‘Feel the Feeling’: Psychological practitioners’ experience of acceptance and commitment therapy well-being training in the workplace

Background

The amount of psychological distress in the working population has been found to be substantial. Recent surveys in the United Kingdom have found that 25 to 40 per cent of workers in various occupational settings experience distress that could be diagnosed as minor psychological disorder – predominantly depression and/or anxiety disorders (Hardy et al., 2003; Stride et al., 2007; Wall et al., 1997).

Psychological practitioners seem particularly prone to work stresses, with over a third of psychologists experiencing high levels of emotional exhaustion, depersonalisation and decreased sense of personal accomplishment, indicative of professional burnout (Ackerley et al., 1988). Burnout has been linked to job stress, over-involvement with clients, lack of control and disruption of professional identity. Burnout has also been linked with decreased job satisfaction, increased absenteeism, job turnover and work–family conflict (Lacoursiere, 2001; Lee et al., 2011; Rupert et al., 2009). Moreover, the personal impact of burnout has a detrimental effect on the quality of service delivered resulting in less effective intervention and lower client satisfaction (McCarthy and Frieze, 1999; Sherman and Thelen, 1998).

These findings highlight the potential for psychological interventions in the workplace in helping to improve mental health and well-being, and also as a preventative measure (Flaxman and Bond, 2010a). A contemporary cognitive and behavioural approach, acceptance and commitment therapy (ACT said as a word rather than three letters), has a growing body of research indicating its effectiveness within the working population (Bond and Bunce, 2000; Bond and Flaxman, 2006; Flaxman and Bond, 2010b; Hayes et al., 2004).

ACT attempts to increase psychological flexibility, 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: 7). ACT works with mindfulness and acceptance processes in order to develop skills that help to change a person’s relationship with their painful thoughts and feelings, thereby reducing the influence of undesirable or unhelpful psychological content on behaviour. The emphasis is on letting go of the tendency to control thoughts and feelings as a prerequisite to valued goal pursuit, and instead making room for unwanted internal events, clarifying what is truly important and committing to meaningful behavioural changes (Harris, 2009). Value clarification, goal setting and taking actions are termed commitment and behaviour change processes.

ACT is grounded in the behavioural sciences and emphasises an experiential approach to behavioural change. Experiential exercises are considered a key vehicle for change, rather than greater intellectual understanding, rational thinking or insight (Hayes et al., 2012). This experiential approach applies as much to therapists as it does to clients. Therapists are invited to embody the ACT philosophy and practice the techniques themselves in order to best demonstrate the approach to others (Luoma et al., 2007a). One way of doing this is to provide ACT as a personal well-being intervention to give professionals the required experiential learning before they use it with their own clients. Stafford-Brown and Pakenham (2012) demonstrate this approach in practice and found that ACT had a positive impact on managing stress and improved therapeutic competencies in trainee psychologists. In addition, a number of studies have suggested that ACT has a swift and powerful impact on psychological practitioners’ psychological flexibility, psychological well-being and clinical practice (Dahl et al., 2004; Hayes et al., 2004; Luoma et al., 2007b; Luoma and Vilardaga, 2013; McCracken and Yang, 2008; Varra et al., 2008).

Aim of this study

There is a growing body of quantitative studies supporting the efficacy of ACT for improving psychological practitioners’ well-being and clinical effectiveness. Despite the strong emphasis in ACT on experiential understanding, few qualitative studies have explored individuals’ direct experiences of learning ACT. To the authors’ knowledge, there have been two qualitative studies investigating clients’ (Bacon et al., 2013) and caregivers’ (Williams et al., 2014) experiences of ACT, and one mixed-methods study investigating staff experiences of changing treatment model from cognitive behavioural therapy (CBT) to ACT for chronic pain (Barker and McCracken, 2014). This third study indicated staff’s positive engagement with ACT as well as experiencing anxiety and discomfort with the change. The aim of this study is to employ a qualitative approach to explore the lived experience and impact of ACT-based training delivered to therapeutic practitioners. It is anticipated that the study will enhance our currently limited understanding about how practitioners experience and use ACT within their personal and professional lives with the aim of helping to inform better implementation of ACT.

Participants

Purposive sampling and snowballing were used as the primary sampling procedures for recruiting participants. Eight participants took part in the study, a sample size considered suitable for a comprehensive IPA study (Smith et al., 2009). Participants consisted of seven females and one male aged between 31 and 62 years. Participants described their ethnic origin as White British (six), White Irish (one) and White Other (one). Seven were qualified psychological practitioners (clinical and health psychologists, speech and language therapists, integrative psychotherapists) with between 1 and 25 years post-qualification experience, and one third-year psychological therapy trainee. All participants worked in National Health Services (NHS) in the United Kingdom. Five participants had no previous ACT experience, with two having had traditional CBT training; three participants had previously attended ACT and/or mindfulness training: (1) 5-day ACT course, (2) 2 days ACT plus 4 days mindfulness (3) and part-time 3-month mindfulness-based cognitive therapy (MBCT) course. Pseudonyms are used below when identifying quotes and all identifying details have been changed in order to protect participant confidentiality. All participants had completed ACT-based training within their occupational setting between 2 and 5 months prior to being interviewed.

Intervention

The ACT intervention was delivered to small groups of employees during working hours using a two-plus-one format. Specifically, each participant received three sessions of training, two of which occurred on consecutive weeks, with the final session occurring 2 months later. Each session lasted for approximately 2.5–3 hours. All sessions were facilitated by the second author who had extensive prior experience of delivering ACT programmes in the workplace.

The training content was based on earlier ACT manuals developed for group worksite interventions (Flaxman and Bond, 2006; Flaxman et al., 2013). In all three sessions, participants practiced a series of mindfulness exercises, including brief (10 minutes) mindfulness of body and breath exercises and the physicalising exercise (Hayes et al., 2012). These experiential practices were designed to increase present moment awareness, reduce struggle with undesirable thoughts and emotions and locate a core sense of self that is distinct from difficult psychological content. The mindfulness training was supported by guided instructions recorded to CDs and a schedule of home practice. Participants also practiced cognitive defusion exercises, such as a word repetition exercise, and experiencing unhelpful thoughts in an unusual context (e.g. writing a thought on the front page of a mock-up trashy magazine and speaking unhelpful thoughts in a cartoon voice). In addition, participants completed written values, value-based goal clarification and action planning exercises to contact chosen life directions, identify psychological barriers to value-based action and increase commitment to valued actions. The consistency of the training protocol with the ACT model was assessed by two external ACT experts not involved in the study (including the developer of the originating ACT protocol for workplace settings).

Data collection

Semi-structured interviews were used to elicit participants’ experiences. The aim was to give both the researcher and participants a balance between structure and flexibility, to allow specific topics or themes to be followed up during the interview process (Smith et al., 2009). Participants were encouraged to share their experience and talk about what was important to them, while a basic structure was provided using prompts and open-ended questions (e.g. ‘Can you describe to me what the training was like for you?’). These general questions were followed with summaries, reflection and use of prompts (e.g. ‘Can you tell me more about that?’). Six interviews were conducted at the participant’s workplace, while two were conducted by telephone. All interviews (which lasted between 30 and 65 minutes) were audio recorded and transcribed verbatim by the first author.

The study was conducted according to the ethical code of the British Psychological Society, including confidentiality, informed consent, right to withdraw, debriefing and monitoring of participant welfare. The study was also approved by the ethical procedures of City University London and local NHS ethics committee (Reference: 09/H0709/39).

Data analysis

Smith et al. (2009) suggested that there is no one prescriptive method for conducting data analysis in IPA and recommends flexibility so that a process most appropriate to the data can be employed. Both Willig (2008) and Smith et al. (2009) have outlined descriptions of the analysis stage, which were used as the primary sources in creating the researcher’s own analytical process. This process consisted of five key stages: initial encounter with a participant’s account; identifying emergent themes; clustering emergent themes; moving to the next participant’s account; and finally, integration of accounts and formation of master themes. The data analysis was conducted by the first author. The findings were reviewed by two colleagues, and a summary of the findings was sent to participants for review.

Role of past experience

Each participant’s previous personal and professional experience seemed to influence experience of the training, from their reasons for attending to how they engaged in the training. All but one participant described a sense of it being familiar, that they understood ‘where it was meant to be going’ (Christina) and that the training seemed to come naturally to them: ‘a lot of the concepts are like ‘yeah naturally’!’ (Jim). This experience of familiarity seemed to come from both a similarity to previous training and an often natural affinity to what was being taught. This emerged from a perception that the training personally made sense, as described below:

[The training] made sense, actually, which is something I like … it’s sort of connected. Made sense and felt good … intellectually, or whatever, with the head and made sense with the heart. (Nina)

Nina’s comment illustrates quite a strong connection with the training, where it genuinely fitted with her both intellectually and emotionally, and this felt good to her.

Most participants also made comparisons to previous training experiences and/or other therapeutic models, including ACT and mindfulness training, CBT, breathing, relaxation and exposure techniques, hypnosis, psychodynamic, systemic and narrative therapies. Many participants described ‘a lot of overlap’ (Leslie) with CBT and there was an overall impression of their experiences of CBT and ACT as being similar but different. Nadine summarises this well:

It was just a different way of looking at things, obviously I’ve done CBT for years but it just was different. (Nadine)

The mere mentioning of Nadine’s experience of CBT creates a comparison and a similarity between the approaches, yet there is clearly something different in her experience of ACT. Three participants had previously experienced ACT and/or mindfulness training, with all of them referring to it in some way as a ‘refresher’ as well as finding something new and fresh with this experience of ACT. Leslie, however, struggled to engage in the training. Although she was keen to find something to help her with stress and potential burnout, she felt she had encountered it all before, finding herself ‘trying hard … [to] notice if there are any new aspects’. Despite the lack of newness for Leslie, she did find a different way to engage in the training, rather than ‘imposing all these requirements on myself … I just decided to go with it’, which represented a new, freer approach for her where she could let go of self-imposed rules and relax into the experience. In addition to therapeutic comparisons, three participants linked their experience with their religion. Most striking was Katherine, who said ‘when I was doing these exercises I thought gosh this is so similar … [to] what I do when I pray’. This sense of familiarity and comparison was not, however, experienced by everyone. Mary, a recently qualified therapist with no ACT experience revealed that she ‘found it kind of different … I’d done nothing like that before’.

A lot of the participants described the training as giving them a new, formalised way of viewing their own situation and/or that of their clients. In addition to the training making sense and fitting with previous experience, participants described a psychological approach that had been ‘thought through well’ (Nina), gave ‘structure to ways of thinking’ (Jim) that was in some way ‘more developed … more advanced’ (Nadine) and it somehow ‘all came together’ (Nina). Jane sums up this theme well:

I was aware of that kind of thing anyway but until I’d taken the time out to do the training I maybe didn’t have a mental perspective for myself as to how to think about it … it’s nice to have that mental framework to fall back on, it gives you a sense of a little bit of direction. (Jane)

Jane, not having formally engaged in ACT before, felt a strong familiarity with the approach and that it pulled together her previous experiences, including her religious practices, to give a structure and sense of direction to guide her both personally and professionally.

Impact and influence of ACT training

However diverse the participants’ previous experience was, they frequently described how ‘useful’ and rewarding they had found the training, with over half experiencing a form of revelation, a powerful realisation and/or of having an ‘aha’ moment, where their experiences ‘clicked into place’. Christina describes this experience in relation to the Bull’s Eye exercise (Lundgren and Dahl, 2006):

A revelation, it was really, really, really useful, yeah … as you’re sitting there thinking where you should be putting the cross, it’s like ‘Aha’ you know, yeah, very immediate, very satisfying. (Christina)

Christina is emphatic about the impact of the ACT training, the use of ‘really’ and ‘very’ indicating the importance of the stark realisation she experienced. Christina then spoke of using the impact of this realisation to make lifestyle changes in ‘many, many areas’ including increased exercise, improved nutrition and family relationships, which in turn left her with a great sense of satisfaction. Most participants described making behavioural changes in their lives following the training.

Most of the participants emphasised the importance placed on the experiencing of ACT in the training rather than focusing on learning the theory behind it. Most of the participants seemed to value the experiential nature of the training and how they engaged in the various exercises that gave them firsthand experience of ACT. Nina captured this well with a metaphor of a marathon:

So this in fact was a wonderful [experience] … I really felt the feeling, very much so and it’s quite different really … You know, I can read all about the theory of running a marathon, I will never be able to run a marathon full stop, end of conversation. (Nina)

Nina describes what the training was like experientially and states that there is no substitute for that; it cannot be read about, it has to be experienced. The impact of the training is evident for Nina, as this thread runs throughout her account. While she spoke of enjoying the theoretical learning she had from previous ACT training, she connected with it on a deeper level during this experiential training. The experiential learning helped the training make sense to Nina with ‘the head and … with the heart’, a theme found in a number of other participants’ accounts.

Issues of stress were common, as were accounts of organisational stressors, change, uncertainty, risk of redundancy and heavy workloads. A number of participants described various ways in which the training helped them manage these issues as well as applying them to other areas of difficulty in their lives. In particular, most participants described a change in how they related to their thoughts and feelings, such as ‘letting go, opening up to, and allowing’. This new perspective was often associated with their practice of mindfulness techniques. Some of the participants had previous experience of mindfulness while others had none. Irrespective of previous experience, almost all participants described experiencing acceptance of their thoughts, feelings and/or physical sensations. For instance, ‘[it’s] an empowering thing to be able to say “it’s ok to think that”’ (Jim), ‘well, yes you have these thoughts, it’s fine’ (Jane) and an appreciation for being in the ‘here-and-now and not let yourself get carried away with things that may never happen’ (Mary). Jane described how she cried unexpectedly when talking about her mother being unwell while attending the training:

I felt these tears welling up, I started thinking about the physical aspect, well it’s just wetness coming down my face, you know, it doesn’t mean I’m falling to pieces and losing control, you know, and looking silly in front of everybody else, it’s just a physical response to something that’s quite important to me. (Jane)

Jane’s words show a stark difference between the physical sensation she was experiencing versus her previous judgements that she was on the verge of falling apart and looking silly. By focusing on the actual physical sensations rather than what her thoughts were telling her was happening, she shifted perspective and encountered greater acceptance of her experience. Jane became enthused when she described this and later said it was a ‘very effective’ approach. This change in perspective indicates how distress can be experienced in a different way and therefore can be responded to differently.

Some participants described how this acceptance and perspective taking gave them a distance from issues they had previously struggled with. Participants took a posture of allowing their experience to be as it was, observing it without getting caught up in it. At times, however, there seemed to be a blurred line between this distancing and what was described as ‘shutting off’ (Jim) or ‘holding back’ (Leslie) from thoughts or feelings. Katherine spoke in more detail of the latter:

Just concentrating on one thing that you’re good at for example breathing, you can immediately just withdraw into your inner self and in other words cut off whatever is bothering you, if it’s getting too much … To shut off what’s unpleasant in my thoughts. (Katherine)

Although Katherine uses similar language to some other participants, there seems to be a clear difference in the intent of her actions. Katherine describes focusing on her breath in order to avoid what was troubling her. The difference here appears to be that Katherine was moving away from her thoughts in order to not experience them rather than creating some distance or perspective, as with the majority of other participants. Such contrary accounts are useful in providing an account of the lived experience of participants.

Dual focus on the self and others

All the participants described looking for something they could gain personally out of the training, whether that was in relation to their personal and/or work life. A number of participants illustrated how they relished the time to focus on their own experience, having an opportunity to personally reflect and learn about themselves. Most participants described spending limited time focusing on themselves or that, as clinicians, their focus had been on giving rather than receiving. Jim typified this view as follows:

It’s just as a therapist you are always giving, giving, giving it’s that sort of same old thing, so it’s actually quite nice to be able to sit back and reflect on me and myself and how I am. (Jim)

Jim’s comment ‘same old thing’ suggests it is the usual way of things to give to others rather than to himself. He talks in generalised terms ‘as a therapist’ rather than using the first-person pronoun ‘I’, which he implies may be a general trait of psychological practitioners. Jim seems to savour this novel experience, one that releases him from his therapist role and gives him the luxury of considering himself for a change. There was a common link throughout the participants’ accounts of relishing and/or giving permission to prioritise themselves and their well-being.

A number of participants frequently switched between describing how the training related to themselves and then also to others. There was an emphasis on the dual role the participants had in the training, between being a participant experiencing ACT intervention and as psychological practitioners intending to deliver ACT interventions. This dual role helped them to tune in to their own needs while also improving their therapy skills and considering how to apply their lived experience to their own client work, as described by Nadine:

To experience it yourself is actually a really good way of then being able to go on and make it meaningful for other people. (Nadine)

Nadine’s description of this as ‘a really good way’ shows the value of this experiential approach in imparting her learning to others. A number of participants described applying the training to their clinical work in two ways: either by using the techniques with clients as they were taught in the training or by using their new approach themselves to be more present and engaged with their clients and their work in general.

There seemed to be a complex interplay between self and others, with participants indicating a flexible ability to shift focus from self to others and vice versa. There were also a few times where participants’ accounts seemed to blur and it was unclear whether they were talking about themselves or their clients. The following brief interaction between Nina and the interviewer illustrates this blurring. Nina had described her use of an ACT exercise where you ‘imagine putting stuff in front of yourself’ ¹ and was subsequently asked whether she had used this technique in her personal or professional life as it was initially unclear. Here is the interaction that followed:

Nina describes using an ACT mindfulness technique more than she used to, at which point it seemed unclear to the interviewer whether she was still referring to her clients or herself. She then touches on its use both personally and with clients, before relating to its application with clients. It seems as though Nina is weighted at this point towards talking about her clients rather than her own personal practice even though she had initially been asked a non-directive question and had then been invited twice to talk about personal application. It may be that she was more focused on clients at this particular moment, while also acknowledging the use of this exercise with herself. Although Nina seemed to be quite open about describing her experiences, this could also point towards the relative safety of focusing on clients rather than her own needs. This experience links to a subtle tension between self and other in participants’ accounts, where dual personal/professional roles became blurred, and it was at times unclear when participants were talking about themselves or their clients.