Acceptance and Commitment Therapy to Improve Psychological Resilience and Physical Function in Allogeneic Hematopoietic Stem Cell Transplantation
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ABSTRACT Cancer therapies such as allogeneic hematopoietic stem cell transplant (HCT) are associated with significant toxicities, which can significantly impair function and quality of life. This may be ameliorated by actions such as engaging in physical activity during treatment; however, many patients find it difficult to maintain these behaviors. This challenge is magnified by the stress of a life-threatening situation: many patients have limited coping skills, which may contribute to depressive affect and withdrawal that further diminishes functional capacity. Acceptance and Commitment Therapy (ACT) is an evidence-based cognitive behavioral therapy (CBT) intervention that has been effective in reducing symptom interference in a variety of clinical populations, including individuals with late-stage cancer. ACT may be particularly well-suited to conditions of cancer in which patients experience unavoidable treatment-related discomforts (e.g., fatigue, pain, nausea), and thoughts/feelings that are distressing but not illogical or irrational (e.g., possibility of death). Unlike traditional CBT that focuses on changing unwanted thoughts/feelings, ACT focuses on psychological flexibility: having an open and receptive posture with respect to moment-to-moment experiences; and acting effectively in their presence, guided by personal values (i.e., what is most important to the individual and how they want to live the moments of their lives). In the context of HCT, ACT may help HCT patients focus on actions that may help maintain adequate physical activity, despite physical and emotional discomfort, thereby optimizing transplant outcomes. Caregivers are also central for HCT success, particularly during the most acute stages of pre- and post-transplant. Including caregivers in skills training may help them encourage their loved one to eat or move when it is most challenging, despite their own distressing thoughts/feelings about their loved one’s illness. We piloted an ACT skills protocol we named “ACTivate” that consists of 7 ACT skills sessions delivered to HCT patient and caregiver dyads by Zoom between transplant Day -30 and Day +90. Patients and caregivers rated the sessions as highly acceptable, with 95% recommending ACT to others in similar situations. Moreover, while we hypothesized that ACT would attenuate the decreases in physical function that are typically seen post-HCT, patients who received ACTivate increased their 6-minute walk distance after HCT; they also reported better functional well-being at Day 90 compared with controls. We now propose to conduct a more rigorous test of the intervention in a multicenter randomized controlled trial to evaluate the impact of ACTivate on physical function, psychological flexibility, and clinical outcomes. We will also examine multimodal processes of change and the impact of caregiver psychological flexibility and self-efficacy and association with patient outcomes. This is the first study that targets psychological barriers to maintaining physical activity during HCT using ACT. If successful, it could establish an evidence- based protocol to increase treatment tolerance in HCT. Future studies may evaluate the applicability of the protocol to other cancer treatments and conditions.
