Ageing Mindfully During COVID: Therapists Reflections from Delivering Acceptance and Commitment Therapy Groups via Tele-Health Within an Aged Persons Mental Health Service
Paul Sadler1*, Julian Nolan2, Isabelle Gardiner1 and Miriam Wan1
1Eastern Health, Aged Persons Mental Health Service, Australia
2Monash Health, Rehabilitation and Aged Care Services, Australia
Submission: August 02, 2021; Published: August 17, 2021
*Corresponding author: Paul Sadler, Eastern Health, Aged Persons Mental Health Service, Australia
How to cite this article:Paul S, Julian N, Isabelle G, Miriam W. Ageing Mindfully During COVID: Therapists Reflections from Delivering Acceptance and Commitment Therapy Groups via Tele-Health Within an Aged Persons Mental Health Service. JOJ Pub Health. 2021; 6(1): 555676. DOI: 10.19080/JOJPH.2021.06.555676
Publically-funded community mental health services assess and treat older adults (aged over 65 years) who experience severe mental illness. Treatment for these clients generally follows the case management medical model of care (Sadler, McLaren, Klein, & Jenkins, 2018) . In line with the emerging mental health recovery model of care, less restrictive and more person-centered psychotherapy options are being offered to older adults (Sadler et al., 2018) . Group-based psychotherapy is currently being explored within an aged persons community mental health service in Victoria, Australia. This paper briefly discusses the reflections from allied health therapists who co-facilitated three Acceptance and Commitment Therapy (ACT) groups between 2020 to the current day. Ideally these ACT groups would have been conducted face to face, however, the groups were moved to a tele-health mode of delivery due to the COVID-19 pandemic.
ACT via Tele-Health: Content and Process Considerations
Acceptance and Commitment Therapy (ACT) is a modern form of psychotherapy that aligns well with the concepts of ageing (Harris, 2019; Jacobs, Luci, & Hagemann, 2018) [2,3]. The ACT hexaflex theory supports recovery principles by promoting the older adult’s psychological flexibility and resilience whilst reducing their experiential avoidance (Coto-Lesmes, Fernández-Rodríguez, & González-Fernández, 2020; Harris, 2019; Luci, Jacobs, & Hagemann, 2016) [2,4,5]. The use of tele-health for older adults is a novel field (Quinn, O’Brien, & Springan, 2018) . The three tele-health ACT groups discussed in this paper were co-facilitated and ran weekly over 8 to 9 sessions. Participants were cognitively intact and presented with a variety of mental health diagnoses. The core skills of ACT were taught during the groups, including mindfulness, values/strengths, committed action, self-compassion, acceptance, and defusion. Therapists observed that the participants particularly benefitted from the mindfulness-based activities (offered during each session); despite initial hesitation from the therapists that it may be too challenging to effectively deliver mindfulness-based interventions via tele-health. The ACT groups followed a set session agenda and therapy workbook that were developed by the therapists. The protocol slightly changed over time to meet the situational needs of participants (e.g., increased time spent validating the participants distress during local changes to the COVID restrictions). Group sessions also often ran over time (e.g., needing 90 minutes) as participants wanted to share their experiences and socialise with others. This was more prevalent when there was a stronger peer connection within the group. In the first two groups, a therapeutic alliance formed between a core group of participants (usually 3 - 4 participants who attended every/most sessions). The third group did not form as cohesively, likely impacted by logistical issues leading into the group start date and reduced participant attendance due to increased symptom severity. Participant disengagement also seemed to occur more frequently when (1) participants either missed one of the first two sessions (where the core group formed together), and (2) when they did not fully understand the requirements of participation (e.g. level of commitment involved; practicing therapy skills between sessions).
Since the groups were conducted via tele-health during to the current COVID pandemic, these circumstances posed major additional challenges. Both the therapists and older adults had to display agility and learn new pathways of interacting. Extra time was required (particularly within the first half of the program) to help participants familiarise themselves with using the tele-health skills/platform. As the groups progressed, participants became more confident with using the technology, reducing the amount of trouble-shooting time it took to log on successfully (e.g., having both audio and visual elements working). There were still later sessions where participants had issues with their internet and/or their device connections, which continued to test the therapists and participants interpersonal and technology problem solving skills.
Much consideration was also given to managing ethics and risk with the use of tele-health. For example, risk management plans were individually created before the groups and implemented for participants alongside their case managers in cases of mental state deterioration. Although confidentiality of who could hear the group call in participants’ homes could not always be guaranteed, participants were thankful of being able to attend the group in the comfort of their own homes and benefitted from not needing to arrange transport/carer support to attend the outpatient clinic. There were some salient elements that appeared to help the older adults engage better with the tele-health modality, these included:
1. Ensuring participants had easy access to the technology,
2. Spending 1:1 time both in and out of the group to provide encouragement with using the online platform,
3. Providing participants with a printed therapy workbook with the agenda, brief notes, and exercises each week for them to utilize independently,
4. Sending weekly emails between sessions with additional content to encourage homework compliance.
Notwithstanding the opportunities that can be generated by adopting tele-health for mental health recovery, significant barriers are also present. One challenge for older adults living with persistent mental illness is they often had conflicting health appointments, which could disrupt their weekly group attendance. Another cultural service-based implementation barrier was the running of a psychotherapy group program within a public mental health service. ACT groups are new recovery options that have not been trialed with this setting before; hence this created some apprehension amongst the wider service’s clinicians. Developing guidelines for other clinicians in the service who have a client participating in the group may prove beneficial to address any uncertainty that was present.
ACT for the Future
The therapists formulated recommendations for aged persons mental health services to consider. Firstly, ACT-based psychotherapy groups appear to show promise as a viable adjunct treatment option to traditional psychopharmacology for older adults with major mental illnesses. ACT groups can also be delivered via tele-health when certain measures are put in place to ensure it can safely and effectively meet the older persons’ needs. To facilitate tele-health delivery and maximize therapeutic engagement from participants, additional time should be allocated before and during the group to assist therapists build rapport with each participant and prepare them appropriately for the program. Adequate protected time for therapists is required to ensure clear documentation, supervision, follow-up tasks, outcome measures, and communicating with relevant stakeholders are completed. Finally, it is important that psychotherapy groups are supported by publically-funded mental health services, as this form of specialized treatment is not readily available for older adults with mental illnesses.
- Sadler P, McLaren S, Klein B, Jenkins M (2018) Advancing cognitive behaviour therapy for older adults with comorbid insomnia and depression. Cognitive Behaviour Therapy 47: 139-154.
- Harris R (2019) ACT made simple. (2nd ed.), New Harbinger, Victoria, Australia.
- Jacobs ML, Luci K, Hagemann L (2018) Group based acceptance and commitment therapy (ACT) for older veterans Findings from a quality improvement project. Clinical Gerontologist 41: 458-467.
- Coto Lesmes R, Fernández Rodríguez C, González Fernández S (2020) Acceptance and Commitment Therapy in group format for anxiety and depression A systematic review. Journal of Affective Disorders 263: 107-120.
- Luci K, Jacobs L, Hagemann L (2016) ACT for older adults Group therapy for fostering psychological flexibility in older adults. The Gerontologist 56: 59-60.
- Quinn WV, O Brien E, Springan G (2018) Using telehealth to improve home-based care for older adults and family caregivers. AARP Public Policy Institute 135: 1-12.