The Effects of Acceptance and Commitment Therapy (ACT) on Self-Compassion, COVID-19 Related Stress, and Psychological Distress Post-Pandemic among Adults with Depression in Indonesia

Introduction: The magnitude of the COVID-19 pandemic can function as an indicator
of the possible adverse consequences of newly emerging infectious diseases. There is no instrument used to measure COVID-19 related stress among the general population stress in Indonesia. Otherwise, there is a lack of studies examining self-compassion, COVID-19-related stress, and psychological distress including depressive symptoms, anxiety, and psychological flexibility, among adults with depression.
Objectives: The purpose of this study was to explore the psychometric analysis of the COVID-19 stress scale (CSS)-Indonesian version. The study also tries to investigate the effects of Acceptance and Commitment Therapy (ACT) on self-compassion, COVID-19 related stress, and psychological distress before and after intervention between intervention and control groups among adults with depression in Indonesia.
Methods: The study was divided into two phases. The phase one was a psychometric analysis of the COVID-19 stress scale (CSS). A total of 466 participants were included in the study. Confirmatory factor analyses (CFA) were used to assess the model fit of the CSS. Internal consistency and test-retest were used to assess reliability. The second phase was a randomized controlled trial (RCT) study. A total of 70 adults with depression were randomized into intervention (35 participants) and control (35 participants) groups. This is a double-blind study. The intervention group received ACT during 3 weeks, and the control group received therapy as usual (TAU). The outcomes of this study were self-compassion, COVID-19 related stress, and psychological distress including depressive symptoms, anxiety, and psychological flexibility. The outcomes were compared between groups using a generalized estimating equation (GEE).
Results: The first phase of the study found that the model fit criteria of CSS were found: X2/df=2.51, SRMR=0.07, RMSEA=0.06, GFI=0.85, AGFI=0.82, NFI=0.91, IFI=0.95, TLI=0.94, CFI=0.95. The internal consistency of the CSS yielded satisfactory outcomes across all subscales and the total scale, with alpha values ranging from 0.91 to 0.96 for each sub-scale, and 0.96 for the total scale. Test-retest reliability shows that the ICC value ranges from 0.88 (95% CI = 0.81 – 0.93) to 0.97 (95% CI = 0.95 – 0.98) for each sub-scale and 0.97 (95% CI = 0.96 – 0.98) to 0.98 (95% CI = 0.96 – 0.98) for total CSS. The randomized controlled trial study found, compared to the control group, there was a significant difference of -10.06 (95% CI=-16.56, -3.56; p=0.002) in the self-compassion score of the ACT group. Nevertheless, the self-compassion of the ACT group significantly increased by 5.44 (95% CI=1.46, 9.41; p=0.007), 7.05 (95% CI=2.00, 12.09; p=0.006), and 8.70 (95% CI=3.27, 14.16; p=0.002) one, two, and three weeks after intervention respectively. Additionally, compared to the control group, the COVID-19 related stress of the ACT group significantly decreased by -15.54 (95% CI=-26.96, -4.13; p=0.008) at three weeks after intervention. The changes of psychological were measured including depressive symptoms, anxiety, and psychological flexibility. Compared to the control group, there was a significant difference of 3.51 (95% CI=0.21, 6.82; p=0.037) in the depressive symptoms score of the ACT group. Otherwise, depressive symptoms significantly decreased by -3.07 (95% CI=-5.37, -0.76; p=0.009), and -4.32 (95% CI=-6.94, -1.70; p=0.001) at two and three weeks after ACT intervention respectively. Compared to the control group, there was a significant difference of 5.34 (95% CI=0.01, 10.67; p=0.049) in the anxiety score of the ACT group. However, compared to the control group, the anxiety of the ACT group significantly decreased by -5.03 (95% CI=-9.13, -0.92; p=0.016) three weeks after intervention. Compared to the control group, the AAQ-II scores of the ACT group significantly decreased by -5.33 (95% CI=-9.53, -1.14; p=0.013) three weeks after the intervention, indicating better psychological flexibility after three weeks of ACT intervention. No significant difference in unadjusted and adjusted analysis.
Conclusion: This study was conducted with 2 different phases. In the first phase, this study performed the CSS as a valid and reliable to assess COVID-19 related stress. As a result, obtained from the present study could serve as a reference for an instrument utilized in Indonesia to measure COVID-19 related stress. In the second phase, the ACT intervention has been found to significantly enhance self-compassion both after one to three weeks following the session. ACT can also mitigate COVID-19 related stress, improve psychological inflexibility, and decrease anxiety within three weeks after intervention. In addition, ACT was effective in substantially reducing depressed symptoms within two and three weeks after intervention.
Keywords: self-compassion, COVID-19 related stress, psychological distress, acceptance, and commitment therapy, randomized controlled trial