In South Korea, 273,076 new cancer cases are anticipated to occur in 2023 [1]. Furthermore, cancer (i.e., malignant neoplasms) constituted the top cause of death in South Korea, accounting for 26.0% of the total deaths [2]. According to the National Hospice and Palliative Care (NHPC) registry in South Korea, 15,234 terminally ill cancer patients were enrolled in the NHPC system in 2020 and received inpatient hospice care [3].

The primary goal of hospice and palliative care is to improve the quality of life for people facing a serious or life-limiting illness and their family members [4]. Since many patients near the end of life encounter a broad range of physical, psychosocial, and spiritual challenges [5], psychological interventions can be beneficial. These interventions can assist them in effectively managing these issues and in improving their quality of life [6].

Acceptance and commitment therapy (ACT), a mindfulness-based type of cognitive behavioral therapy, has been introduced and applied as an effective therapeutic approach for patients with a range of conditions, including those in hospice and palliative care [7,8]. However, there is a scarcity of empirical evidence regarding the application of ACT interventions in hospice and palliative care environments in South Korea. This brief communication aims to provide a concise overview of ACT, empirical evidence of the application of ACT in hospice and palliative care settings, and the potential future trajectory of ACT interventions in South Korea.

ACT has emerged as a component of the third wave or generation of cognitive behavioral therapy, and it is theoretically grounded in the pragmatic approaches of functional contextualism [9] and relational frame theory [10]. ACT is a psychological intervention designed to enhance psychological flexibility, which allows individuals to fully engage with the present moment as conscious beings, and to modify or maintain their behaviors in service of valued goals [11]. Psychological flexibility can be cultivated through the six core processes of ACT: acceptance, cognitive defusion, being present, self-as-context, values, and committed action [12].

Acceptance, as an alternative to experiential avoidance, involves actively and willingly embracing personal experiences in the present moment, without attempting to alter their frequency or form [13]. Cognitive defusion, meanwhile, is the process of distancing oneself from negative thoughts and emotions, observing them dispassionately rather than trying to suppress or eliminate them [14]. An example of a defusion technique is the “cancer, cancer, cancer” exercise. In this exercise, a therapist instructs a client to visualize a gallon of milk for a few moments, then repeat the word “cancer” aloud for about a minute, and finally observe and note what happens. The experiential takeaway is that the word seems to lose its meaning and becomes merely a sound. This exercise assists clients in recognizing thoughts as just thoughts, reducing their attachment to the thoughts’ meanings [15]. ACT encourages awareness of the present moment, which is tied to the development of a sense of self. Being present allows individuals to experience the world more directly and responsively. ACT also aids individuals in connecting with and developing a sense of self-as-context, as observers or experiencers, through metaphors and experiential mindfulness exercises [14]. A popular metaphor used to help clients connect with their sense of self is the chessboard metaphor. In this metaphor, the self is compared to a chessboard, while the chess pieces represent the clients’ thoughts, feelings, or sensations. After establishing this metaphor, a therapist can point out that the pieces, although threatening to each other, pose no threat to the board (self-as-context) [15]. Mindfulness exercises can also be employed to achieve cognitive defusion and present-moment awareness in ACT. For instance, a therapist might ask a client to imagine clouds floating by in the sky, assign each thought to a cloud, and then let it gently float away [13]. Values, in ACT, are qualities of purposeful action that can be demonstrated through behaviors but cannot be owned as an object. ACT uses various exercises to assist individuals in choosing life directions in different areas such as family, intimate relationships, spirituality, and so forth [13,14]. Lastly, ACT aims to establish broader patterns of effective committed action associated with chosen values. Goals for behavioral changes can be achieved through this committed action [13].

Since the flexibility processes of ACT are closely linked to the therapeutic relationships between therapists and clients, ACT is particularly relevant for health-related behavioral interventions that promote positive growth and empowerment [12]. In fact, ACT has been applied to several physical and psychological disorders, and previous studies have documented the effectiveness of ACT for various health-related outcomes as compared to usual care [7,8].

Hospice and palliative care is centered on alleviating symptoms and enhancing the quality of care for patients grappling with severe illnesses, such as cancer, or those approaching the end of life, along with their families [16]. As their disease advances, many patients in hospice and palliative care encounter a range of physical and psychological issues, including physical pain, distress, loss of dignity, and feelings of hopelessness [17]. These issues can potentially lead to additional problems. Consequently, psychological interventions have been developed and implemented for hospice and palliative care patients to effectively manage their emotional difficulties [18,19]. ACT has been identified as a promising psychological intervention in hospice and palliative care settings [8,20]. ACT encourages patients in hospice and palliative care to accept experiences that are beyond their control, to engage with the present moment rather than living in fear of the future, and to uncover meaning and values in life. Through these processes in ACT, patients can achieve psychological flexibility [14].

1. ACT for hospice and palliative care patients

There is a growing body of evidence that suggests ACT is an effective psychological approach for patients in hospice and palliative care. For instance, a feasibility randomized controlled trial (RCT) of ACT versus a standardized talking control (TC) was conducted by Serfaty and colleagues [21] from 2015 to 2016. The study involved 42 advanced cancer patients from three hospice settings in London, United Kingdom (UK), who were randomly assigned to either the ACT (n=20) or TC (n=22) group. The ACT intervention for adults with advanced cancer (CanACT) consisted of eight weekly sessions, each lasting up to an hour. Six therapists, each with at least two years of experience in ACT, independently conducted the sessions. These sessions took place face-to-face, either in the hospice unit, the therapist’s clinic, or the participant’s home. The CanACT sessions covered a range of topics, including the principles of ACT, psychopathological elements such as experiential avoidance and cognitive fusion, and ACT practice techniques like increasing acceptance and defusion. The study found that the ACT intervention was both feasible and acceptable, with participants expressing satisfaction with the intervention.

Hulbert-Williams and colleagues’ study [22] developed and tested a brief engagement and acceptance coaching for hospice settings (BEACHeS) intervention, specifically designed for individuals diagnosed with incurable cancer. The study, conducted between 2018 and 2019, involved 10 cancer patients aged 16 or older, recruited from three different hospice settings in the UK. Out of these, five patients completed the intervention. The research methodology employed a single-case experimental design, complemented by a mixed-methods approach. The intervention, based on ACT, consisted of five individual, face-to-face sessions, each lasting between 40 and 60 minutes. Two clinical psychologists were responsible for delivering the intervention within the hospice settings. The BEACHeS intervention included an initial assessment, followed by three additional sessions, and concluded with a one-month follow-up. While the single-case experimental design analysis did not yield significant effects, both quantitative and qualitative data indicated that the BEACHeS intervention was acceptable, perceived as effective, and feasible.

2. ACT for caregivers of patients in hospice and palliative care

Previous research has suggested that it is beneficial to provide psychological support for caregivers [23], and ACT can be an effective method for managing the burdens of caregiving, grief, and psychological distress. A study by Mosher and colleagues [24] focused on both advanced cancer patients and their caregivers in the United States, with the aim of assessing the feasibility, acceptability, and efficacy of ACT. The study involved 40 patient-caregiver dyads, who were randomly assigned to either six weekly 50-minute telephone ACT sessions or to receive education/support care. The ACT intervention was administered by a mental health clinician and a psychologist, while oncology social workers provided the education/support. The dyads participated together in sessions 1 and 4~6, and separately in sessions 2 and 3. The ACT sessions covered topics such as mindfulness, adaptive coping skills (for example, perspective taking), clarification of values, and the setting of SMART goals (specific, measurable, achievable, relevant, and time-bound) based on these values. The study found that the ACT intervention was feasible and acceptable for the dyads dealing with advanced cancer, although it was noted that further testing was required.

Davis and colleagues’ study [25,26] serves as another example of ACT for addressing grief and psychological distress in caregivers of hospice and palliative care patients. The researchers conducted a two-arm RCT comparing an ACT self-help intervention with standard psychosocial support. A total of 55 caregivers participated in the study, with 35 completing the ACT intervention and 20 receiving the usual treatment. Those in the ACT group were given a self-help booklet containing psychoeducation and experiential mindfulness exercises. Additionally, they received a phone call from a clinical psychologist 1~2 weeks after receiving the booklet. The self-help booklet covered various topics, including assessing the current situation and identifying areas they wished to control, embracing feelings, acknowledging thoughts, living in the present, exploring personal values, and setting goals. The study’s findings suggested that the ACT intervention was both feasible and acceptable to caregivers. It also showed a slight effect on acceptance, valued living, grief, and psychological distress.

3. ACT for health professionals in hospice and palliative care

Although empirical evidence on psychological support for healthcare workers is lacking, a few studies have been conducted on ACT interventions for health professionals, including those in palliative care. Waters and colleagues [27] developed a one-day ACT workshop specifically for healthcare workers experiencing clinical distress. The study employed a quasi-controlled design, with 35 participants divided between an ACT intervention group and a waiting list control group. The workshop, led by an ACT therapist, provided participants with a blend of mindfulness techniques and values-based action skills. The findings of this study suggest that even a brief ACT intervention can effectively improve the mental health of distressed healthcare employees.

As another example, Finucane and colleagues conducted a study [28] to assess the feasibility and acceptability of an 8-week online ACT-based intervention aimed at enhancing the mental health and well-being of palliative care staff. The researchers implemented a single-arm trial, providing a brief ACT-based intervention to 30 staff members who care for terminally ill adults. This ACT intervention incorporated key ACT principles such as values, awareness, openness, and defusion. It consisted of three synchronous virtual classroom sessions and five asynchronous, self-directed e-learning modules. Although the results of this study, completed in 2022, are not yet available, the research serves as a valuable example of an ACT intervention for health professionals in hospice and palliative care settings.

Previous research [8,20] has reported that ACT is a viable and well-received intervention for patients, caregivers, and healthcare professionals in hospice and palliative care settings, despite certain methodological challenges such as a lack of RCTs, small sample sizes, and high attrition rates. It is recommended that ACT interventions in these settings be developed and implemented with carefully considered recruitment strategies and intervention delivery plans. Several suggestions are put forth for future studies. First, it is crucial to employ RCTs or quasi-experimental designs and compare the outcomes of an experimental group with a control group at various stages, such as pre-intervention, post-intervention, and follow-up. Second, researchers should contemplate recruiting both existing and potential patients in hospice and palliative care to increase the sample size. Third, it is essential to choose and utilize a limited number of the most relevant outcome measures. This approach can help lessen the burden on study participants, thereby improving attrition rates. Lastly, it is important to explore various methods of delivering ACT interventions, such as online or offline, individually or in groups, and using short-term or long-term approaches. For example, ACT can be administered briefly or over several weeks, depending on the participants’ needs and physical conditions. However, short-term interventions are generally more efficient and effective than longer ones with regard to the risk of early dropout or death. In light of the above recommendations, we encourage future empirical research based on ACT to develop ACT interventions and conduct ACT trials in hospice and palliative care settings in South Korea.

Supplementary materials can be found via https://doi.org/10.14475/jhpc.2023.26.3.140.

^{No potential conflict of interest was reported by the author.}