A behavioural intervention for young adults with dental caries, using acceptance and commitment therapy (ACT): treatment manual and case illustration | BMC Oral Health | Full Text
The ACT treatment manual for young patients with dental caries is outlined below. The patient receives two individual ACT sessions (45 min each), two to three weeks apart, delivered by a clinical psychologist with competence in CBT and ACT at a general dental clinic. To increase treatment adherence, work sheets are used for the sessions. For a treatment overview, see Table 1.
Table 1 Treatment overview
The psychologist welcomes the patient and asks about his/her expectations and hopes for the session. If the patient seems ambivalent or hesitant, potential underlying values guiding the patient’s choice to participate in the intervention in the first place are investigated. The aim (1) and rationale (2) of the intervention are then presented: 1. “This is a health counselling session, with the aim to explore possible improvements of your oral health.” 2. “I will first ask you some questions about your life situation and then about your oral health, after which we will discuss a plan for you to improve your oral health. How does that sound? We have about 45 minutes today and another session in two weeks.”
The patients are asked questions about their life (in line with the “Love, work, play” section in Strosahl et al. [17]), general health (e.g., medication, tobacco, alcohol and drug use), and oral health (e.g., food and drinking habits, toothbrushing, flossing and use of fluoride). They also get to describe their own oral health and rate how much of an issue it is today (on a scale from one to ten, ten meaning that their oral health is experienced as a great problem).
The patients are asked to notice the current status of their oral health. The psychologist assists the patient with instructions, such as, “If you feel your gum and teeth, how do they feel today?”. The exercise aims to increase the awareness of oral health but can also give an indication of the patient’s openness and engagement in the treatment.
At this stage, behaviour of importance to the patient’s oral health is summarised and the patient is asked if there is any behaviour that he/she is willing to try to change to improve their oral health. Clinically relevant information is then gathered through the focused questions in a “Focused interview” [17], including: “What have you tried?”; “How has it worked?”, and “What has it cost you (or what might be the cost in the future)?”
During the work described above, a behaviour analysis is performed [29] for a deeper understanding of the chosen behaviour to be changed. The psychologist also completes the “Four Square Tool” [17] and rates the patient’s levels of openness, awareness and engagement (on a scale from one to ten, where ten is the highest) to generate a hypothesis about effective ACT interventions for this particular patient.
The patient is encouraged to think about what oral health he/she desires, how it might feel, why it is important and what the patient would be able to do. Patients may wish for whole and white teeth to eat and smile with, and to feel fresh so that they can kiss their loved ones. A modified version of the Bull’s Eye Value Survey [27] is also used, where the patients write down their oral health-related values, and put an “X” on a drawn dartboard to signify how close to, or far away from, their values (at the centre of the dartboard) they are today. They are also asked to write down their obstacles to change (e.g., urge for sweets, the thought “I need something sweet”, sadness) and rate their intensity on a scale from one to ten (where one is low).
The psychologist actively addresses fused material that could be of importance for the patient’s oral health behaviour. The psychologist describes and labels thoughts as thoughts and asks perspective-taking questions.
Plan for behavioural change
The patient specifies by writing a plan for behavioural change (e.g., what to do, when to do it and how to do it) and helpful strategies when faced with obstacles. The psychologist may add suggestions, such as functional strategies that the patient has mentioned or shown in terms of ACT-relevant skills. The patients are also asked to rate how likely it is that they will comply with the behavioural plan on a scale from one to ten. If the patient rates below six and there is time left, the plan is revised, otherwise the work continues in Session 2. The patients also get a copy of the Bull’s Eye to take home.
The patient is asked how the prior session was experienced and to describe how the plan for behavioural change has worked. Additional strategies, solutions and obstacles are noted. Setbacks are separated from relapses, and value-driven actions highlighted as more important than reaching goals. The patient is then asked to rate how much of an issue their oral health is today on a scale from one to ten (as in Session 1).
The patient is asked to perform the same mindful oral health exercise as in Session 1.
The psychologist provides a copy of the patients’ Bull’s Eye Value Survey from Session 1 and a new one. The patient is asked to put a new “X” on the second dartboard, representing how close to their values they are at this point. The patients are asked to reflect on how they feel, if they are satisfied with where the “X” is now or would like to discuss possible actions to reach the Bull’s Eye. The patient writes down what has worked since the last occasion (i.e., what to continue with), possible obstacles in the year to come and helpful strategies to handle them.
In addition to the strategies used in session 1, the exercise found in Harris [28] is used. The patient is asked to write down recurring obstacles to toothbrushing, such as the thought, “I’m too tired,” on a post-it sticker, and experiment with the physical distance to it and its influence on the patient’s possibility to view and reach the Bull’s Eye. Mindfulness and acceptance often complement this exercise.
Plan for behavioural change
In this session, a new written behavioural change plan is formulated. The psychologist helps the patient to formulate realistic and specific plans for change and normalises and helps the patient handle possible setbacks. The patient rates the likelihood of each suggested behavioural change being carried out on a scale from one to ten. If the rating is below six, additional work is considered. The patient gets a copy of the new Bull’s Eye to take home. The psychologist encourages the patient to continue to attend the dental clinic for examinations, health promotion and treatments, and to take an active role in the treatment planning.
This is a hypothetical case illustration, constructed using material from several individuals.
The (fictional) patient Eva (E) is 22 years old and works at a café. According to the focused interview, E lives with her parents during the week and with her boyfriend at weekends. She brushes her teeth every morning, but rarely in the evening. E drinks a can (33 cl) of soft drink on a daily basis, and about one litre on weekends. E is overweight, says she often feels stressed and smokes half a pack of cigarettes every day. E has had a number of restorative dental treatments due to dental caries. During the mindful oral health exercise, E notices her latest two fillings, and the taste of a snack she ate just before the session. She rates her oral health as an issue as a four on a ten-point scale (ten being the maximum). When her oral health-related behaviours are summarised, E says she would like help to drink less soft drink.
During the functional behavioural assessment E describes that she started drinking soda on a daily basis when she got a job at a café. She stopped drinking it for a couple of months when she was out of work, but started again when she got another job at a café with easy access to it. “I usually open a can after an hour at work and sip on it until lunch, and on weekends I share a two-litre bottle with my boyfriend.” When asked the focused questions, E says that she drinks soft drinks because she loves the taste and wants to stay alert. She knows it only works momentarily, because she is often thirsty or tired again after a while. When asked about costs, E says that it is not that expensive. The psychologist rates E as being fairly open, but not in contact with her emotions at this stage of therapy. When asked about other costs of soft drink consumption, E says diabetes. The psychologist notices how E clenches her teeth and looks away. The psychologist asks if E notices what is happening inside her at that moment. E says: “Nothing”, but then “Anxiety”. The psychologist asks where in the body and E points at her chest. The psychologist normalises this and credits E for being in touch with her feelings. E says that she has seen the consequences of diabetes. With a bit of encouragement, she describes those consequences. Afterwards E sighs, and says she really does not want that for herself.
The session naturally shifts focus to values. When E is asked about what oral health she desires instead she first replies: “Whole and white teeth”. When asked why that is important (for more genuine values), E answers that it is a sign of taking care of oneself. And when asked to elaborate, E says that she wants to be healthy. The psychologist asks what E would be able to do then, whereby E answers with emphasis: “Have children!” The psychologist: “It sounds like that is truly important for you?” “Yes, I have always dreamt of having children”. E then summarises her values in writing: “It is important for me to have whole and white teeth, to take care of myself, remain free from illness and be able to have children”. E puts an “X” halfway to/from the centre of the Bull’s Eye dartboard. E writes “stress” and “the urge for soft drink” as her main obstacles to change, and rates them as a seven on a ten-point scale. She writes that she could try to stop drinking soft drink and drink water instead. After considering what else might be helpful, she adds: “Not carrying coins with me, and tell my family about my plan for better teeth”. When asked how likely it is that she won’t drink soft drink the next two weeks she says eight on a ten-point scale.
E immediately says: “I have stopped drinking soft drinks! Can you imagine?” According to E, it was a great challenge the first week, with tiredness and an urge for soft drink, but she had stuck to the plan and the urge wore off. E says that she has thought a lot about her teeth, and that she told her family and boyfriend, who suggested brushing together in the evenings, which has worked well. E says that she has also started to pay off a loan using the money she saves on not drinking soft drink. She seems happy and says she also feels proud. E rates her current oral health as a three as an issue on a ten-point scale, and puts her “X” one step closer to the Bull’s Eye (the middle of the dartboard). When doing the oral mindful exercise, E notices freshness in her mouth after brushing before the session; however, E says that she has thought about another habit detrimental to her health: chocolate drinks. E says she drinks eight glasses per day, and has done so since she was a teenager. Similar factors contribute to these behaviours.
The psychologist introduces the defusion exercise. E writes, “tastes good”, on a post-it sticker. During the exercise, E identifies more obstacles, such as tiredness, stress and the thoughts, “I need chocolate”, “I must have chocolate”. When asked to show how persuasive these thoughts may be, E puts the post-it stickers on her face. When asked how well she sees the Bull’s Eye, she says: “I don’t see it at all!” E laughs and speeds up. The psychologist shares noticing that E laughs, but also asks how she feels inside right now. E pauses and says: “Actually, I feel that anxiety in my chest again”. The psychologist helps E stay with that emotion. E slows down and says: “All this (points at the post-it sticker) feels overwhelming sometimes, but at the same time, I know I can change. I mean I stopped drinking soft drink! I had all these thoughts but I didn’t listen to them.” The psychologist praises E for noticing, and recommends her to write that down. E writes: “I can notice but not act on my thoughts or urges for soft drinks and chocolate”. E specifies a plan for how to keep brushing twice a day, for not drinking soft drink and for giving up chocolate drinks. After information about potential setbacks, E rates the likelihood of her following her plan as a ten out of ten. E still smokes, but seems more willing and committed to seizing opportunities for a healthier life.
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