How To Develop An Effective 1-Day Workshop And Improve Mental Wellbeing For People With Pain, Anxiety, Depression And PTSD Using Acceptance And Commitment Therapy With Lilian Dindo, PhD

Welcome back to the Healing Pain Podcast with Lilian Dindo, PhD

We have another incredible interview in our Radical Relief series, which has been running all through the month of January and February. The Radical Relief series focuses on practitioners, academics and researchers who are using three times tested and evidence-based approaches for the treatment of both physical and mental wellbeing with the focus on chronic pain. Recovering pain neuroscience education, mindfulness, acceptance and commitment therapy. In this episode, we’re zeroing in on acceptance and commitment therapy for the treatment of mental wellbeing.

You’ll meet ACT Psychologist, Dr. Lilian Dindo. Her career has been focused on developing pragmatic and innovative ways to improve the mental health and functioning of patients suffering from psychiatric and chronic medical conditions. Through her research and development of applying a one-day transdiagnostic acceptance and commitment training presented as a workshop, she has found this to be less stigmatizing than traditional therapy. Also, ensures treatment adherence and completion for people suffering from both physical as well as mental health issues.

Dr. Dindo has been involved in several clinical trials, examining the efficacy of one day ACT treatment workshops, which have included those who are suffering from chronic pain, traumatic brain injury, orthopedic surgery, migraines, depression and anxiety, as well as a post-traumatic stress disorder. You’ll learn how to conduct a one day ACT workshop, the acceptability of this type of approach, as well as the positive outcomes and why this approach may be soon competing for the evidence-based gold standard treatment for the effective treatment of mental health due to its amazing completion rate.

If you are a mental health professional or a physical medicine professional and you’re interested in learning more about acceptance and commitment therapy and how you can create your own workshop, make sure to check out my book, Radical Relief: A Guide to Overcome Chronic Pain, which is deeply rooted in the principles of acceptance and commitment therapy. One of the key reasons I wrote Radical Relief is so that you, the clinician, or the practitioner would have a manual for employing this type of work in your clinical practice or for delivering it in workshop or community settings as Dr. Lilian Dindo did. You can pick up your copy of Radical Relief available now on Amazon and in most countries. Without further ado, let’s begin, and let’s meet Lilian and learn all about ACT-based workshops.

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How To Develop An Effective 1-Day Workshop And Improve Mental Wellbeing For People With Pain, Anxiety, Depression And PTSD Using Acceptance And Commitment Therapy With Lilian Dindo, PhD

Lilian, thanks for joining me on the show.

It’s nice to be here.

It’s great to have you back on. For those who’ve been following along, Lilian was on in 2019. Coincidentally, before this episode, I was chatting with a physical therapist who uses ACT and practice. His name is Davide Lanfranco, and he was on the show. After the episode was complete, he and I were chatting and he was talking about some of the up and coming ACT research. He was talking about many of the ACT researchers that are common in the literature and he said, “Whose work do you follow with regard to ACT?” I said, “I follow Lilian Dindo’s research because her work is groundbreaking as far as taking evidence-based mental health approaches and moving them into the community where people need them,” which is what we’re going to be talking about.

Most importantly, we’re going to be talking about a paper that was published in September of 2020 in the Journal of Behavioral Medicine and it’s called Combination outreach and wellness intervention for distressed rural veterans: results of a multimethod pilot study. You’re the lead researcher and we’re going to talk all about that, but let’s start here. That pilot study is for veterans specifically veterans with mental health conditions and mental health challenges. Tell us the mental health challenges that veterans have faced since the post 9/11 service era.

The post 9/11 era that has been deployed to Iraq and Afghanistan have high rates of distress based conditions, PTSD, depression and generalized anxiety. Sometimes you get confused when you’re talking to them because it seems like it might be a social phobia. It seems like it might be agoraphobia, but it’s often related to PTSD. They’ve become hypervigilant to their surroundings and avoidant of being out in the community. There’s a lot of PTSD. The rates range from 20% to even up to 70% of that population having some post-traumatic stress. Relatedly, other forms of distress like depression and anxiety.

Interestingly, this population has a high rate of other conditions like mild traumatic brain injury and chronic pain. This is often called the polytrauma triad in this literature because it’s common in this group of post 9/11 veterans. The mild TBI symptoms complicate the mental health symptoms. They’re bi-directional and there’s this overall picture of suffering that can be demoralizing and debilitating in this group of patients. They often don’t get good treatment. They don’t understand even what’s happening to them.

It’s important to note that even though they suffer from PTSD acutely, what you’re saying is they’re still suffering from PTSD now and that has been undertreated or in some instances not treated at all.

The particular paper, you’re talking about, when I was doing a study at the VA, we would get qualitative feedback after our ACT intervention from veterans. We would say, “What do you think we should do to reach more veterans?” Veterans like the ACT. They resonate with the model. They resonate with the idea of connecting to values. We replaced the word values with a mission. We say, “You know what it’s like to be committed to a mission and to engage in the mission even when it’s painful, difficult, or scary. Now, you’re back stateside. What’s your new mission?” You know how to do this. You know how to do something that’s hard because it’s consistent with something that’s important to you.

Now, what’s new for you here? What’s your new purpose? How are you going to honor the people you’ve lost along the way by living a full, rich and meaningful life? They resonate with this idea with the concepts in ACT like values translate to the mission. Acceptance works in this population because you can’t undo the memories, Joe. You can’t undo some of the traumatic events. You can’t change those. You can’t undo some of the chronic pain they’re now encountering. To tell them like, “This is it. It’s here to stay. How can you suffer less with it?” It’s a better approach than saying, “Let’s figure out how to change this or get rid of it.” They know that some of it is not to be removed.

When we asked them, “What do you think we should do?” They would say to us, “Get outside of the VA, go find people,” because many of them dislike coming to the VA. It’s a pain and sometimes they don’t trust the VA. It’s impractical. There are many reasons why veterans often don’t want to come to the VA hospital. We kept hearing over and over again, “Please do this out in the community. Please do this somewhere else.” That’s what we did. We started teaming up with community organizations, universities that enroll a lot of veterans, vet centers and churches. I have a veteran that works with me that goes to trailer parks. He goes to bars. We go out into the community and try to identify veterans. We do the workshop in a more benign setting. We’ve done them in universities, vet centers and community organizations. It’s more non-threatening that way.

There are many great things that you mentioned there and I want to touch base on some of those topics. The first one, which you brought into the conversation. As I was reading through your paper, it’s an academic paper. It’s a research paper. There is that one line in there that you had that question once they completed that workshop, the question was, “What is your mission now?” That got me. When I read that, I was like, “This is such a values-based contextual ACT question.” I love that you put that in the study because all of a sudden, even though I don’t necessarily know what your intervention consisted of, right there I was like, “This is contextualize for the population that you’re working with, which is important.”

HPP 214 | Acceptance And Commitment Therapy
ACT works with the veteran community because they recognize that you can’t undo some memories, trauma and chronic pain.


As you mentioned, there are barriers for anyone entering into the mental health system. A lot of it revolves around stigma, which is unfortunate, and work like this helps to break that down because everyone can benefit from some type of mental skills training, whether you’ve had trauma or not. I want you to talk about this. The importance of taking it out of the hospital medical center clinic and you partnered with not-for-profit organizations that work with veterans and delivered it there. How important was that for the work?

It was critical for the work. When we started out, we would reach out to different leaders in the community organizations. I’ll give you one example which is the vet center in Beaumont. The head of that center in Beaumont is a guy by the name of Dr. Harris. He was distrustful of us and didn’t know what he thought of us. He had a lot of veterans that would to the vet center either for basics, like maybe for food stamps, for help getting jobs or for other purposes. They also do lead basic educational workshops over there.

I gave him a little presentation about what ACT is and I asked him to give me a shot like, “Let me run one workshop with one group of his veterans.” He led us and that was it. The veterans loved it and they went and told him, “This is great. You should absolutely do it with other veterans.” He became our biggest recruiter. Anyone who came through the door for him, he would say, “You need to do this workshop.” Related to that, we don’t call it a mental health treatment. It takes away the edge of the stigma of saying, “Please go to this therapy for your PTSD.”

The word workshop is the pivotal moment in almost all of this.

Never do we say, “We’re going to do a treatment or a therapy.” What we say is, “We are going to do a life skills workshop, that’s it. We’re going to try to teach you about some of the experiences that veterans encounter and how to better cope with them with the hopes that this would enrich your life.” I don’t think we ever even talk about depression as a disease or post-traumatic stress disorder as a disorder. We remove the stigma from coming to the workshop. You’re coming to a class, you’re going to a retreat, a class and you’re with other veterans.

In fact, as the workshop leader to one of the things that can be helpful is to be human yourself. Who has not had anxiety? Who has not been down? Who has not to use short short-term relief strategies that haven’t worked and have hindered life progress? We start the workshop by talking about what matters most to all of us in the room. We’re setting the stage, not talking about, “I have depression, PTSD, and chronic pain, but what’s important to me is my children and being the best possible mom and colleague I can be.” What are the things we can do to move us in that direction?

My problem is, I’m not the kind of person I used to be. Where do I want to go from now forward?

We can talk a lot about, I care about my children, my wife and my partner, but talk is cheap. The child, the partner, your friends, your colleagues and your fellow veterans are not going to feel that you care unless you put that into action.

You mentioned you sit down with maybe the program director and you give them a little presentation about ACT. They learn about the ACT. Two things I’m curious about is if you didn’t have an opportunity to give a presentation, if some of you got a phone call and said, “I work in the VA center in New York City, and I heard you do these ACT-based workshops.” Can you tell me what ACT is in a couple of sentences? I’m curious to know how you describe ACT to other professionals or potentially if someone is seeking that type of service, and then two, do you ever mention ACT in the workshop at all?

That’s one of the things, to be honest with you, the vet center, the director, the people at the universities have asked us to create small videos to describe ACT. We’re working on that as we speak and also to create little informational brochures, infographics, they call them. We’re in the process of creating 1 to 2-minute informational videos. One set of videos for the community partners and then one set of videos for the veterans. That is something we are working on because that’s something they specifically asked us for. I have a hard time describing it in two sentences.

That’s why I prefer to give a presentation where I walked through the processes and the philosophy of ACT. Briefly, I tell them that it’s not disease-focused and disorder-focused, it’s strength-focused. We’re trying to build on their strengths and to help them develop resilience. The term psychological flexibility is too jargony for the community, but resilience is a term people get and in a way, psychological flexibility is resilience. I will say things like, we help people develop greater resilience by connecting to the life that would honor the things that they’ve been through.

HPP 214 | Acceptance And Commitment Therapy
ACT is not disease-focused by strength-focused. It builds on people’s strengths to help them develop resilience.


How do you live a life that honors the people you’ve lost along the way? What do you think you would tell or what do you think a fallen soldier would want? How do you think they would want you to live your life now? Do you think they would want you to withdraw? What would it look like to turn a page so that you’re not rereading the same chapter of your book and that you’re now opening up a new book? We give you the skills to do that.

We help you recognize what are some of the challenges and what are some of the behaviors that feel good at the moment, but lead to long-term negative impacts? I don’t think I’ve gotten good at describing it briefly. They get the values piece, they get the acceptance piece and I say like, “Our brain doesn’t work by subtraction.” I don’t ask my veterans to try to change their memories or change their experiences. I try to help them build on those experiences.

A lot of that resonates well because instead of describing, “What I’m going to do to you?” You’re describing the benefits, strength, resiliency, more life, a fuller life, a richer life, your activities and your goals. Those benefits are important for us as professionals to discuss with people versus, “Here, you’re going to come in twice a week. Each session, you’ll be here for about 50 minutes. We’re going to talk about your thoughts.” We now know that it doesn’t land well with people. People like, “I’m here because I’m struggling and my life is difficult and I want your help creating a new life for me. That’s what I want.”

What’s fascinating, when we do qualitative interviews, the weirdest thing how many veterans have said to me, “I’m not trying to comfort them.” Do you know how many have said, “You rip off the Band-Aid to me?” There’s something that’s honest about that. We’re not trying to minimize or decrease the amount of past suffering. We’re saying, “This is it, rip it off, move forward.” It’s here to stay. It’s interesting that they’ve used that term. I would have never thought about it that way, but many people have said exactly that like, “You rip off the Band-Aid. You’re not scared to tell us what it is.”

That’s a great metaphor though, for so much of the work that we deal with people because it is, it’s like, “Are you willing to be with a moment or two of pain if this is going to move you a couple of miles forward in your life.” People even in practice can use that metaphor. Give us an idea of what this workshop looks like. How many people? Who’s facilitating it? How long is it? Are there milk and cookies? What happens during the workshop?

Pre-COVID or post-COVID?

Talk to me about pre-COVID first.

Pre-COVID, workshops ideally are about 6 to 8 people. We’ve done more than that and I don’t think it’s as good. We’ve done less than that and I also don’t think it’s as good. There’s something good about that 6 to 8 number. Depending on the population, we usually start at about 9:00 AM and we ended about 3:00 PM. We buy lunch for everyone and we have lunch all together as a group. We take little breaks throughout. The way it starts is that we go around the room and we say, “Tell me your name. What branch of the military were you in? Have you been deployed? Where have you deployed and one thing that’s important to you?” We have a whiteboard.

We go around the room, each person just says one thing that’s important to them and we write it on the board. If someone says, for example, my son, then I might say, “Who else here has children or children important to anyone else?” As you said, Joe, the introduction is around values. It’s not about I have PTSD. I have depression and TBI. It’s, what’s important to me. We’re setting the stage for values being front and center. By the end of that, we have a list of value domains on the board, which stays up on the board the whole day.

We’ve done 100 of these workshops over the last several years and the list of domains is the same. We as humans share common values, friends, family, a meaningful career children, the environment, God and spirituality. It’s the same list and then we say, “This workshop now is about how do we make these things that you just said important in our moment-to-moment daily lives.” We do the matrix. We talk about, “What are internal experiences?” The word we’re using for that in the veteran population is invisible wounds. There’s this term in the military culture called Invisible Wounds of War.

We talk about them with veterans as the things that are painful that no one can see like the memories, the pain and the moral injury. That’s an important term in this veteran population. That’s the way we distinguish the inside world. Look around the room, you can see the veteran has black hair, brown eyes and they’re wearing a black shirt. That’s the outside world, but you have no idea what this person has been through, their history, or their background. You don’t know unless you ask them. That’s the way we start to distinguish between the inside world and the outside world.

HPP 214 | Acceptance And Commitment Therapy
Everyone can connect with the idea of “There’s something I want to move toward, but my mind won’t shut up.”


This is important I’ve learned in the veteran population and in PTSD because they have many re-experiencing moments. Many difficulties have to do with them driving down the road, they hear a loud noise and in a moment, they’re back in Iraq where an IED went off. We helped to say, “If something like that happens, are you in the outside world or are you in the inside world?” You’re here right now. That’s a memory that was from the inside world. They can start getting better at noticing the distinction between the inside and the outside world and how important that distinction is and how many interpretations are automatic.

How many interpretations are based on their, history and their experience of the war rather than the current moment? We then go onto the horizontal line and we talk about, “We’d all love to be living a value-driven life. We’d all love to be the perfect mom, dad, sister, brother or partner but there are things that get in the way. What are those things that get in the way? Anxiety, fatigue, my TBI and my PTSD.” After we built this basic matrix, then we do experiential exercises. Those are without a doubt, the most powerful to the point where you have sometimes several people in the room tearing up.

I’m curious, are you facilitating this on your own or do you have a colleague that’s facilitating with you?

The best way to do this is to have two people. Usually, I do it with another person and I find that to be most effective because if I’m doing an exercise, then my co-facilitator can pay attention to what’s happening in the room. If someone’s not connecting or feeling off, we can help clarify things if we feel like one person wasn’t clear. Usually, there are two.

Tell us about it an experience or a small little case from that workshop.

I’ll give you one example of an exercise that I feel like every single time we do it is powerful. I asked for one veteran volunteer and I stand right next to him. I asked for permission and I ask if I can put my hand on his shoulder and I’ll say, “Tell me, what was one of the things you identified as something that’s valuable to you?” I’ll give you an example. One veteran said that his daughter was important to him, but that he hadn’t spoken to her in many years. I take out a sticky note and I put, “Daughter” and I put it on the wall. I’ll say, “Tell me what about this is important to you. Tell me a little bit more about your daughter.”

I asked him to describe her to me, to tell me what she means to him, what it would mean to him to be a good father to her and what is one small concrete behavior he would have to do to move forward in that. For example, this one veteran said he would have to call her after many years of not talking to her. I put that on a sticky note and I would say, “Call her,” and I put it back up on the wall and then we would stand on the other side of the room and I would say to him, “Tell me what gets in the way of that.” He’ll say, “Fear that she won’t want to talk to me and anxiety.” Everybody in the room starts helping him out and giving him ideas. I give each person one of the barriers like, “I don’t deserve to talk to her. She will reject me. I’m not good enough. It’s not worth it anyway. It’s never going to change.”

I give each person a barrier. As I have my hand on his shoulder, I’ll say, “Let’s start walking towards calling your daughter. Remind me of why this is important to you,” and he’ll remind me why it’s important to him. As he starts walking, I tell everyone in the group to start yelling out the barriers, “You’re not worth it. She doesn’t want to talk to you. You’re a loser. You’re broken.” As he’s walking, he’s hearing these barriers. I then turned him around and I make him go back, not go towards his daughter and I’ll ask him what that feels like to turn away from what matters and he’ll respond.

I’ll ask him what it was like to hear those sounds and he’ll tell me what that was like. I’ll say, “Let’s try this again.” We start walking again and then the voices are louder. I tell the people in the room to get even louder, more annoying and more obnoxious. I turned him around again and when I turned them around, I tell the others to be quiet because that’s how it works. When you avoid something, you shut down the voices temporarily. I keep doing that several times and then I eventually say to him, “What are you going to have to do to keep going? What are you going to have to do with these voices?” The idea is that they have to be there. They’re never going to shut up. In qualitative interviews, people always remember this exercise and it combines all the processes of ACT. You’re continuing to move forward, committed action towards a value, even in the presence of all these barriers.

There’s a fusion happening there. There’s acceptance. There’s committed action of having to make the phone call or thinking about to make the phone call. Even thinking about making a phone call can be an important first step. I love the way you’re describing this. This is important for mental health professionals who don’t know ACT at all as well as physiotherapists, other health care professionals who are looking to see their practice with a little bit of this. What Lilian described is not your typical, “I’m sitting in a chair across from someone and we’re talking about their physical or emotional pain.” This is an experiential therapy where, “I’m up and active. The patient is up and active.” As you’re describing this group, I’m getting this idea of like, “There’s the tribal support that people feel from it,” which is important, especially with the group you’re working with but I think with everyone.

It’s powerful for everyone because the content might be different, but the idea is the same. Everyone can connect with the idea that there’s something I want to move toward, but my mind won’t shut up. My mind won’t stop giving me all the reasons why I shouldn’t do this. After this exercise, there’s this moment where everyone’s like, “Great job. You can do this.” It’s interesting because as I’m touching this person on the shoulder, I can feel the pain. You feel it experientially at the moment. You’re contacting how hard this is.

HPP 214 | Acceptance And Commitment Therapy
ACT is CBT. They both have a strong behavioral component and a strong cognitive approach. What sets ACT apart is the inclusion of values.


Even the fact that you’re a mental health professional, you don’t have to massage someone or mobilize an entire joint. Just placing your hand on a shoulder or on their lower back or wherever safe, wherever is okay for them, that makes them feel supported as they’re going through this in essence, and exposure to something that’s uncomfortable is super important. Throughout the research, you measure things, quantitatively things like depression, anxiety and distress. Everyone can read about those. Positive outcomes at 1 month and 3 months, which is important. You follow them for about three months and then qualitatively, you’ve already read some of those qualitative descriptions that people described. I want to point out to people. One of the most important parts of this study was the acceptability for patients that patients, people found this therapy, this approach, this workshop to be acceptable with four themes.

The first theme is that the workshop met or exceeded the participant’s expectations. The second is veterans perceive the workshop environment as welcoming and interactive. The third is veterans report using skills and knowledge from workshops after in their daily lives. There was carry over and four, most participants would encourage other veterans to attend this workshop. People are saying, “I like this, I enjoyed it. I use it in my life and you should try it too,” which is important.

This was the most interesting thing about this study. The Office of Rural Health funded this for one year. They told us, if we met our recruiting goals, they would fund us for another year and another year. In the first six months, we struggled. We had a hard time recruiting and we did a lot of outreach work. We spent a lot of time connecting with the community. We finally had our first group. After we had our first group, we can’t keep up now because veterans are telling other veterans, community partners are telling other community partners. One day we showed up to run a workshop where we were told there would be six people and there were 23. We had to turn them away because we’re like, “We can’t do this with 23 people.” It’s such an honor to feel like I don’t even need to be recruiting anymore. Other veterans are telling veterans about this. They feel like it’s worth their time.

I want to shift gears slightly and talk about some of the research with regard to ACT and CBT. People may have noted episode 197. I interviewed a brilliant psychologist. Her name is Amanda Williams who does great work. She’s done two Cochrane reviews on psychological therapies for the management of chronic pain specifically. She’s talking about chronic pain. The outcome of her latest Cochrane review was that there’s sufficient evidence across a wide body of evidence that CBT has small to very small beneficial effects in reducing pain, disability, distress, and those living with chronic pain. CBT may be considered the gold standard for the treatment of chronic pain, nothing too much new there. I’m quoting her directly from the study.

She goes on to say, and I quote, “Evidence of trials of ACT are of moderate to low-quality evidence. We’re uncertain about the benefits of these treatments for adults with chronic pain.” As I read this and we’re uncertain about the benefits and then I’m reading research like yours and my brain doesn’t comprehend what she said. I pushed her on this a little bit on the show because it’s important that we discuss this. I don’t want to necessarily get into the minutia of research, stats and things like that because that’s dangerous for us as practitioners. My question ultimately is ACT is a form of CBT. It’s another way to help people with their thoughts, feelings, emotions and behaviors. Is that too harsh of an approach to say we’re uncertain about the benefits of these treatments?

Two things about that. First, I would like to reiterate what you said. ACT is cognitive-behavioral therapy. They both have a strong behavioral component and have a strong cognitive approach. The approach in traditional CBT of challenging thoughts, do you replace negative thoughts with more adaptive thoughts or are you doing more cognitive distancing, which is the ACT approach? I don’t think we know for sure that the traditional CBT approach of changing the thought if you changed it as much as if you’ve cognitively distanced from it. As you said, ACT is cognitive-behavioral therapy.

We stand on the shoulders of some of that research and we’ve built on it in some meaningful ways by adding values. What makes it worthwhile to do the hard work? It has to be connected to values. A lot of behavioral activation like traditional BA protocols, now have added values to them because if you dig into the traditional CBT literature, do you need the C part? It’s unclear. There isn’t much data to support that we need the cognitive challenging piece. If you look at the traditional BA literature, now they’ve added values because they find that heightens the findings. That’s one piece of it.

The other piece about moderate to low quality, that’s an important issue and it’s a complex issue because what’s considered the gold standard and high quality is double-blind, randomized controlled trials. We can’t do double-blind and psychotherapy. You do single-blind randomized controlled trials with clear inclusion and exclusion criteria and all these fidelities. There are clear guidelines about how to do gold standard studies and a lot of the ACT in chronic pain literature. ACT is considered an empirically supported treatment for chronic pain as listed by the American Psychological Association.

If you look at the studies that have led to that outcome, it is not RCTs. It’s a lot of effectiveness trials, which means studies in chronic pain centers, in hospitals and in more traditional clinical settings. I would potentially argue that might be a better test of the model that this clean-cut inclusion, exclusion criteria don’t necessarily generalize to what’s being seen in the clinic. Yes, the ACT studies in chronic pain officially are considered lower quality than these gold standard RCTs at the same time, these are the people and the settings that you see the patients and it works in those settings.

There’s something else from her research that I wanted to bring in and relate to your study specifically. This is the most important part that people should leave this episode with. When we look at traditional cognitive behavioral therapy, specifically for the treatment of things like anxiety, depression, which your specialties in, which is what your study targeted in certain ways. There’s a 25% dropout. When people start CBT for depression, anxiety about 25% drop out. It’s the same as in physical therapy. This is a big concern because we want our patients to finish a nice full course of therapy so we can reassess, yet your study with this workshop and you’ve run this workshop in multiple places, multiple different groups, 97% of the people are completing the entire workshop, which is incredible. I know you’re going to talk about this, but what does that say about gold standards? What we think is the gold standard and what we should be aiming for with regard to a gold standard?

I have a lot of thoughts on that because that was the whole reason why I did a workshop intervention. To say that there’s a 25% dropout rate is quite generous because the modal number of therapy sessions that people go to is one. Most people go to one therapy session and then don’t come back. Number two, the mean number of therapy sessions is four. That was the data that led me to develop the workshop idea. I was like, “Most people go to one. The average number they get obsessions is four.” The attrition rate is outrageous. Most people are not getting a full dose or even close to a full dose of the treatment.

HPP 214 | Acceptance And Commitment Therapy
It’s a dream to make ACT more widespread. It’s basic education, basic life coping.


If I do one day and do six hours, then I’m giving people more than they would usually get if they were going to go to therapy and 97% is for this study. It’s 100% of all my other studies. I have, not until this study had anyone leave the workshop ever. You get the entire treatment protocol. You don’t walk away after one hour and that’s huge. The other thing that was huge about this, sometimes it’s like a foot in the door. Especially with veterans that feel like it’s stigmatizing to seek treatment.

Sometimes the people that came to this workshop, a large portion of them said to us afterwards, that they decided to seek out more intensive treatment after that. It took away the edge of the stigma, but you can’t have a gold standard treatment. Others have argued this too. In my mind, it can’t be a gold standard treatment if it’s only gold and standard clinical trials and not in clinic settings. How can it be a great clinical intervention if no one is doing it?

It looks good on paper but when you put it to play in real life, it doesn’t necessarily look so good.

If it has all these inclusions, exclusion criteria, how well is it going to reflect the population out there? That’s what I also like about this particular study is we had hardly any exclusion criteria. We said, “Are you distressed? Let’s go.” These people had many medical conditions, many other issues going on. Those are the people that need help.

This is why I believe it was the VP of the VA who tweeted your study and some of the results on it.

The Deputy Secretary of the VA created a video of it and tweeted it without even telling us.

It’s a tremendous honor. In the United States of America, the VA’s the closest thing we have to a public health system that is organized in some way. It’s a tremendous honor because it shows that, “You had great results.” The people you’re working with, “This is what we should be paying attention to and we should have more of this, both in the VA and outside the VA.” As we talk about that, I think about that tweet, why is this work important to you? What would you like to see happen with this work that you have created a wonderful foundation for?

The reason why it’s important to me is because I feel like there are many distressed veterans out there, and they go to bootcamp to get ready for a war. They get intense training to go out to war, and then they get no training on how to get back into the community. They’re not taught how to cope with all these symptoms that are naturally going to show up. How could you not have nightmares or flashbacks? How could you not struggle with moral questions about what happened? For me, it feels important to give them a bootcamp in return.

What do you do with these emotions? What do you do with these thoughts that are going to show up? Why do we prepare them so well to go out there, but not to come back? What do they do with their wives, their children, their husbands, their partners? That’s another thing I should tell you, Joe. I’m hearing this much more, the veterans are telling me like, “You should let partners come in. You need to talk to my partner, help my partner understand some of this.” I have veterans tell me that their partners have gotten PTSD just from their behaviors, their anger outbursts and so on. My dream is for this to be more widespread. We do it for people coming back right away, a few weeks, a month. That’s another thing a lot of people said to me like, “You should do this right after people back.” For me, it’s a dream to make this more widespread. It’s basic education, basic life coping.

We’ve been speaking with Dr. Lilian Dindo. She is an ACT-based psychologist who focuses on how to help people improve their mental health. Lilian, it’s been a pleasure speaking with you, let everyone know how they can follow you and your great work.

It was nice to talk to you, Joe. Thank you for having me. You can find more information about me on the Michael E. DeBakey, Houston VA Medical Center website. You can also find more information about me at the Baylor College of Medicine in Houston, Texas website and finally, Health Services Research & Development Center of Excellence also at the Houston VA. You can also contact me via email. I’m happy to respond to emails anytime. I’m good about email and it’s [email protected]. Twitter is @LilianDindo.

At the end of every episode, I ask you to share this information with your friends, family, and colleagues who are interested in helping veterans and others by using evidence-informed acceptance and commitment therapy. I especially asked you to share this episode with anyone who’s a veteran or knows a veteran because that’s where this work is most important. I want to thank Lilian for joining us once again. We’ll be following her work closely and I recommend you do as well. We’ll see you on the next episode.

Important Links:

About Lilian Dindo, PhD

HPP 214 | Acceptance And Commitment TherapyThe focus of Dr. Dindo’s career has been on developing pragmatic and innovative ways to improve the mental health and functioning of patients suffering from psychiatric and chronic medical conditions. A significant obstacle to effective delivery of mental health services is treatment adherence and dropout. Additionally, depression and anxiety are often under-reported and undertreated in medical settings. Applying a 1-day (5-hour) transdiagnostic Acceptance and Commitment Training, presented as a “workshop”, is less stigmatizing than “therapy” and also ensures treatment adherence and completion. Dr. Dindo has been involved in several clinical trials examining the efficacy of a 1-day ACT treatment on the mental health, functioning, and quality of life of Veterans and Civilians with who have chronic medical conditions and are experiencing significant distress. Among the populations studied are: 1) Veterans with pain, mild traumatic brain injury, and distress; 2) Veterans undergoing orthopedic surgery and are at-risk for developing chronic pain; 3) patients (Veteran and non-Veteran) with migraine pain and depression; and 4) Veterans with inflammatory bowel disease and significant distress. In addition to developing 1-day interventions, she also examines the use of electronic technology to assess various psychiatric measures and to deliver treatments.

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