Group-Based Resilience Program Improves Psychological Outcomes in Multiple Sclerosis

A group-based resilience training program based on Acceptance and Commitment Therapy (ACT) was associated with improvements across several psychological and quality-of-life outcomes in patients with multiple sclerosis (MS), although the intervention did not significantly outperform group relaxation on the study's primary resilience end point.¹

Published in the Multiple Sclerosis Journal, the cluster-randomized multi-READY for MS trial evaluated Resilience and Activities for every DaY (READY), an ACT-based intervention designed to strengthen adaptive psychological processes, in patients with MS with low baseline resilience. The trial included assessments immediately after the intervention and at 3- and 6-month follow-up.

The primary end point was the between-group difference in change in resilience, measured using the Connor-Davidson Resilience Scale 25 (CD-RISC), from baseline to the 3-month follow-up. Secondary outcomes included anxiety and depression, affect, health-related quality of life (HRQoL), well-being, and psychological flexibility.

“Although the primary endpoint—improved resilience at 3-month follow-up—was not met, READY was associated with consistent and sustained improvements, relative to relaxation, across several secondary outcomes, including anxiety and depressive symptoms, affect, HRQoL, well-being, and psychological flexibility,” senior author Alessandra Solari, MD, neurologist and researcher at the Fondazione IRCCS Istituto Neurologico Carlo Besta in Milan, Italy, and colleagues wrote.¹

The authors suggested that the findings may indicate broader and longer-lasting psychological benefits compared with relaxation-based approaches, while cautioning that these outcomes were secondary endpoints.

READY Does Not Meet Primary Resilience Endpoint

The trial enrolled 226 participants across 7 Italian MS centers, with 197 participants included in the analyzed population and 188 completing the study. Participants were randomized to 24 groups, with 12 groups assigned to READY and 12 to a group-based relaxation intervention. The mean participant age was approximately 45 years, 67% were women, and 84.3% had relapsing-remitting MS.

READY consisted of 7 weekly group sessions followed by a booster session at 12 weeks. The intervention incorporated ACT principles, including acceptance, cognitive defusion, mindfulness, self-as-context, values, and committed action, with participants completing experiential exercises, mindfulness practices, and between-session activities. The active control group participated in a similarly structured relaxation program based on autogenic training.

At 3 months, CD-RISC scores increased by 2.53 points in the READY group compared with 0.43 points in the relaxation group. The between-group difference was 2.10 points (95% CI, −1.06 to 5.26; P = .193), failing to demonstrate a statistically significant difference in the primary end point.

Resilience scores continued to increase through 6 months, with a 4.09-point change from baseline in the READY group compared with 1.06 points in the relaxation group. However, the between-group difference remained nonsignificant (P = .129).

Improvements Seen Across Secondary Outcomes

Despite the lack of a significant between-group difference in resilience, READY was associated with greater improvements in several secondary measures. At 3 months, participants in the READY group had significantly greater reductions in anxiety symptoms compared with those in the relaxation group, as measured by the Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A; P = .016). The authors noted that this difference persisted at 6 months (P = .008).

Depressive symptoms also favored READY at 6 months, with the between-group difference on the HADS-Depression subscale reaching statistical significance (P = .039). The intervention was also associated with improvements in psychological flexibility, a central target of ACT. Between-group differences on the Multidimensional Psychological Flexibility Inventory emerged at 3 months (P = .033) and remained significant at 6 months (P = .023).

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Generic HRQoL, measured using the EuroQol 5-Dimension (EQ-5D) utility score, also favored READY at post-intervention, 3 months, and 6 months, with P values of .042, .001, and less than .001, respectively.

Well-being, assessed using the Mental Health Continuum Short Form, showed a significant between-group difference at 6 months (P = .036). The investigators did not observe significant between-group differences in the physical or mental health component scores of the 54-item Multiple Sclerosis Quality of Life measure, or in positive and negative affect measures.

Intervention Was Well Received

Participant satisfaction was high in both treatment groups, although several measures favored READY.

At the post-intervention assessment, READY participants reported greater perceived helpfulness, enjoyment, willingness to recommend the intervention, and perceived benefits for coping with MS and daily life. Some of these differences remained significant at the 3-month assessment. READY participants also reported greater satisfaction with the home activities and program workbook.

Attendance was high in both groups, with a median of 7 sessions in the READY group and 6 in the relaxation group. The difference in attendance was statistically significant (P = .022). Home-activity adherence did not significantly differ between groups.

The investigators also reported high intervention fidelity. All 192 sessions were audio-recorded, and a random sample of 24 READY sessions reviewed by 2 ACT experts demonstrated excellent inter-rater reliability (intraclass correlation coefficient, 0.96; 95% CI, 0.90-0.98).

Interpreting the Findings

The investigators said the findings add to evidence supporting psychological interventions for patients with MS, particularly in the context of anxiety, depression, well-being, HRQoL, and psychological flexibility.

The absence of a significant effect on the primary resilience endpoint does not necessarily indicate that READY failed to affect the psychological processes targeted by the intervention. The authors suggested that psychological flexibility may represent a more proximal outcome of ACT-based treatment, whereas resilience is a broader construct that may take longer to change.

This interpretation is consistent with the observed pattern of results, in which psychological flexibility and several other secondary outcomes demonstrated between-group differences while the CD-RISC did not.

The study's active relaxation control also provides context for interpreting the findings. Both groups improved across several outcomes over time, potentially reflecting nonspecific benefits associated with structured group participation, attention from clinicians, or engagement in a behavioral intervention.

Limitations and Future Research

Several limitations temper interpretation of the findings. Recruitment fell below the original target because of disruptions associated with the COVID-19 pandemic, which the investigators said may have reduced statistical power to identify between-group differences in the primary outcome.

Additionally, psychological outcomes were assessed using patient-reported measures rather than structured clinical assessments. The trial was not primarily powered for its secondary end points, requiring those findings to be interpreted cautiously. Differential attrition between the groups, with greater withdrawal in the relaxation arm before intervention initiation, may also have introduced engagement or expectancy biases.

The investigators suggested that future research should further examine the mechanisms underlying resilience-focused interventions, evaluate strategies for maintaining treatment effects over longer periods, and assess how programs such as READY could be integrated into routine MS and rehabilitation care.

Digital or hybrid delivery models could also potentially expand access to psychosocial interventions for patients with MS, particularly for patients who have limited access to specialized mental health services.

Overall, the multi-READY for MS findings suggest that an ACT-informed group intervention may have broader effects on psychological and quality-of-life outcomes in patients with MS with low resilience, despite failing to demonstrate superiority over relaxation on the primary measure of resilience at 3 months.

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REFERENCES
1. Giovannetti AM, Pakenham KI, Copetti M, et al. A group resilience training program for people with multiple sclerosis: A cluster-randomized controlled trial (multi-READY for MS). Mult Scler. Published online September 7, 2026. doi:10.1177/135245852614648861464886