Feasibility Trial of an Acceptance and Commitment Therapy Intervention for Individuals Experiencing Homelessness
Condition: Shame; Stigma, Social; Well-Being
Study type: Interventional

Summary: 
      The current project's overall aim is to develop and evaluate the feasibility and preliminary
      efficacy of an ACT intervention to promote psychological well-being and mitigate the
      deleterious effects of shame and self-stigma in people experiencing homelessness. This
      project will advance current knowledge using systematic and empirical methodology to develop
      and evaluate the benefits of a group-based ACT intervention, which to date has not been
      explored with this population.
    

Detailed description: 
      On average homeless persons have higher rates of childhood and adult adversity, challenging
      behaviour, substance and alcohol misuse, poor educational, occupational achievement,
      co-morbid physical and mental illness. In mental health, services delivered on the basis of
      address can struggle to mount a satisfactory response to the needs of homeless persons. Many
      homeless persons rely on emergency department visits or inpatient hospitalizations for health
      care. When admitted to hospital, they have longer stays with higher costs. With the rates of
      homelessness increasing in both national and international contexts coupled with the several
      barriers to accessing mainstream health services, the development of brief, cost-effective
      interventions, that address comorbidity of various mental illnesses and substance abuse is
      necessary.

      In addition, individuals who have experienced homelessness can have their growth and
      development curtailed by applying a punitive, shame based, and defeatist perspectives to
      their own goals and values in life. Direct acts or discrimination, as well as diminished
      opportunities offered to people experiencing homelessness, can be understood as a
      manifestation of public stigma. Labelling someone as "homeless" or an "addict" tends to
      activate common stereotypes such as thinking that the person is likely to be unreliable,
      deceitful, or weak, among other stereotypes. This often leads to some sort of social sanction
      or devaluation, reducing the probability of the person being hired, or being trusted as a
      parent, friend, or lover.

      People who identify with a stigmatised group often internalise the stereotypes associated
      with that group. In addition, the effects of enacted stigma, the emotional and cognitive
      barriers erected by the individual experiencing homelessness in response to perceived or
      experienced stigma, can also serve to obstruct access to opportunities. The person may
      self-identify as a loser, being damaged goods, or always hurting others. Attachment to these
      self-conceptions entails giving up on important and valued life directions. These are
      manifestations of self-stigma. Studies of individuals with serious mental illness and
      co-occurring disorders have shown that self-stigma is associated with delays in treatment
      seeking or avoidance of treatment, diminished self-esteem/self-efficacy, increased mental
      health symptoms, and lower quality of life. Therefore, it is imperative that interventions
      actively address and aim to mitigate the deleterious effects of shame and self-stigma.

      Assertive Community Treatment and case-management interventions have been proven moderately
      effective in improving mental and physical health outcomes for homeless populations, however,
      the resources and expertise required to run such interventions are; unavailable to most
      sectors and communities, time consuming and normally used on an individual case basis,
      leaving large portions of this population untreated. Research into brief psychological
      interventions with the homeless population has revealed promising effects, however, these
      interventions often target specific sub-populations, chose to focus on one aspect of recovery
      such as substance abuse and do not address comorbidity of illness.

      The Acceptance and Commitment Therapy(ACT) model is compatible with conceptualisations of
      recovery from severe mental illness (defined as "living a satisfying, hopeful and
      contributing life even with limitations caused by the illness"; and "having a sense of
      purpose and direction"). From an ACT perspective 'addictive-', 'depressive-', 'anxiety'- and
      "stress-' behaviours might share the same function; and those with high levels of
      comorbidity, such as the homeless population might therefore be treated using an ACT.

      The focus on specific cognitive behavioural processes of mindfulness, acceptance, distancing,
      and values-based action makes ACT interventions typically brief and have been proven to be
      effective after a single session and mediation studies suggest that the positive clinical
      effects of ACT are achieved by changing these targeted psychological processes.

      A two-arm feasibility pilot randomised control trial will be conducted to investigate
      differences in the proposed outcome variables between participants assigned to a group-based
      ACT intervention and those assigned to peer support group. A process level investigation will
      also be used to investigate the feasibility of conducting a full scale RCT with the
      population.
    

Intervention name(s): Acceptance and Commitment Therapy Group Treatment; Peer Support Group
Intervention type(s): Behavioral; Behavioral
Intervention description(s): The intervention presents, a mixture of instruction, discussion, and the use of metaphor and experiential activities designed to sensitise participants to the effects of self-stigma and shame on how they live their lives. This training condition provides instruction and experiences that train participants to notice, and then to override, the very human tendency to categorise and then avoid aversive thoughts and feelings and the people and situations that evoke them. The acceptance and commitment training condition will cover the following topics: (a) introduction to enacted and self-stigma (b) cognitive defusion/behavioural flexibility (c) acceptance vs. avoidance and control of emotions and thoughts and (d) values and committed action.; The peer support group will allow participants to share and discuss experiences related to their experiences of homelessness, shame and stigma. The group will be facilitated by an expert in facilitating peer support groups with marginalised populations.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Care Provider)
Primary purpose: Treatment
Keywords: Shame; Self-Stigma; Homelessness; Well-being