Online First

2020 : Volume 1, Issue 1

Acceptance and Commitment Therapy: A Systematic Review of Psychological Adjustment and Reduction of Psychological Distress Following a Traumatic Brain Injury in Adults

Author(s) : Tammi R. McCoy 1 , Amanda C Philp 1 and Kelly Kates-McElrath 1

1 Applied Behavior Analysis Department , The Chicago School of Professional Psychology , Illinois

J Addict Psychiatry Ment Health

Article Type : Review Article

Abstract

This systematic literature review investigated whether Acceptance and Commitment Therapy (ACT) intervention facilitates psychological adjustment and reduces psychological distress following a Traumatic Brain Injury (TBI) in adults. An extraction procedure yielded 12 studies published between 2005 and 2020, with a total of 444 adult subjects diagnosed with a TBI, or a TBI with co-occurring disorders. Across all 12 studies, different measuring tools to measure distress and psychological adjustment were used; however, results indicated ACT’s effectiveness in maximizing acceptance of circumstances through values by targeting avoidance with individuals diagnosed with a TBI. The results are promising, and ACT may be an alternative to medication-based treatments in assisting individuals with TBI and psychological disorders.

Introduction

A traumatic brain injury (TBI) is an alteration of the brain functioning caused by external forces impacting the head [1]. There are several different types of brain injuries including those caused by an external force, direct impact, or inertial injury. Biochemical changes following TBI include various alternation in brain cells, including complement activation, protein trafficking, altered cytoskeletal organization, and protein aggregation [2,3]. In all instances the rehabilitation journey after a traumatic brain injury involves a complex adjustment process as individuals cope with multiple changes [4]. These changes include motor-sensory, cognitive, and emotional/behavioral impairments [5]. Post-injury adjustment involves cognitive, behavioral, and emotional adaptation as well as a search for new meaning [6]. This process commonly occurs within the context of significant psychological distress [7,8].

A TBI is a major cause of debilitating psychiatric disorders such as depression and anxiety [9]. Major depressive disorder (MDD) is the most prevalent psychiatric disorder, with over 25% of individuals with a TBI diagnosis developing MDD [10]. Long-term care and supervision may necessitate for individuals with brain injuries due to communication dysfunction and cognitive impairment. Cognitive impairments can include difficulties with attention, remembering, problem-solving, and decision-making, which may impair an individual's level of independence, educational engagement, vocational engagement, social interaction, or ability to perform daily living tasks. An individual's ability to mentally represent, organize, or manipulate the environment diminishes. This diminished state triggers behavioral episodes metastasized by psychological distress.

Clinicians have limited evidence-based treatment options to draw upon in responding to psychological distress and challenges associated with TBI in adults. Current existing psychological treatments, predominantly Cognitive-Behavior Therapy (CBT), have largely focused on reducing symptoms of distress. Research has suggested efficacy in reducing a range of psychological symptoms after TBI including anger [11], anxiety [12], depression [13], and hopelessness [14,15]. Despite the promising individual results, a Cochrane review found the evidence-based for the efficacy of traditional CBT to have no effective with psychological distress for adults with TBI [16].

Psychological Distress

With TBIs, psychological distress or emotional suffering from the complications of processing and engineering demands may evolve without cognitive rehabilitation for psychological adjustment. This distress escalates psychological disorders, which are patterns of behavioral symptoms that impact daily living. The prevalence of MDD within the first year of a TBI is 33%-42% [17], and within the first seven years is 61% [18]. There is also an increased risk of suicide following a TBI that is different from plausible suicidal ideation associated with the multiple concussions diagnosed at autopsy known as chronic traumatic encephalopathy (CTE). According to Iverson [19], macroscopic and microscopic neuropathology, are characteristic of CTE. Macroscopic neuropathology, as defined by Aldga et al. [20] refers to gross anatomical abnormalities such as reduced brain weight, enlarged ventricles, and atrophy of structures. On the other hand, microscopic neuropathology refers to intra- and intercellular processes of neurodegeneration [20]. Although suicide is associated with CTE, research supporting a suicidal causal relationship is inconclusive. CTE's clinical features mimic TBI clinical features, which include headaches, anxiety, depression, suicidality, anger control, gambling, gait, dysarthric speech, mild cognitive impairment, motor neuron disease, and dementia [19].

Pharmacological treatments are prevalent in the treatment of psychological disorders with individuals diagnosed with TBIs. Although pharmacological therapies for neurobehavioral complications, including mood disorders, prevails in treatment after a TBI, limited evidence supports medication effectiveness [21]. Rosenthal et al., [22] conducted a study on psychotherapy conducted with depressed persons with TBIs which demonstrated little evidence supporting efficacy towards reducing MDD with clients diagnosed with TBIs.

Psychological Adjustment

Grief and loss often emerge after TBIs, which may contribute to post-injury adjustment [23]. Carroll & Coetzer [23] examined perceived identity change in adults with traumatic brain injury (TBI), exploring associations between identity change, grief, depression, self-esteem, and self-awareness. Results indicated substantial changes in self-concept with current self-being viewed adversely in comparison to pre-injurious identity. The perception of self positively associated with depression and anguish and negatively associated with self-worth [23].

Acceptance of circumstance and redefining personal success is vital in rehabilitation after a TBI [24]. Depending upon the brain damage region, a TBI may impair emotional control, verbal expression, eye-hand coordination, or language comprehension, promoting psychological distress. Quality of life fades with cognitive impairment. Self-awareness also suffers from impairment due to brain damage, which contributes to cognitive decline, leading to psychological anguish [25]. Hoffman & Harrison discovered that chronic inflammatory processes in the brain might contribute to depression and stress responses and inhibit repair (Table 1).

GCS Total Score

Level of Brain Injury

13-15

Mild Brain Injury

09-12

Moderate Brain Injury

03-08

Severe Brain Injury

Note: From "The Essential Brain Injury Guide," Brain Injury Association of America.  (2016). The Essential Brain Injury Guide (5th ed.). (https://www.directtextbook.com/isbn/9780927093064)

                     
                          Table 1: Glasgow Coma Scale Scores Range from 15 to 3.

Unconscious adjustment mechanisms relating to a TBI may be emotional reactions, including denying feelings associated with traumatic experiences. Trauma survivors have difficulty regulating anger, anxiety, sadness, and shame, and substance abuse is one method of choice to regain emotional control [26]. Individuals diagnosed with TBIs may benefit from a therapy that targets psychological adjustment and reduces psychological distress.

Individuals with TBIs may be more susceptible to pharmacological treatments' aversive effects attributed to altered brain functioning consequential of brain damage. Antidepressants can have adverse effects by inducing nausea and increasing confusion, sleepiness, anxiety, and suicidal attempts. According to Plantier et al. [27], antidepressants are among the five most frequently used drugs to treat agitation and depression with patients diagnosed with a TBI, while depression after a TBI can be resistant to treatment with antidepressants. Antiepileptic medications of Carbamazepine and Valproate are leading therapies administered as psychotropic for mood stabilization with individuals diagnosed with TBIs. These medications increase in usage rather than decrease during inpatient rehabilitation with individuals diagnosed with TBIs [28]. Studies on the effects of antidepressants after a TBI on mood and behavioral disorders are insufficient to support validity [27].

Acceptance and Commitment Therapy

Trans-diagnostic approaches, like ACT, may provide an alternative therapeutic modality to reduce psychological adjustment after TBI [29]. ACT is an evidence-based treatment that draws on the same principles of CBT; however, without tailoring the treatment protocol for a specific diagnosis. ACT as a treatment aims to either decrease or increase behaviors that are internal or external that allows an individual to move toward valued goals rather than focusing on symptom reduction.

ACT exhibits a behavioral therapeutic approach versus a psychotropic approach to decrease patterns of behavior from psychological distress caused by TBIs. In the science of behavior, organisms survive through adaptation to the environment. After a TBI, individuals must readapt to newly acquire cognitive and physical limitations. ACT applies mindfulness and acceptance skills to responses helping individuals to interact with their values coherently. This cognitive-behavioral-based therapy is associated with improved psychological adjustment and reduced psychological distress [30]. Acceptance-based approaches [31] postulate that instead of opting for change alone, the most effective method may be to accept and change. Hooper and Larssen’s [32] research shows that ACT accelerates psychological adjustment after a brain injury and cognitive impairment (Table 2).

Diagnostic State

Quality of Life

Dead

Severe injury or death without recovery of consciousness

Vegetative

Severe damage with a prolonged state of unresponsiveness and a lack of higher mental functions

Severely Disabled

Severe injury with the permanent need for help with daily living

Moderately Disabled

No need for assistance with everyday life; Employment if possible but may require special equipment

Good Recovery

Light damage with minor neurological and psychological deficits

Note: From "The Essential Brain Injury Guide", Brain Injury Association of America.  (2016).  The Essential Brain Injury Guide (5th ed.). (https://www.directtextbook.com/isbn/9780927093064)


                                              Table 2: Glasgow Outcome Scale.

Hayes [31,33,34] credits ACT as a contextual, psychotherapeutic approach based on relational frame theory (RFT) examining individuals' natural and social environmental pyridoxal interactions. RFT focuses on verbal behavior and language, while emphasizing recontextualization to accept private events. Development of clarity about personal values and commitment targets promoting behavior change.

The core of ACT is a change in internal (self-talk) and external (action) verbal behavior beginning with a discussion about desires and strategies of achieving aspirations. Mattaini [30] explains that ACT does not mean accepting every aversive situation but accepting non-threatening circumstances with the expectation of future change. Psychoeducation in ACT involves metaphors, stories, and experiential exercises to demonstrate the acceptability of psychological experiences with goal setting and graduated activity scheduling toward goals directed by values. This model teaches mindfulness and acceptance skills for responding to uncontrollable experiences, thereby increasing the enactment of personal values. Hayes [34] denotes and describes ACT's six core processes as acceptance, cognitive defusion, being present, self as context, valuing, and committed action.

ACT Six-Core Flexibility Processes

There are six core process of ACT. They include being present in the moment, values directed behaviors, cognitive defusion, committed actions, context as self, and acceptance [35]. From a behavioral standpoint, being present is defined as not judging the environment or private thoughts as they occur in the moment, but allowing an individual’s behavior to be more flexible and consistent with the values that the individual holds [36]. Values can be compared to goal-directed behaviors. Studies conducted on human behavior suggest that “goals delineate an important area of investigation when it comes to health, well-being and behavioral change” [37]. In fact, Ramnero and Torneke [37] suggest that having a goal or value will allow both the client and therapist to identify a criterion for the purpose of evaluating the progress that is being made for the client. Understanding that we are not the content of our experience, we are not our thoughts or feelings, nor are we sensations or images that pass through our thoughts, are what is meant by self as context. This is important when helping parents respond to difficult private events [38]. Acceptance is taught as an alternative to experiential avoidance. It occurs when an individual is actively aware of their private events. Exposure to these private events is used in ACT to assists therapist and individual when attempting to control or change thoughts [39]. Acceptance does not mean that the individual has to indicate that what has led to experiential avoidance is in any way acceptable, but rather that the individual is transcending those experiences and accepting them as having happened but being present in the moment by distancing themselves from past experiences and being able to move forward without holding onto the past [35].

Private events can be described according to their response and stimulus properties due to behavior and the environment constantly interacting [40]. Acceptance and change are two goals of ACT and address private events. This includes accepting unhelpful thoughts and feelings that may or may not need to be controlled, and, living according to an individual’s chosen values through committed action [41]. Accepting can also be considered synonymous with an individual who accepts their thoughts and feelings are allowing the experience of private events without trying to reduce, manipulate or avoid them [42].

ACT Targeted Population

The empirically tested intervention ACT may be beneficial for multiple populations. According to Wilson et al. [43], sexual abuse survivors, at-risk adolescents, and individuals diagnosed with mood disorders and psychotic ideation benefited through ACT’s usage. Gaudiano and Herbert [44] showed that psychiatric inpatients using ACT demonstrated improved affective symptoms, social impairment, and distress associated with hallucinations and phobias. ACT focuses on the psychological function of thoughts [43]. Over the last several years, ACT has begun to gain momentum with the TBI population.

Purpose of Study

This study examined published research articles relating to ACT’s effectiveness with psychological adjustment and reducing psychological distress following a traumatic brain injury in adults. This research aimed to explore the viability of ACT through RFT contextual measures of human language controlling private events' associations through acceptance, reasoning, and conduct promoting adaptability.

Methods

Initial Article Search

The first author conducted an electronic search of PyscINFO, and ProQuest for literature related to the literature review. Key search terms included: "acceptance and commitment therapy", "ACT", "Acceptance and commitment therapy” AND/OR psychological adjustment", AND/OR TBI, TBI AND Anxiety, ACT AND TBI, and "psychological distress with Traumatic Brain Injury”. Electronic search parameters were set to identify peer-reviewed articles which were published in English between 2005 and 2020.

The first author downloaded articles into RefWorks that were directly related to the research purpose and met the keyword search. The initial article searches repeated until saturation was reached (Table 3).

Component

Definition

Acceptance

Acceptance of private events involves approving internal, private incidents without changing frequency or form.  Exposure exercises foster acceptance through flexible interaction with previously avoided experiences.

Cognitive Defusion

Cognitive defusion creates nonliteral contexts in which language presents in the current moment untying relationships between words and actions through contextual control.

Being Present

Being Present allocates attention to present moment awareness creating flexible, responsive learning.

Self-as-Context

Self-as-Context establishes a solid sense of self-awareness through perspective-taking (deictic framing).

Defining Valued Directions

Defining Valued Directions focuses on strengthening language, choosing valued life directions through functional contextualism.

Committed Action

Committed action encourages adopting a values-based life establishing patterns of actions connected to chosen values.

Note: Adapted from "The Essential Brain Injury Guide", Brain Injury Association of America. The Essential Brain Injury Guide (5th ed.). (https://www.directtextbook.com/isbn/9780927093064)


                        Table 3: Components and Definitions of ACT Hexaflex.

After logging articles, each article was coded using inclusion criteria, created by the researcher, for the determination of meeting further eligibility for the literature review (Appendix A). To be considered eligible for inclusion, articles needed to meet the following inclusion criteria.

 

                                               Appendix A: Coding Form.

For an article's consideration for this literature review, the material must have met the following inclusion criteria. First, the research must be published in English language in a peer-reviewed journal between the years 2005 and 2020. Second, the participants must be 18-years of age or older with a diagnosis of a TBI or a TBI with co-occurring disorders at the time of the study. Third, the intervention must be Acceptance and Commitment Therapy with studies focusing on one or more psychological distress types of depression, anxiety, or stress. Fourth, the experimental design presented as a pretreatment/post-treatment group motif with results or single-subject research with results. If any articles did not meet all inclusion criteria, that article was deemed ineligible for further review.

Data Extraction

Following coding for inclusion, data were extracted from the accepted articles based on the search criteria for results related to ACT and TBI. The first author independently extracted data from each article on the following criteria: participant's demographics, participation in psychotherapy or psychotropics, experimental design, and dependent measures (Table 4).


Study

Experimental Design

Number of Participants per Study Group

Severity of Injury based on Glasgow Coma Scale

Mean Age or Age Range of Participants

Outside Psycho-therapy

Psycho-tropics

Outcome Pre/Post or adjustment

Sander et al.

Pre/Post Treatment Random Group Design

A

B

A

B

A

B

A/B

A/B

A

B

44

49

Severe 18

Severe 18

37.73

38.27

+/+

+/+

DASS-21

DASS-21

25M

31M

Moderate 7

Moderate 9

 

Combined

Combined

19F

18F

Mild 19

Mild 22

68.80/62.67

69.78/63.18

Dindo et al. [46]

Pre/Post Treatment Random Group Design

A

B

A

B

A

B

A/B

A/B

A

B

20

12

Mild 20

Mild 12

37.7

34.7

+/+

+/+

DASS-21

DASS-21

 

Combined

Combined

53.4/42.7

59.7/65.6

Whiting et al. [51]

Pre/Post treatment Random Group Design

Dyad A1/A2

A1

A2

A1

A2

A1

A2

A1

A2

2

Severe 1

Severe 1

19

 

+

+

DASS-21D

DASS-21D

 

34 /34

23/16

DASS-21A

DASS-21A

22/20

32/14

DASS-21S

DASS-21S

24/22

26/20

Bomyea et al.

Pre/Post Treatment Random Group Design

A

B

A

B

A

B

A/B

A/B

A

B

62

67

Mild- moderate 41

Mild-moderate 42

35.27

34.24

+/+

+/+

Pre/Post

Pre/Post

48M

53M

 

74/65

76/69

14F

14F

 

 

Whiting et al. [50]

Pre/Post Treatment Random Group Design

A

B

A

B

A

B

A/B

A/B

A

B

10

9

Severe 10

Severe 9

18-65

18-65

+/+

+/+

DASS-21D

DASS-21-D

8M

7M

 

23.4/15.5

19.6/11.6

2F

2F

DASS-21A

DASS21-A

 

17.2/9.6

21/12.4

DASS21-S

DASS21-S

23.6/17.4

23.0/15.1

Roche, L. [47]

Pre/Post Treatment

A1

A1

A1

A1

A1

A1

 

1

Moderate 1

48

x

x

HADs          

 

Depression

11/6

HADs

Anxiety

15/02

Whiting et al. [55]

Pre/Post Treatment

A1

A2

A1

A2

A1

A2

A1

A2

A1

 A2

1

1

Severe 1

Severe 1

20

28

x

x

DASS-21S

DASS -21A

 

-2.54

-5.11

Whiting et al. [49]

Pre/Post Treatment

A

A

A

A1

A

DASS-21D

 

75

Mild-Severe 75

?18

x

x

-0.67

 

Alderman [45]

Pre/Post Treatment

A1

A1

A1

A1

A1

A1

 

 

 

1

Severe 1

?18

x

x

DASS-21S

 

 

 

 

15/02

 

Straits-Troster, K.

Pre/Post Treatment Open Clinic Trial

A

A

A

A

A

A

 

8

Mild-Severe 8

34.5

x

x

Overall

 

 

Decreased

 

Stress

 

Meyer et al.

Pre/Post Treatment

A

A

A

A

A

A

 

117

Mild-Severe 117

?18

+

+

AAQ-ll

 

 

-0.71

 

Wharton et al.

Pre/Post Treatment

A

A

A

A

A

A

 

10

Mild 10

? 50

+

+

AAQ-II

 

 

25.44/32.00

 

Note: A= test group and B= control group.  A1 = participant 1 and A2 = participant 2 for nongroup data. + = yes and - = no. x=not stated.


Table 4: Data Extraction in Determining the Effectiveness of ACT in reducing distress in individuals diagnosed with a TBI.

Participant Demographics: Data extraction on participant demographics was extracted. Data related to diagnosis, gender, and age was documented for comparative measures to indicate patterns.

Experimental Design: The research design was extracted for comparative measures. For example, group design, pre-post, multiple baseline design across behaviors and participants were noted.

Dependent Measures: Each research study’s dependent measures were extracted. Information obtained was regarding what the behavior to be changed was during the intervention (e.g., anxiety, depression, behavioral changes, etc.).

Quality Program Indicator

A secondary measure used to determine if the current research for clients with a TBI and ACT as an effective intervention was the Quality Program Indicator (QPI). An adapted method was used across primary and secondary quality measures. Under the primary quality indicators, the following information was scored: participant characteristics, independent variable, dependent variable, baseline, visual analysis, and experimental control were evaluated on a Likert scale of 0-5, with a score of five indicating meeting all expectations and a score of zero indicating none of the expectations were met or listed in the research study (Appendix B).


Score

Scoring Guide

5

Met all expectations at 100%

4

If the study met 90-99% of criteria expectations

3

If the study met 80-89% of the criteria expectations

2

If the study met 50-79% of the criteria expectations

1

If the study met 50% or less of the expectations

0

If no expectations were met in the study


                             Appendix B: Quality Program Indicator Likert Scoring Form.

The secondary quality indicators measured were interobserver agreement (IOA), fidelity, generalization and maintenance, and social validity. Again, the secondary quality indicators were scored on a Likert scale of 0-5. A study would receive a "strong" score if it received a high-quality rating on all primary quality indicators and showed evidence of three or more secondary quality indicators. A study would receive an "adequate" score if it received high-quality ratings on four or more primary quality indicators with no unacceptable ratings on any primary quality indicators and showed evidence of at least two secondary quality indicators. Finally, a study will be considered "weak" if it received fewer than four high-quality ratings on primary indicators or showed evidence of less than two secondary quality indicators.

Inter-Scorer Reliability

Data were collected for purposes of Inter-Score Reliability (iSr). The first author and a second independent reviewer viewed the coding forms and extracted data for reliability. The researcher first extracted data for identified articles. Then, the iSr reviewer randomly received 40% of the articles to perform the same data extraction style for each article received. Afterward, the researcher and iSr data reviewer scores were compared for agreement. If iSr data fell below 80%, re-training of the iSr reviewer occurred. To calculate inter-scorer reliability the following formula was used: Agreement/ (Agreement + Disagreement) x 100.

Results

The initial search returned 1,938 (PsycINFO) and 1,285 (ProQuest) articles related to the keywords and phrases for a total of 3,223 article returns. A review of abstracts and titles and removal of duplicates resulted in 25 articles being reviewed for inclusion into the study. Of the 25 studies 12 articles met full inclusion criteria.

Participants within the 12 research studies were veterans, catastrophically injured, or military personal experiencing psychological disorders of anxiety, depression, stress, or posttraumatic stress disorder (PTSD). Three of the 12 studies reported gender statistics of 172 males and 69 females. Combined studies consisted of 444 adult subjects (i.e., 18 years of age or older) diagnosed with a TBI or a TBI with co-occurring disorders.

Classification by the severity of injury showed 60 of 444 subjects (13%) categorized within the severe TBI range, 17 of 444 subjects (4%) categorized within the moderate TBI range, 83 of 444 subjects (19%) categorized within the mild TBI range. Four studies combined the Glasgow Coma Scale categories. Classification by the Glasgow Coma Scale for those studies showed 84 of 444 subjects (19%) categorized within the mild-to-moderate TBI range, and 200 of 444 subjects (45%) categorized within the mild-to-severe TBI range.

Classification by the mean age demographic showed a mean age of 35.53 for eight out of 12 studies. Classification by external variables indicated the subjects continued psychotropic and psychotherapy during treatment. Nine publication studies conducted as pretreatment/posttreatment randomized group design with three studies conducting as pretreatment/posttreatment single-subject research.

Discrete Outcome

Alderman's [45] study presents a pretreatment Depression, Anxiety, and Stress Scale (DASS-21) score of 15 for stress for the single research design and a posttreatment DASS-21S score being 2. A decrease (-13) occurred. ACT showed effectiveness in reducing stress levels with TBIs.

Bomyea et al. study pretreatment combined DASS-21 score for the test group reflects 74, with the posttreatment score being 65. A decrease (-7.0) occurred. Comparatively, the pretreatment combined DASS-21 score for the control group reflects 76, with the posttreatment being 69. A decline (-7.0) occurred. ACT and treatment as usual were effective in reducing psychological distress.

Dindo et al. [46] research presents a pretreatment combined DASS-21 score for the test group of 53.4 with the posttreatment combined DASS-21 score reflecting 42.7. A decrease (-10.7) occurred. Comparatively, the control group pretreatment combined DASS-21 score reflects 59.7 with the posttreatment reflecting 65.6. An increase (+5.9) occurred. ACT showed effectiveness with TBIs in reducing psychological distress (depression, anxiety, stress) while treatment as usual displayed ineffectiveness.

Meyer et al. study presents an Acceptance and Action Questionnaire (AAQ-II-) measure of -0.71 ACT showed effectiveness with TBIs in acceptance and reducing psychological distress. Roche [47] study presents a Hospital Anxiety and Depression Scale (HADs) pretreatment score for depression and anxiety of 11 and six respectively, and a posttreatment score for depression and anxiety of 13 and two, respectively. ACT showed effectiveness with TBIs in reducing stress.

Sander et al. study pretreatment combined DASS-21 score for the test group reflects 68.8, with the posttreatment score being 62.67. A decrease (-6.13) occurred. Comparatively, the pretreatment combined DASS-21 score for the control group reflects 69.78, with the posttreatment being 63.18. A decline (-6.6) occurred. ACT and treatment as usual were effective in reducing psychological distress with individuals diagnosed with TBIs.

Straits-Troster study indicates decreased stress levels between pretreatment and posttreatment data for individuals diagnosed with TBIs. Wharton et al. study pretreatment AAQ-II group score presents 25.44. The posttreatment AAQ-II group score presents 32.00. ACT showed ineffectiveness with TBIs in acceptance and reducing psychological distress. Whiting [48] study presents a DASS-21S measure of -2.54 and a DASS-21A measure of -5.11. ACT showed effectiveness in reducing stress and anxiety with individuals diagnosed with TBIs.

Whiting’s [49] study presents a DASS-21D measure of -0.67. ACT showed effectiveness in reducing stress and depression with individuals diagnosed with TBIs.Whiting's [50] study pretreatment DASS-21D, DASS-21A, and DASS-21S scores for the test group were 23.4, 17.2, and 23.6 for depression, anxiety, and stress. Posttreatment DASS-21D, DASS-21A, and DASS-21S scores display 15.5, 9.6, and 17.4. Pretreatment DASS-21D, DASS-21A, and DASS-21S scores for the control group display 19.6, 21, and 23. Posttreatment DASS-21D, DASS-21A, and DASS-21S scores display 11.6, 12.4, and 15. ACT showed effectiveness with TBIs in reducing psychological distress (depression, anxiety, stress) and treatment as usual displayed effectiveness in reducing psychological distress (depression, anxiety, stress).

Whiting [51] study pretreatment DASS-21D, DASS-21A, and DASS-21S scores for the test group display 34, 22, and 24. Posttreatment DASS-21D, DASS-21A, and DASS-21S scores display 34, 20, and 22. Pretreatment DASS-21D, DASS-21A, and DASS-21S scores for the control group display 23, 32, and 26. Posttreatment DASS-21D, DASS-21A, and DASS-21S scores display 16, 14, and 20. ACT showed effectiveness with TBIs in reducing psychological distress (anxiety and stress) and treatment as usual displayed effectiveness in reducing psychological distress (depression, anxiety, stress).

Inter-Score Reliability

OutcomeInter-Score Reliability (iSr) results were calculated on 40% of randomly selected articles from the initial 25 article search. Therefore, 10 articles were randomly selected using google randomizer for iSr. Inter-scorer reliability agreement was 100%.

Discussion

This review examined studies to determine ACT’s effectiveness in psychological adjustment and reducing psychological distress following a TBI in adults. The results are encouraging regarding the effectiveness of ACT as an alternative intervention for individuals with TBI. This optimism stems from improvements in participants’ reduction of psychological distress. This review asserts that individuals acquiring a TBI quality of life may rapidly change depending on the severity of the injury. The DASS-21, AAQ-II, and HADS measures used in this review, presented as comparative group data and single-subject comparative data, and showed ACT's effectiveness in maximizing acceptance of life through values by targeting avoidance with individuals diagnosed with a TBI.

When comparing the mean values of age, ACT showed ineffectiveness with TBI in reducing psychological distress with participants who are 50 years of age or older. A possible reason for this result may be that the senior population is less resilient with combating stress due to declining health and chronic disease affecting the body's ability to function. Altering the environment to limit risks, which decreases independence, necessitates at higher levels for the senior population. Maintaining an optimistic viewpoint may decrease as the reality of lifespan dominates more than accepting adapting to life. In comparison, ACT showed effectiveness with TBI with psychological adjustment in reducing psychological distress with participants ages 18 through 49 years old. A probable cause of this result may be that the young to middle-age adult populations are actively advancing to higher cognitive functioning levels through higher learning or higher levels of job performance. Therefore, the motivation for cognitive rehabilitation may be much higher when compared to the senior population. Also, executive functioning may have been more robust at the onset of the TBI for the young adult to middle-aged population. Growing from novice to competent to proficient (usually occurring from young adult to middle-aged) in all areas of life strengthens cognition through dendrite development within the brain [52]. Higher levels of cognitive functioning at the onset of a TBI help determine progress outcomes.

Upon comparing the Severity of Injury domain values, ACT showed greater effectiveness with a mild TBI in reducing psychological distress than reducing psychological distress with individuals diagnosed with a moderate TBI or a severe TBI. This result correlates with a mild TBI having less detrimental effects than a moderate TBI or a severe TBI. Agitation and confusion are not as dominant and subside faster with a mild TB due to the severity of the injury being less profound. Integration of health services may also be more immediate for a mild TBI than a moderate to a severe TBI since intense specialty treatment may not be needed. These physical and psychological factors gauge the quality of life for individuals suffering from a TBI, which regulates emotional, cognitive, and daily living indicators for depression, anxiety, and stress levels. ACT displaying greater effectiveness with a mild TBI in reducing psychological distress compared to a moderate TBI and a severe TBI may correlate with severity of injury correlating with adjustment and adaptation.

Comparing the distress factors of depression, anxiety, and stress, ACT showed greater effectiveness in reducing anxiety than reducing depression and stress in individuals diagnosed with TBIs. Stress is the effects of anything that threatens to keep an individual's internal climate constant in the face of a changing environment [53]. It may be harder to control stress due to not being able to control the environment. Basowitz et al. [54] define anxiety as internally derived, intense dread unrelated to external threats. ACT focuses on accepting present conditions in the here and now. Focusing on accepting current conditions in the here and now counterbalances focusing on intense dread relating to external threats. It may be easier to accept present situations, which aids in anxiety reduction. Also, depression results from altered environmental dynamics and deteriorated health conditions due to TBIs. Often, these conditions usually do not improve with individuals diagnosed with TBIs, making depression harder to treat than anxiety due to motivation.

Upon comparing the gender domain, ACT was implemented 2.5 times more with males than females. Direct impact or inertial force TBIs may result from motor vehicle crashes, which may be higher for males than females. This higher rate of incidence for males may be due to behaviors related to risk taking and more ‘aggressive’ behaviors. Hirschberg et al. reported that males were 2.3 times more likely to sustain a TBI from vehicle impact than females, 2.5 times more likely to acquire a TBI from falls than females, and 6.0 times more likely to acquire a TBI from gunshot wounds than females. These statistics coincide with reviewed articles showing ACT being implemented 2.5 times more with males than females. Reviewed articles did not indicate the effectiveness of ACT concerning gender, however.

The following limitations should be considered when reviewing these results. First, the sample size of the included articles was small, with only 12 articles. While the sample size was small, this is not viewed as a severe limitation of the current review. Second, this review only studied distress measures of depression, anxiety, and stress to determine ACT's effectiveness because literature is limited to behavior-based interventions with individuals diagnosed with a TBI. Future studies should broaden distress measures related to a TBI that should include post-traumatic stress disorder or irritability. Also, two studies only had aggregate outcome measures. Pretreatment, compared to posttreatment data, yield discrete results, and provide starting points for references. Another limitation of this research review is the narrow focus population. A TBI is an acquired brain injury. Future investigations should broaden this study to acquired brain injuries (traumatic and non-traumatic). Future directions should also examine sequelae factors. Sequelae of the brain may alter this current review of ACTs effectiveness.

ACT is a functional contextual approach to cognitive behavioral therapy. ACT may be effective with the TBI population because it is a behavioral therapy approach that appears to be combining operant learning, psychological treatment, and intellectual science. Individuals who suffer from psychological distress due to inadequate psychological adjustment to an altered lifestyle rely on reinforcement through perusing self-values. TBIs can destroy or diminish an individual’s quality of life through psychological distress and aversive private language. Acceptance and understanding of private events (language and thoughts) necessitate in understanding perception versus reality. Relational frame theory stress functionality through contextual measures of human language, allowing mental associations or relations to be changed and controlled. Associations with private events change through acceptance, reasoning, and conduct promoting adaptability. The psychological presentation after a TBI is complex and multifaceted and may require a transdiagnostic approach. From the current literature research using ACT yields positive results with individuals diagnosed with TBIs in individuals who are younger and present with less severe symptoms. Research should continue to determine optimal effectiveness and implementation of ACT with psychological adjustment with individuals diagnosed with TBIs.

Disclosure statement

No potential conflict of interest is known to the authors.

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Correspondence & Copyright

Corresponding author: Dr. Amanda Philp, Applied Behavior Analysis Department, The Chicago School of Professional Psychology, USA, E-mail: aphilp@thechicagoschool.edu

Copyright: © 2020 All copyrights are reserved by Ahmed Nada, published by Coalesce Research Group. This work is licensed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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