Evaluation of a web-based Acceptance and Commitment Therapy (ACT) program to increase self-care and mental health skills in university students

Abstract

The health of university students requires urgent attention. Epidemiological studies of university students worldwide, indicate 19.2 to 50% meet the criteria for one or more mental health disorders (Blanco et al., 2008; Bruffaerts et al., 2018; Hunt & Eisenberg, 2010; Stallman, 2010; Verger, Guagliardo, Gilbert, Rouillon, & Kovess-Masfety, 2010). However, 65% to 85% of these students do not seek help (Eisenberg, Golberstein, & Gollust, 2007; Stallman, 2010). Research from on-campus university counselling and health services indicate a lack of resources to meet student needs, as well as an increase in the complexity and severity of issues that students present (British Association for Counselling and Psychotherapy, 2017; Gallagher, 2014; Stallman, 2012b). Alternatives to traditional face-to-face therapy, such as web-based interventions, are required to help alleviate student distress. Web-based interventions have shown efficacy with university students in treating a wide variety of disorders (Davies, Morriss, & Glazebrook, 2014); however, the interventions are disorder specific, thereby limiting their reach. In addition, disorder specific interventions targeting psychopathology typically neglect teaching positive mental health skills necessary for flourishing (Keyes, 2005; Westerhof & Keyes, 2010). Transdiagnostic approaches target generic risk and protective factors relevant to a wide range of disorders, highlighting applicability for use in a universal intervention for university students. The purpose of the present research was to develop and evaluate a web-based mental health promotion program for university students. The intervention, called YOLO (You Only Live Once), is informed by a transdiagnostic framework, Acceptance and Commitment Therapy (ACT). The research consisted of three studies. Study 1 was the pilot evaluation of the YOLO program with 130 university students in a single arm pre- to post-intervention design. Participants were randomised to one of three intervention groups investigating varied program delivery methods in order to ascertain a suitable design for this cohort. Participants were assessed on primary outcomes of depression, anxiety, stress, well-being, self-compassion, alcohol use, and life satisfaction; and on ACT processes acceptance, cognitive fusion, education values, valued living, and mindfulness. Analyses showed significant improvements on primary outcomes depression, anxiety, stress, well-being, self-compassion, and life satisfaction; and on ACT processes acceptance, cognitive fusion, education values ratio, engaged living, and mindfulness. All ACT processes mediated changes on one or more primary outcomes in the intention-to-treat (ITT) sample. Intervention effects were consistent on most primary outcomes and ACT processes across three sample groupings. Study 2 was the randomised controlled trial (RCT) of the YOLO program with 1,162 university students randomised to intervention (n= 596) or waitlist control (n= 566). Online measures of the primary outcomes (depression, anxiety, stress, well-being, self-compassion, life satisfaction, and academic performance) and ACT processes (acceptance, cognitive fusion, education values, valued living, and mindfulness) were completed at pre- and post-intervention and at 12-week follow-up for intervention participants, and the same pre - post interval for waitlist control participants. Analyses showed significant improvements from pre- to post-intervention compared to waitlist control on primary outcomes depression, anxiety, stress, well-being, self-compassion, life satisfaction, and academic performance, and on all ACT processes. All intervention gains were maintained at follow-up. Improvements on all the primary outcomes were mediated by three or more ACT processes. Intervention completion was influenced by levels of depression, anxiety, self-compassion, academic performance, and education values. Intervention effects were consistent on all primary outcomes and ACT processes across two sample groupings. Study 3 presents quantitative and qualitative data from the RCT of YOLO that were obtained from participants’ completion of intervention experiential exercises. This study provides a valuable insight into the lived experience of university students in relation to the core ACT processes, values and committed action. Exercise content is related to education and personal values. Data for each exercise are presented and their implications discussed. This program of research provides preliminary evidence for the effectiveness of a transdiagnostic web-based ACT mental health promotion program for university students. Both pilot and RCT evaluations of YOLO showed improvements across multiple negative and positive mental health dimensions, including outcomes highly relevant to university students, academic performance and education values. Of theoretical importance, mechanism of change analyses indicated that all of the core ACT processes were associated with improvements in the primary outcomes; supporting the psychological flexibility model in fostering mental health. The present research has important implications for the use of ACT mental health promotion programs with university students. ACT interventions can increase positive mental health skills and decrease psychopathology in students via a universal program with wider reach and student appeal than disorder specific interventions. Programs such as these have the potential to be used by universities as standalone web-based interventions, ameliorating a wide range of mental health problems and skill deficits in students.