauma presentations.

    • 16:50

      MICHELLE WOIDNECK KIEFFE [continued]: There's definitely more research needed there.So in addition, although the two separate samplesprovide promising support for the utility of ACTacross unique groups, there are multiple complicationsrelated to conducting research in a residential setting.The residential participants were

    • 17:11

      MICHELLE WOIDNECK KIEFFE [continued]: receiving ongoing, individual family and group therapy,specifically targeting the eating disorderwhile they were also participating in this study.At the time, I worked very closelywith the residential treatment team.And the residential therapist reported that trauma

    • 17:34

      MICHELLE WOIDNECK KIEFFE [continued]: with not being targeted in individual, family, or grouptherapy, and that was separate justwith what was going on in the study.But there was no data gathered on this.So taped sessions or formal assessmentsof the treatment as usual to confirm this report

    • 17:55

      MICHELLE WOIDNECK KIEFFE [continued]: would have strengthened this study.Also, the consistent self-report monitoring data collectionwas more challenging than we initially expected,particularly during the baseline phase,and particularly among the community sample.

    • 18:15

      MICHELLE WOIDNECK KIEFFE [continued]: So given that avoidance is a primary componentof post-traumatic stress, simply tracking the frequencyand distress of post-traumatic symptoms is form of exposure,and it directly challenges the avoidance agendacentral to the pathology itself.So in this study, inconsistent daily data collection

    • 18:39

      MICHELLE WOIDNECK KIEFFE [continued]: was conceptualized as a form of avoidance of trauma reminders.And so the fact that we saw more regular completionof the daily symptom ratings as treatment went onwas a positive thing.But future research using occasional data probes

    • 19:02

      MICHELLE WOIDNECK KIEFFE [continued]: or alternate treatment designs thatdo not include daily symptom trackingcan help isolate the effects relatedto ACT versus those related to regular symptom monitoringitself.So it's also possible that the explanationof this study to potentially interested participate who

    • 19:23

      MICHELLE WOIDNECK KIEFFE [continued]: call to inquire about the study mayhave affected the decision whetheror not to engage in the study.It's possible that potential participantsmay have been deterred upon discoveringthat regular symptom tracking would be required,particularly given that participantswere being asked to track the very symptoms they were trying

    • 19:44

      MICHELLE WOIDNECK KIEFFE [continued]: to avoid.This also may be relevant to the participants that didagree to continue in the study.So future research investigating factors related to treatmentseeking behavior and acceptance or refusal of treatmentcan help us better understand this phenomenon.

    • 20:07

      MICHELLE WOIDNECK KIEFFE [continued]: So overall, the results of this studyare promising regarding ACT as the treatment for adolescentswith post-traumatic stress.However, it's clear that additional researchis very much needed before any strong conclusions can be made.And maybe some of you out there in the audience

    • 20:29

      MICHELLE WOIDNECK KIEFFE [continued]: can help answer these research questions.So thank you for inviting me to be a part of the Sage videoinitiative.And hopefully, this information can be helpful for some of youout there.Thank you.

Acceptance and Commitment Therapy for the Treatment of Posttraumatic Stress Among Adolescents

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Dr. Michelle Woidneck Kieffe discusses her study on using ACT to treat post-traumatic stress disorder in adolescents. ACT is acceptance and commitment therapy, which helps patients accept difficult points in life. Woidneck Kieffe discusses her study design, the assessment process that she used, and the results of her study.

Acceptance and Commitment Therapy for the Treatment of Posttraumatic Stress Among Adolescents

Dr. Michelle Woidneck Kieffe discusses her study on using ACT to treat post-traumatic stress disorder in adolescents. ACT is acceptance and commitment therapy, which helps patients accept difficult points in life. Woidneck Kieffe discusses her study design, the assessment process that she used, and the results of her study.

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