Effectiveness of Acceptance and Commitment Therapy to Reducing

Depression in Nursing Home Residents

Ajeng Harlika Puspitasari

and Hamidah

Faculty of Psychology, Universitas Airlangga

Keywords: Psychotherapy, Nursing Home Residents, Value.

Abstract: Each elderly person is expected to achieve successful aging so as to live to the end of their life with

prosperity, but they are vulnerable to psychological disorders, especially depression. Nursing home

residents have a higher risk of depression caused by several factors, such as loss of independence, isolation,

loneliness, loss of personal space, monotonous activities, and conflicts with the nursing home staff.

Acceptance and Commitment Therapy is an intervention aimed at improving psychological flexibility and

the ability to adapt to change so as to make the individual able to deal with various problems that become

stressors. The purpose of this study is to examine the effectiveness of Acceptance and Commitment Therapy

in reducing depression in nursing home residents. This research is a quasi-experimental study with the non-

randomized research design pretest-posttest control group. This study was applied to 6 elderly female

subjects divided into two groups, 3 subjects in the experimental group and 3 in the control group. The

measuring instrument used in this study is the Geriatric Depression Scale - 15 (GDS - 15). The results

obtained in this study indicate that Acceptance and Commitment Therapy has a high effectiveness in

reducing depression in nursing home residents. There was a significant difference between the mean score

before and after intervention in both groups.

1 INTRODUCTION

The number of elderly people in the world increases

annually. The WHO (2012) states that the elderly

population around the world is increasingly growing,

even estimating that in the next five years the

number of elderly could exceed the number of

infants worldwide. The growing number of elderly

people is affecting the emergence of social and

economic problems.

Reduced ability of organs in the elderly makes

this group susceptible to various chronic diseases

that not only adversely affect their physical health

but also the mental health of the elderly (Infodatin,

2016). Nursing home residents have a tendency to

experience higher psychological problems. Common

psychological problems in elderly people living in

nursing homes are dementia, mood disorders

(depression and bipolar disorder), psychotic

disorders and anxiety disorders (Fullerton et al.

2009). Several studies suggest that nursing home

residents have a higher likelihood of depression than

the elderly living in the general population (Kramer

et al. 2009). As many as 22% of elderly people

living in a nursing home experience major

depression (Rovner & Kats in Kramer et al., 2009).

The risk of depression in nursing home residents

is higher when compared with older people living

with their family due to several causes. These

include factors such as losing the ability to be

independent and free, and losing the opportunity to

live as before; feeling socially isolated and lonely;

lack of personal space, frustration at disturbing room

mates, and being disturbed about sharing a bathroom

with other residents; loss of rights and freedom due

to rules of the nursing home; ambivalence associated

with cognitive impairment of other inhabitants;

witnessing death and grief; turnover and lack of

institutional staff, monotonous daily activities, and

lack of meaningful home activities (Choi et al.,

2008).

Depression in residents is not solely due to

environmental factors in the nursing home, but

rather a complex interaction between factors, such as

biological and

psychosocial factors (Azis &

Steffens, 2013). Elderly who are depressed

according to the basic theory of acceptance and

commitment therapy have the characteristics of

174

Puspitasari, A. and Hamidah, .

Effectiveness of Acceptance and Commitment Therapy to Reducing Depression in Nursing Home Residents.

DOI: 10.5220/0008586901740179

In Proceedings of the 3rd International Conference on Psychology in Health, Educational, Social, and Organizational Settings (ICP-HESOS 2018) - Improving Mental Health and Harmony in

Global Community, pages 174-179

ISBN: 978-989-758-435-0

thought suppression, for example suppressing the

mind, ineffective coping strategy, and reason-giving

in which the subject associates the experience with

self-blame (Bond & Dryden, 2004). Depression in

the elderly has consequences such as reduced

functioning and increased disability, increased use of

non-mental health services, increased risk of cancer,

increased mortality from cardiovascular and

cerebrovascular disease, and increased risk of

suicide (Dines, Hu & Sajatovic, 2014).

Depression in nursing home residents is often not

recognized and does not receive proper treatment

from nurses and doctors in nursing homes where the

elderly live, increasing the adverse impact on the

physical and psychological condition of the elderly

themselves (Kramer et al., 2009). Furthermore,

depression experienced by nursing home residents is

treated more often by anti-depressant medications

without clear medical history documentation.

Meanwhile, treatment-handling for depression in the

elderly in general requires not only pharmacotherapy

techniques but also using a psychotherapy approach

and psychosocial intervention (Glover & Srinivasan,

2017).

Acceptance and commitment therapy is one of

the therapeutic approaches that use processes of

acceptance, commitment and behavioral change to

produce more flexible psychological changes.

Acceptance and commitment therapy is a technique

that has a high success rate in overcoming problems

related to mood disorders, such as depression and

anxiety (Swain et al., 2013). Acceptance and

commitment therapy has the goal of improving the

psychological aspects of the individual to become

more flexible and improves the ability of individuals

to adjust to changes that are happening (Hayes et al.,

2006).

The effectiveness of acceptance and commitment

therapy in dealing with depression in the elderly has

been tested through research conducted by Karlin et

al. (2013). It concludes that acceptance and

commitment therapy enhances a person's ability to

respond flexibly to difficult life events and take

action in accordance with their ability to improve

their quality of life.

This study aims to examine the effectiveness of

acceptance and commitment therapy in reducing

depression in the elderly living in nursing homes.

Treatment of acceptance and commitment therapy

was given to an experiment group of 6 sessions for 5

weeks. Measurements of depression were performed

in both groups using a GDS-15 scale to compare the

depression levels of both groups.

2 RESEARCH METHOD

The research is an experimental study that aims to

see the effectiveness of Acceptance and

Commitment Therapy interventions to reduce

depression in the nursing home residents. This

research will use a quantitative approach and is

quasi-experimental. The quasi-experimental type of

experiment itself is a type of research without

randomization and is done by placing subjects in

experimental and control groups (Latipun, 2015).

2.1 Ethical Considerations

This research has gained approval from the head of

the nursing home institution where the research is

conducted. Each subject is informed with details of

the implementation of the intervention and has given

agreement by signing informed consent.

2.2 Participants

Participants in this research have criteria (1) Women

aged 60 - 74 years. The elderly group in this

category was chosen because they still have good

cognitive and health conditions, which will facilitate

the process of intervention. In addition, this age

range is the stage where the elderly must adapt to

changes from the next stage of development, so that

the success of the adaptation process in this category

affects the mental health of the elderly in the next

stage of development. (2) Able to communicate

well. Communication ability is necessary to collect

data about the condition of the participants. (3) Have

moderate to severe depression score category

according to the Geriatric Depression Scale (GDS) -

15. Medium depression category according to GDS

– 15 is indicated by a score 9 - 11 and category

Severe depression is indicated by a score of 12 - 15.

Medium and severe depression categories according

to GDS-15 scale are depressed categories requiring

further treatment. (4) Willing to follow a series of

Acceptance and Commitment Therapy interventions.

Participants of the study who met the criteria

were six elderly women who lived at nursing homes

in Surabaya. Six participants were divided into two

groups, the experimental group receiving acceptance

and commitment therapy and the control group not

given any treatment as comparison. Each group

consisted of three participants, in which participants

who had higher depression scores were fused into

the experimental group.

Effectiveness of Acceptance and Commitment Therapy to Reducing Depression in Nursing Home Residents

175

2.3 Research Variables

This study aims to measure the effectiveness of the

independent variable (X) towards the dependent

variable (Y). Independent variable (X) in this

research is Acceptance and Commitment Therapy.

The dependent variable (Y) in this research is

depression.

2.4 Data Analysis

The research design used was quasi-experimental

with non-randomized pretest-posttest control group

design. Data analysis was performed by comparing

the depression scores on the GDS-15 scale in the

experimental group before and after treatment and

the control group were not given any treatment as

comparison. The data was analyzed by independent

sample t-test and testing the effectiveness of

acceptance and commitment therapy using online

effect size calculators by Lee A. Becker.

2.5 Materials

The material used in this research is the Geriatric

Depression Scale (GDS-15) by Sheikh and

Yesavage (1986) and the intervention module, which

is the result of developing acceptance and

commitment with the older adult module by Petkhus

and Wetherell (2013). GDS-15 is used to measure

the depression level that is specific to the elderly.

GDS-15 has alpha Cronbach reliability of .80

(Wongpakaran, 2013) and specificity of .75 (Nyunt,

et al., 2009).

The acceptance and commitment therapy module

in this research is the result of developing the

acceptance and commitment therapy module with

older adults by Petkus and Wetherell (2013). In the

original module, the acceptance and commitment

therapy was conducted for five sessions with two

meetings at each session. This research module was

developed according to the needs and abilities of the

research subject.

2.6 Intervention

Interventions are conducted individually consisting

of six individual sessions with a duration of 60

minutes each session. Each session consists of two

meetings a week. An outline of the components of

the intervention program is included in Table. 1.

Table 1: Overview of Intervention ACT

Session 1

1. Performed early depression level

measurements.

2. Introduce acceptance and

commitment therapy interventions

and build rapport with all

participants.

3. Gathering information about

depression-causing experience.

Session 2

1. Mindfulness breathing.

2. Introduce the participants with a

living value.

3. Determine and re-identify the value

of life.

4. Establish short-term goals that match

the value of life.

5. Metaphors “what do you want life to

stand for?”.

Session 3

1. Mindfulness breathing.

2. Be aware of emotional experiences

that are felt.

3. Promote acceptance of painful

experiences and emotions.

4. The metaphor of “pouring water into

a hollow glass”.

Session 4

1. Mindfulness breathing.

2. Identify negative self-concept.

3. Perform cognitive diffusion.

Session 5

1. Mindfulness breathing.

2. Live and focus on the moment.

3. The metaphor of “leaves are falling”.

Session 6

1. Mindfulness breathing.

2. Evaluate values session and

objectives.

3. Resolve the obstacles experienced

during the intervention process.

3 RESULTS

The results of this study indicate a decrease in

depression rates in the experimental group and the

level of depression that is relatively constant in the

control group based on the mean score. Furthermore,

data analysis was done by independent sample t-test

technique and effectiveness test using effect size

calculator online by Lee A. Becker on the gain of

pretest and posttest score of both groups. The

following is the result of statistical analysis test:

ICP-HESOS 2018 - International Conference on Psychology in Health, Educational, Social, and Organizational Settings

176

Table 2: Descriptive Statistics

N Mean SD Min Max

xperiment Pre-test 3 11.67 1.155 11 13

Post-test 3 6.33 1.528 5 8

Control Pre-test 3 10.00 1.00 9 11

Post-test 3 9.33 0.577 9 10

Table 3: Significance Independent Samples Test.

Gainscore

t 3.395

Df 4

Sig. (2-tailed) .027

Table 4. Effect Size

Gainscore

t 3.395

Df 4

Sig. (2-tailed) .861

Based on the results of statistical analysis it can

be concluded that the hypothesis of this study is

accepted. Acceptance and commitment therapy has a

high effectiveness in reducing depression in nursing

home residents.

4 DISCUSSION

Acceptance and commitment therapy is an effective

intervention to apply for the elderly to overcome

mental disorders that are classified as mood and

anxiety disorders; depression is a type of mood

disorder (Petkus & Wetherell, 2013). Karlin et al.

(2013) explains that acceptance and commitment

therapy effectively reduces depression in the elderly

because it allows the basic capabilities associated

with acceptance in the individual self, which

increases flexibility in responding to difficult

situations in life. Acceptance and commitment

therapy also encourages individuals to behave and

act in accordance with their life values so that

quality of life can improve. Acceptance and

commitment therapy supports acceptance of loss

experiences and other pressing experiences at the

end of life. Through acceptance and commitment

therapy the subject also shows a decreased risk of

negative thoughts and bad mood changes due to

ineffective coping strategies (e.g. experiential

avoidance).

Roberts and Sedley (2015) provide a

classification of the causes of acceptance and

commitment therapy being effective in overcoming

depression in the elderly, first because of the

transdiagnostic nature of acceptance and

commitment therapy that focuses more on how

individuals respond differently to problems. It does

not only "fix" the problem or change the mind,

which is difficult for the elderly to do due to the

decline in ability in general. Secondly, acceptance

and commitment therapy supports the achievement

of positive aging through validation of individual

experiences and reactions by accepting the event of

loss where the individual cannot avoid and change

the event. Third, acceptance and commitment

therapy encourages elderly individuals to engage in

meaningful activities that match the value of life at

the end of their lifetime.

The results of this study show that the three

participants in the experimental group have the same

characteristics in dealing with and solving the

problem. Participants in the experimental group had

ineffective coping strategies such as thought

suppression and avoidance coping. Thought

suppression and avoidance coping have been

associated with increased levels of depression,

anxiety and suicidal risk in the elderly as it inhibits

self-functioning (Rosenthal et al., 2005). The

approach of acceptance and commitment therapy

explains that psychopathological conditions that

occur in a person occur because of psychological

inflexibility characterized by the presence of

experiential avoidance in both cognition and

behavior (Hayes et al., 2002). Acceptance and

commitment therapy is effective when applied to

these characteristics because the therapy promotes

acceptance as one of the better coping alternatives

and connects individuals with their values so that

every event becomes meaningful (Petkus &

Wetherell, 2013).

The results of this study also showed that there

were two subjects in the experimental group who

had a higher depression score on the GDS-15 scale.

This is because both subjects have a higher

enthusiasm and commitment to follow a series of

therapeutic processes. The success of the acceptance

and commitment therapy process depends on how

the subject has a willingness to apply the basic

principles of therapy and increases their acceptance

of an unpleasant experience based on acceptance and

commitment therapy guidelines. During the course

of the intervention, the two subjects were

enthusiastic and focused on implementing activities

and assignments taught in each session. This finding

is consistent with the results of the research

conducted by Ruiz (2010) who found that the

Effectiveness of Acceptance and Commitment Therapy to Reducing Depression in Nursing Home Residents

177

commitment of subjects in the implementation of

acceptance and commitment therapy in accordance

with the protocol and the basic principles of therapy

greatly influenced the success of the intervention.

Commitment had an influence especially related to

its commitment to behave according to its value and

process of cognitive de-fusion so as to escape from

the negative self-concept possessed.

The results of the data analysis show that there is

one subject with lower depression level. The subject

had a worse health condition when compared to the

other two subjects of the experimental group.

Fractures in the femur experienced by one

participant mean she has more limited mobility.

Health condition is one factor that helped determine

the success of the intervention process of acceptance

and commitment therapy in the elderly. These

findings are described by Karlin et al. (2013) who

states that the success of the intervention process of

acceptance and commitment therapy in the elderly is

influenced by comorbidity of physical and mental

health conditions, ongoing health care and disability.

Based on observations and interviews conducted

during the implementation of the intervention, the

third session, the acceptance session is the most

significant session to bring changes to the subject.

This is explained by Hayes (2005) who argued that

the acceptance of the experience of suppressing and

accepting the conscious change helps one to adapt to

the experiences of suppressing and changing.

Acceptance expressed by the subject of the research

is evidenced by the emergence of ideas expressed by

the subject. Although still an idea, but with strong

support and motivation from the research subject,

acceptance can be manifested in a variety of

behaviors.

5 CONCLUSION

Based on the results of data analysis and discussion

described in the previous chapter, the conclusion

that can be obtained from this research is that the

intervention of acceptance and commitment therapy

is proven effective in reducing depression in nursing

home residents who have ineffective coping

strategy, that is avoidance coping and thought

suppression. The effectiveness of acceptance and

commitment therapy in this study was proven by the

decrease of depression category score based on the

comparison of pretest and posttest scores in the

experimental group, the group receiving the

intervention of acceptance and commitment therapy.

Recommendations for further research are based

on the limitations of this study. There is a need to

conduct a more accurate assessment to make the

diagnosis of depression in research subjects. And

there is a need to control the causes of depression in

research subjects so that it can be seen if acceptance

and commitment therapy is more effective when

applied to specific causes of depression. This study

has a limited number of subjects due to the

limitations of existing research subjects, although

this study may be a consideration to see the

effectiveness of acceptance and commitment therapy

to reduce depression in nursing home residents.

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