Johns, Louise

McLeod, Hamish J.

White, Ross

English

Enlighten: Publications

  
 
 
 
 
McLeod, H. J., Johns, L., and White, R. (2016) Improving the implementation 
fidelity and reach of ACT for complex needs. In: Menzies, R., Kyrios, M. and 
Kazantzis, N. (eds.) Innovations and Future Directions in the Behavioural and 
Cognitive Therapies. Australian Academic Press: Samford Valley, Queensland. 
ISBN 9781922117700. 
 
   
There may be differences between this version and the published version. You are 
advised to consult the publisher’s version if you wish to cite from it. 
 
 
 
http://eprints.gla.ac.uk/130284/ 
     
 
 
 
 
 
 
Deposited on: 4 November 2016 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Enlighten – Research publications by members of the University of Glasgow 
http://eprints.gla.ac.uk 
Improving ACT Fidelity 
Title: Improving the Implementation Fidelity and Reach of ACT for Complex Needs 
In R. Menzies, M. Kyrios, & N. Kazantzis (eds) Innovations and Future Directions in 
the Behavioural and Cognitive Therapies. Bowen Hills, QLD: Australian Academic 
Press 
 
Hamish J McLeod, University of Glasgow 
Ross White, University of Glasgow 
Louise Johns, University of Oxford 
 
Overview 
Although effective psychological therapies generally attract high acceptability ratings 
and are greatly valued by service users, we need to do a much better job of achieving 
widespread implementation across health service systems. This challenge can be 
particularly evident where service users have complex needs, such as those related to 
psychosis. UK audit data show that despite clinical guideline stipulations (e.g. from 
NICE), the routine implementation of psychological treatments for psychosis such as 
CBTp and Family Therapy reaches less than one tenth of those who could benefit 
from such therapies. As the third wave of psychological treatment approaches expand 
into psychosis treatment, psychosis focused adaptations of Acceptance and 
Commitment Therapy (ACTp) will face many of the real world implementation 
challenges that have diluted the beneficial impacts of CBTp and family therapies. To 
reduce the avoidable suffering and wasted resources that will accompany ineffective 
implementation of ACTp, we propose that researchers and clinicians should actively 
work to understand and address the factors that help bridge the gap between clinical 
trial data and meaningful clinical impact in real world healthcare settings. Choosing to 
Improving ACT Fidelity 
grapple with these challenges of implementation fidelity now will be a good 
investment in the future of effective care for complex needs. This chapter outlines 
how wider work on therapy development and implementation science can inform the 
next generation of ACTp studies.  
 
Major Findings  
Before considering specific issues relevant to implementing ACTp, we will outline a 
number of wider issues pertinent to psychological intervention development and 
therapy trial design that help place the need for implementation research in context. 
We are in an era where randomised controlled trials (RCTs) have become 
synonymous with best quality evidence for treatment effectiveness. This evaluation 
method works well when discriminating between highly replicable medical 
interventions (e.g. drugs or surgical procedures) and enhanced evidence reporting 
standards such as the CONSORT guidance have helped to improve the clarity and 
transparency of published RCT evidence. But psychological therapies are complex 
interventions with many sources of uncontrolled variance that can interfere with 
generalisation of findings across contexts. To mitigate this, several frameworks have 
been published in recent years to help complex intervention researchers convert their 
treatment insights into a form that will maximise real world implementation. The UK 
Medical Research Council’s complex interventions framework and the Delaware 
Project from North America help therapy researchers address questions of treatment 
implementation, not just efficacy. The need for a more nuanced understanding of 
psychosocial intervention implementation has also stimulated extension of the 
CONSORT statement for trial reporting standards1. Clinicians and therapy 
                                                        
1 See additional readings 
Improving ACT Fidelity 
researchers alike will benefit from using these frameworks to understand future trials 
of complex interventions so that effective treatments have a greater chance of being 
implemented in contexts outside of the highly controlled parameters of an RCT.   
 
The ACTp evidence base now comprises several RCTs and a number of uncontrolled 
intervention studies that provide preliminary evidence of effects on outcomes such as 
reduced hospital readmission, improved emotional adaptation, self-ratings of 
functional recovery, and enhanced confidence in managing symptoms such as 
command hallucinations. The treatment effect sizes are in the medium to large range 
(Cohen’s d=.31 to .86), particularly when the comparator is standard care. Although 
the size of these effects are likely to diminish when adjusted for trial quality or when 
compared to active comparator treatments, there are signs that ACTp is developing an 
evidence base that gives clinicians and researchers an expanded range of viable 
treatment choices.  
 
The published ACTp research also allows some preliminary observations about 
patterns of treatment dose, fidelity, and reach. The dose required to achieve an effect 
on primary outcomes varies substantially across trials with an average of 15.8 
sessions but a wide range from 3 to 20 sessions. Data relevant to reach shows that 
ACTp has been applied to people with psychosis across the range of chronicity and 
severity and in different treatment settings from acute admission wards to community 
based care. The context of most treatment outcome research is high resource settings 
in high-income countries such as the UK, USA, and Australia where there are ACT 
communities and increased access to training and supervision resources. This speaks 
to the issue of treatment fidelity and the level of competence needed to ensure that 
Improving ACT Fidelity 
ACTp is delivered at the required standard. To date, we have limited data on how to 
adequately prepare ACTp therapists and how to monitor treatment adherence. The 
minimum requirements is similar to existing psychological interventions; therapists 
need pre-intervention training in the therapy protocol followed by ongoing 
supervision and review of clinical case work by supervisors with ACT expertise. 
 
Clinical Implications 
Helping people to live well in the presence of challenges presented by psychotic 
experiences is well within the scope of ACTp’s philosophy and goals. But, it is also 
clear that there is much to learn about how ACTp can be best delivered with fidelity 
across contexts to people presenting with varying treatment needs. A contextual 
behavioural science approach to clinical practice and therapy refinement has a good 
chance of bridging the gap between trial evidence and real world practice. As outlined 
by Hayes et al (2013), some ways of developing, refining, and implementing 
psychological treatments are more effective than others. An immediate task for 
clinicians and researchers is to create collaborations that maximise the impact of such 
treatment improvement efforts.  
 
Future Directions 
ACTp will make meaningful progress if clinicians and researchers work together to 
evaluate and understand the ways that effective techniques, in the right doses, can be 
delivered to the right people to meet their needs. Intervention studies that use modern 
frameworks for implementation process evaluation will help surmount barriers to 
wider penetration of effective care. Instrumentation and measurement improvements 
will also help (e.g. treatment fidelity scales) as will the use of technology to increase 
Improving ACT Fidelity 
the reach of therapy information and strategies (e.g. via mHealth and ICT delivery 
platforms). Ultimately, ACTp is well placed to mature into a valuable addition to the 
range of therapies available to people seeking help with managing the consequences 
of psychosis.  
 
Further Readings 
Hayes, S. C., Long, D. M., Levin, M. E., & Follette, W. C. (2013). Treatment 
development: Can we find a better way? Clinical Psychology Review, 33(7), 870–
882.  
Mayo-Wilson, E., Montgomery, P., Hopewell, S., Macdonald, G., Moher, D., & 
Grant, S. (2013). Developing a reporting guideline for social and psychological 
intervention trials. The British Journal of Psychiatry, 203(4), 250–254.  
Moore, G. F., Audrey, S., Barker, M., Bond, L., Bonell, C., Hardeman, W., et al. 
(2015). Process evaluation of complex interventions: Medical Research Council 
guidance. British Medical Journal, 350 (March 19), h1258–h1258.   


Improving the implementation fidelity and reach of ACT for complex needs

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