Application progress of Acceptance and Commitment Therapy in patients with permanent enterostomy

Zhao Wang,Yue Wang,Zhang-Yi Wang,Chao-Kai He,Xiao-Li Pang

1Graduate School of Tianjin University of Traditional Chinese Medicine,Tianjin 301617,China.2Peking Union Medical College Hospital,Beijing 100005,China.3School of nursing,Tianjin University of Traditional Chinese Medicine,Tianjin 301617,China.

Abstract The psychosocial disorder of patients with enterostomy is still a huge challenge for the health systems.Acceptance and Commitment Therapy(ACT)has shown good results in permanent enterostomy in recent years.This paper explores the current status regarding ACT for patients with enterostomy in recent years through a literature review approach.The findings can provide scientific evidence for researchers,clinical practitioners and policy makers in this field.The study concludes that as a new psychological intervention method,ACT can significantly reduce the negative emotions and complications of patients with enterostomy,and improve their psychological flexibility,stoma acceptance,psychosocial adaptability,self-care ability and quality of life.

Keywords:Acceptance and Commitment Therapy;permanent enterostomy;cognitive behavioral therapy;psychological flexibility;psychotherapy

Background

According to the latest global cancer burden data in 2020 released by the international agency for research on cancer of the World Health Organization,colorectal cancer has become the third most common cancer in the world after lung cancer[1].Surgery is one of the most common treatment methods for colorectal cancer.Some patients need permanent enterostomy to reduce the risk of intestinal obstruction and promote distal anastomotic healing and disease recovery[2].Enterostomy not only improves the survival rate of patients with colorectal cancer,but also changes their body image and physical function.It can produce complications such as fatigue,loss of appetite,sexual life disorder and sports inconvenience.Some patients can have negative emotions such as self-aversion and shame,and even self-acceptance disorder and social disorder in severe cases[3].In addition,patients with permanent enterostomy have serious psychosocial adaptation obstacles,which seriously affect the quality of life of patients[4].Therefore,it is the focus of medical staff to promote patients' acceptance and adaptation to enterostomy and help them return to normal family and social life.

ACT developed in the early 1990s.It is a psychotherapy method based on functional context and relational framework theory,which was founded by American psychologist Hayes and others.ACT is a new form of cognitive behavioral therapy.It emphasizes acceptance and mindfulness rather than trying to replace wrong ideas.It focuses on the change of behavior strategies under the guidance of personal values,advocates embracing pain and accepting that "happiness is not the norm of life"[5].ACT is currently listed by the American Psychological Association as empirically supported psychotherapy and has been recognized by the U.S.drug abuse and mental health services administration[6].At present,relevant studies have confirmed the positive effect of ACT in patients[7-10].ACT focuses on using various metaphors to help enterostomy patients understand the specific skills and principles of various technologies through flexible and diverse exercises or experiences,establish more flexible and effective coping styles,reduce patients' empirical avoidance and improve psychological flexibility.This paper analyzes and summarizes the relevant studies on the application of ACT in patients with enterostomy,and provides a reference for future research.

The action mechanism of ACT

ACT is a psychopathological model based on empirical avoidance,cognitive integration,conceptualization of the past and fear of the future,attachment to the conceptualized self,lack of clear values,immobility,impulse or continuous avoidance.The center is psychological flexibility and a summary of the interaction between the six processes of psychopathology[6].The ultimate goal of ACT is to improve psychological flexibility through six key processes,as shown in Figure 1.These six processes integrate acceptance and change strategies.Through the first three processes,help patients reduce subjective control and judgment,reduce empirical avoidance,fully experience the present and pay attention to their own value.The latter three processes urge patients to recognize their self-worth,move towards goals and make health promotion behaviors[10].The six processes are interrelated and promote each other.The operation method and sequence are not strictly regulated.As a behavioral therapy,act enables patients to be more fully exposed to their abilities at the moment,so that they can make changes in behavior or make sustained efforts to achieve the established values and goals.Its core is about taking action[11].

Figure 1 Psychological flexibility model of ACT

ACT mainly constructs psychological flexibility through six core processes.Acceptance(In the face of negative emotions,thoughts or physical discomfort,they are willing to actively experience rather than avoid depression).Cognitive defuson(When there are some negative thoughts,observe them without evaluation).Being present(Be able to actively focus their attention on what is happening in the external world or the inner world).Self as contex(Pay attention to the current conscious activities).Values(Find their favorite life goal).Committed action(Commitment to action to achieve their core goals).

Application of ACT in patients with enterostomy

Intervention personnel

As a new psychotherapy method,ACT has been recognized in the society.At present,group intervention is mainly used at home and abroad.Practitioners of ACT must abide by the code of ethics of clinical psychology and obtain professional qualifications.The team members mainly include gastrointestinal surgeons,stoma therapists,psychological counselors and gastrointestinal nurses.All team members should receive professional training on act related knowledge and clinical application.The division of labor among team members is shown in Table 1.

Table 1 Team division of ACT

Intervention method

Face to face intervention is mainly used.Face to face can effectively observe the patient's body language,help to find the patient's emotional changes and give timely feedback[12].Choose a quiet and comfortable environment for intervention to ensure the smooth implementation of treatment.The intervention content focuses on six core treatment technologies.

Acceptance

Researchers use metaphors and other means to help patients accept diseases and various emotions and feelings with an open attitude[13].Acceptance can promote patients to adopt behavior consistent with value[14].By guiding patients to accept colorectal cancer surgery and permanent enterostomy,the interveners make patients have a correct understanding of normal enterostomy and improve various bad emotions.The researchers guide patients to take the pain as the exercise of life and feel the process of fighting the disease with their heart.Guide patients to understand more positive things such as family affection,friendship and improvement of their own ideological realm after illness[15].

Cognitive defuson

Instruct patients to think of ideas as language and words themselves,not the meaning it represents.Due to the particularity of the operation,patients with permanent enterostomy are often worried about the falling of the bag,being discriminated against and being unable to take care of themselves,which is prone to a series of bad emotions[3].Researchers deeply understand the possible bad emotions of each patient,analyze them together,guide the patients to tell their concerns about the disease and future life,and tell the patients that all kinds of negative cognition are only their personal understanding,not the reality itself.Guide patients to completely put aside their current inner avoidance and resistance[16].

Being present

Researchers encourage patients to actively face the disease and strive to extricate themselves from the bad mood caused by the disease.Let patients experience the present and feel the love of relatives,friends,leaders and medical staff.Inform patients that as long as they master how to choose stoma equipment and correct stoma nursing operation in the future,it will not have a great impact on their life.Help patients to let go of their inherent obsession and pay attention to the benefits of stoma[17].

Self as contex

Researchers help enterostomy patients constantly observe and examine themselves from their self-consciousness[18].Guide enterostomy patients to focus their attention purposefully,help them understand the difference between conceptual self and real observational self through metaphor,and help them bring their attention back to the right track more quickly when they are troubled by some thoughts[19].Carry out lectures,carry out patient friendship,imagine possible accidents in different scenarios,and introduce prevention and treatment skills.Encourage patients to exchange their experience in dealing with unexpected adverse events.

Values

Instruct patients how to tap their potential and set goals.The interveners fully stimulate the desire for rehabilitation and survival of patients with enterostomy and make them yearn for the future life.Help enterostomy patients find their own value and meaning of life again.During the intervention,patients are constantly informed that although enterostomy is a chronic disease requiring long-term management,it can still live a normal life and also have social,family and personal values.In the process of intervention,patients should be constantly informed that although enterostomy is a chronic disease requiring long-term management,it can still live a normal life.Patients also have social,family and personal values[20].

Committed action

Help enterostomy patients turn their ideas into actions and return to their current life.Help patients set goals according to their wishes,such as independent stoma care,avoiding alcohol,light diet,and maintaining good living habits.Encourage enterostomy patients to actively communicate with others,such as participating in some patient associations.Enhance patients' confidence in fighting diseases,and promise to take positive actions from now on,overcome all difficulties,and finally achieve the goal of improving long-term quality of life[21].

Measuring scale

The acceptance and action questionnaire(AAQ)is a generic scale.AAQ has two versions:AAQ and AAQ-Ⅱ,which are used to measure the degree of empirical avoidance.The higher the score,the higher the degree of empirical avoidance,and then the worse the psychological flexibility[22-24].The stoma patient specific psychosocial adaptation scale is used to evaluate the level of psychosocial adaptation of patients after enterostomy.The higher the score,the higher the degree of psychosocial adaptation of patients[25].The stoma acceptance questionnaire is used to measure the stoma acceptance of patients with enterostomy.The higher the score,the higher the patients'acceptance of their own stoma[26].The stoma quality of life scale is used to measure the quality of life of stoma patients.The quality of life of patients is directly proportional to the score[27].The specific information of the scale is shown in Table 2.

Table 2 Measuring scale

The stoma acceptance questionnaire The scale includes evaluation importance(4 items),autonomy and acceptance(5 items),evaluation support(3 items),a total of 3 dimensions and 12 items.It was compiled by the researcher on the basis of Orem's self-care theory in 2017 to measure the acceptance of enterostomy in patients with enterostomy,with good reliability and validity.The stoma quality of life scaleThe scale includes four dimensions:physical and mental state,family and friend support,pocket making management and social communication.The scale was developed by Prieto in 2005.At present,it has been widely used to measure the quality of life of patients with enterostomy,and has good reliability and validity.

Intervention effect

From the point of view of act,psychological or physical discomfort is inevitable,and the patient's acceptance of the disease will reduce the pain.It is an important research direction to make enterostomy patients accept and adapt to this change of physiological structure[3].Researchers provided personalized intervention for patients with enterostomy,including metaphor,mindfulness training and other forms of intervention.The results showed that ACT enhanced the patients' psychological elasticity,integrated mindfulness thinking,changed the wrong cognition,and then improved the patients'acceptance of stoma[28].Psychological flexibility refers to the ability of an individual to experience the present and adhere to or change certain behaviors according to personal values based on the actual situation[29].A study showed that after the intervention of ACT,the psychological flexibility score of the observation group was lower than that of the control group(P＜ 0.05),that is,the psychological flexibility was higher than that of the control group,indicating that ACT can improve the psychological flexibility of patients with permanent colostomy,which is consistent with the results of many studies on the application of ACT to improve the psychological flexibility of patients[10,30].Psychosocial adaptation means that individuals adjust their emotions to adapt to their own conditions and maintain a good psychological state[31].In the early stage after enterostomy,patients often have poor stoma adaptation and increased negative emotion,resulting in low social and psychological adaptation[4].The international stoma organization pointed out that stoma patients should better adapt to life not only physically,but also psychologically[32].Researchers helped patients establish correct cognition,change patients' wrong views,enable patients to obtain mindfulness power,reduce patients' negative emotions,improve self-efficacy,and improve the level of psychosocial adaptation[27].Similarly,a study found that after the intervention of ACT,patients can actively accept the stoma bag and strengthen the stoma bag nursing experience learning.One month later,the patients' sense of self-care responsibility,self-care ability and quality of life were significantly improved[33].This is consistent with previous research results[34,35].Improving the nursing ability of patients with enterostomy and preventing the stoma bag related adverse events on various occasions are important measures to improve the quality of life and alleviate negative emotions.

Conclusion

As a new psychological intervention method,ACT can significantly reduce the negative emotions and complications of patients with permanent enterostomy through six core processes,and improve their psychological flexibility,stoma acceptance,psychosocial adaptability,self-care ability and quality of life.At present,there are more and more studies on ACT at home and abroad,but there are few empirical studies,which still need time and more studies to verify.In the future,we need to expand the sample size to further study the mechanism,technical details,measurement tools and clinical effects of ACT.