Acceptance and Commitment Therapy for adults with head and neck cancer experiencing psychological distress: a hermeneutic single case efficacy design (HSCED) series

Background: Individuals with head and neck cancer (HNC) suffer with varying degrees of functional impairment, threats to life and reduced social functioning. They are at an elevated risk of experiencing clinical levels of psychological distress (i.e. anxiety and depression) (Hammerlid & Taft, 2001; Rogers, Ahad, & Murphy, 2007). The cancer-psychotherapy research base largely consists of trials that either regard cancer patients as a homogenous group or focus on patients with the most common cancer sites (e.g., breast). This has resulted in an under-representation of HNC patients (Chong Guan et al., 2016). Acceptance and Commitment Therapy (ACT) has an emerging evidence base for cancer populations (Hulbert-Williams et al, 2015). It is important to test and refine psychotherapy interventions: examining whether effectiveness of ACT extends to those with HNC and – importantly – investigating the processes by which ACT interventions may contribute to positive outcomes (Moyer et al, 2012). Method: A hermeneutic single case efficacy design (HSCED) series is a pragmatic, systematic method for understanding change processes in psychotherapy; while enabling an investigation of repeatability of effects (Elliot 2002; Elliot et al, 2009). Three adult clients with a diagnosis of HNC were recruited from National Health Service (NHS) hospitals and engaged in six sessions of ACT. A detailed matrix of quantitative and qualitative clinical data were collated (‘rich case records’) and subject to critical analyses by three independent psychotherapy experts (‘judges’) who identified change processes, and determined the outcome for each client. Results: Judges unanimously concluded that all clients showed good outcomes; specifically they progressed towards therapy goals and experienced reliable reductions in psychological distress. Judges systematically considered non-therapy factors and attributed client’s changes to their experience of therapy. ACT-specific processes and a strong therapeutic relationship at least partially mediated change for all clients; albeit to different degrees. Moderating client variables were: client motivation, effort and openness to therapy; cognitive intelligence and reflective capacity, and ability to build a trusting relationship and to draw strength from others. All clients behaviourally demonstrated improvements in flexibility through increased valued-action. Discussion: The HSCED enabled a dismantling of therapy components to understand change processes for people with HNC. A strong therapeutic bond and alliance in combination with client characteristics of motivation to do something differently and appropriate expectations appeared to provide a context in which ACT was an effective intervention. Reliable distress reduction (and movement towards behavioural goals) occurred for these clients without therapeutic aims to change or alter their distressing thoughts. This has important theoretical implications for understanding the potential utility of acceptance-based approaches that may authentically validate individuals with cancer, many of whom suffer with ongoing impairment and a realistic possibility of illness reoccurrence. The study findings appear to support a ‘moderate’ common factors position on psychotherapy effectiveness, as described by Sprenkle and Blow (2004). This asserts that the contribution of common therapy processes and model-specific techniques is not a rigid either/or; rather, there are types of problems, clients and circumstances for which a particular model is well-suited. The replication of positive changes between clients in this study demonstrates case-to-case transferability of the intervention model (Schwandt, 1997). Future research would benefit from assessing longer-term ACT interventions and examining how individuals at the pre- or mid-treatment stage of cancer could benefit from ACT