Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy

There are now numerous studies of Acceptance and Commitment Therapy (ACT) for chronic pain. These studies provide growing support for the efficacy and effectiveness of ACT in this context as well as for the role of ACT-specific therapeutic processes, particularly those underlying psychological flexibility. The purpose of the present study was to continue to build on this work with a broader focus on these processes, including acceptance of pain, general psychological acceptance, mindfulness, and values-based action. Participants included 168 patients who completed an ACT-based treatment for chronic pain and a three-month follow-up. Following treatment and at follow-up, participants reported significantly reduced levels of depression, pain-related anxiety, physical and psychosocial disability, medical visits, and pain intensity in comparison to the start of treatment. They also showed significant increases in each of the processes of psychological flexibility. Most uncontrolled effect sizes were medium or large at the follow-up. In correlation analyses changes in the four processes measures generally were significantly related to changes in the measures of depression, anxiety, and disability. In regression analyses the combined processes were related to changes in outcomes above and beyond change in pain intensity. Although in some ways preliminary, these results specifically support the unique role of general psychological acceptance in relation to improvements achieved by treatment participants. The current study clarifies potential processes of change in treatment for chronic pain, particularly those aiming to enhance psychological flexibility.     

Group acceptance and commitment therapy (ACT) for bipolar disorder and co-existing anxiety – an open pilot study

Previous studies have supported acceptance and commitment therapy (ACT) for reducing impairment related to various chronic conditions. ACT may possibly be beneficial for bipolar disorder (BD) with co-existing anxiety, which is associated with a poorer treatment outcome. Efforts are needed to identify suitable psychological interventions for BD and co-existing anxiety. In this open clinical trial, we included 26 patients with BD type 1 or 2 at an outpatient psychiatric unit specializing in affective disorders. The intervention consisted of a 12-session manualized group treatment that included psychoeducation, mindfulness, engaging in values-based behaviour, cognitive defusion, acceptance and relapse prevention modules. Participants completed four self-report questionnaires covering anxiety symptoms (Beck Anxiety Inventory - BAI), depressive symptoms (Beck Depression Inventory - BDI-II), quality of life (Quality of Life Inventory - QOLI) and psychological flexibility (Acceptance and Action Questionnaire - AAQ-2) before, during and after the treatment. At post-treatment, the participants reported significant improvements in all outcome measures, with large effects (Cohen’s d between 0.73 and 1.98). The mean reduction in anxiety symptoms was 45%. At post-treatment, 96% of the patients were classified as responders on at least one of the outcome measures. A limitation is that the trial is uncontrolled. The results suggest that ACT has the potential to be an effective treatment for BD patients with co-existing anxiety. Further randomized studies are warranted.     

A feasibility study of Acceptance and Commitment Therapy for emotional dysfunction following psychosis

The experience of psychosis can lead to depression, anxiety and fear. Acceptance and Commitment Therapy (ACT) facilitates individuals to accept difficult mental experiences and behave in ways that are consistent with personally held values. This study was a single (rater) blind pilot randomised controlled trial of ACT for emotional dysfunction following psychosis. Twenty-seven participants with psychosis were randomised to either: ten sessions of ACT plus treatment as usual (TAU) or TAU alone. The Hospital Anxiety and Depression Scale, Positive and Negative Syndrome Scale, Acceptance and Action Questionnaire, Kentucky Inventory of Mindfulness Skills and Working Alliance Inventory were used. Individuals were assessed at baseline and 3 months post-baseline. The individuals randomised to receive ACT found the intervention acceptable. A significantly greater proportion of the ACT group changed from being depressed at time of entry into the study to not being depressed at follow-up. The ACT group showed a significantly greater increase in mindfulness skills and reduction in negative symptoms. Results indicated that individuals randomised to ACT had significantly fewer crisis contacts over the study. Changes in mindfulness skills correlated positively with changes in depression. ACT appears to offer promise in reducing negative symptoms, depression and crisis contacts in psychosis.     

A preliminary investigation of acceptance and commitment therapy as a treatment for chronic skin picking

The effectiveness of a deliberately limited version of Acceptance and Commitment Therapy (ACT) for chronic skin picking was evaluated in a pair of multiple baseline across participants designs. Self-monitoring of skin picking showed that four of the five participants reached near zero levels of picking by post-treatment, but these gains were not fully maintained for three of the four participants at follow-up. The findings of the self-reported skin picking were generally corroborated by ratings of photographs of the damaged areas and by ratings on a validated measure of skin picking severity. All participants rated the intervention as socially acceptable, and reductions were found on measures of anxiety, depression, and experiential avoidance for most participants as a result of the intervention. Results support the construction of more comprehensive ACT protocols for skin picking.     

The Use of a Child-Based Acceptance and Commitment Therapy Curriculum to Increase Attention

Acceptance and Commitment Therapy (ACT) is a treatment that integrates mindfulness and acceptance training with behavior change processes. One of the core processes in ACT is contact with the present moment which involves shifting attention to what is happening here and now, contacting both internal and external stimuli. An experimental and control group were used to determine the impact ACT had on attention. ACT participants (M?=?5.4, SD?=?9.8) showed fewer inaccuracies on the CPT-X task compared to the control group (M?=?19.75, SD?=?16.1) at posttest F(1, 38)?=?11.49, p?=?.02, ηp²?=?.232. Results of the current study demonstrate participation in the use of an ACT curriculum for children to help increase attention outcomes.     

Life hassles, experiential avoidance and distressing delusional experiences

Life hassles have been implicated in both the formation and maintenance of psychosis symptoms. However, little is understood about the mechanism through which these stressors impact on psychosis. The current study proposed experiential avoidance (EA), a psychological coping style that is a central focus for change in Acceptance and Commitment Therapy (ACT), as a potential mediator of the link between life hassles and both the emergence and maintenance of delusional ideation. Participants were recruited to a non-clinical sample (N = 133) and a clinical sample of psychosis patients (N = 100). All participants completed a self-report questionnaire including a measure of delusions and delusional distress (Peters Delusions Inventory), life hassles (Survey of Recent Life Experiences) and EA (Acceptance and Action Questionnaire-II). Mediation testing (bootstrapping) indicated a significant mediation effect of EA in the relationship between life hassles and both delusions and delusional distress, in both clinical and non-clinical samples. The findings suggest that individuals (irrespective of their diagnostic status) with a tendency to suppress or avoid unwanted thoughts are significantly more likely to experience distressing delusions in response to stressful life occurrences. The use of ACT and Cognitive Behavioural Therapy to reduce EA in those at risk of emerging delusions and in patients with an already established psychosis is discussed.     

Processes in acceptance and commitment therapy and the rehabilitation of chronic fatigue

Acceptance and commitment therapy (ACT) has never been tested for patients with chronic fatigue. We aimed to test if a 3.5‐week ACT rehabilitation program for patients with chronic fatigue improved quality of life (QoL), fatigue, and psychological flexibility. Further, to test if improvements in QoL and fatigue were associated with improvement in psychological flexibility, and if psychological flexibility explained variance above and beyond maladaptive cognitions typically targeted in CBT for fatigue. Patients (n = 140) who had been on sick leave > 8 weeks due to chronic fatigue received a 3.5‐week non‐controlled inpatient rehabilitation program based on ACT. A physician and a psychologist examined the patients, assessing medication use and SCID‐I diagnoses. Patients completed questionnaires about somatic complaints, psychological complaints, and maladaptive cognitions before and after treatment. At post‐treatment, patients reported improved QoL (p < 0.001; g = 1.07) and less fatigue (p < 0.001; g = 1.08), but not increased psychological flexibility (p = 0.6). Changes in psychological flexibility was associated with improved QoL, but not fatigue, in hierarchical regression analyses. When adjusting for other cognitions, changes in fear‐avoidance cognitions and all‐or‐nothing thoughts, but not psychological flexibility, were associated with improved QoL and fatigue. The ACT‐based treatment improved QoL and reduced fatigue for patients with chronic fatigue with large effect sizes. Improvement was associated with a reduction in fear‐avoidance cognitions and all‐or‐nothing thoughts, but not psychological flexibility.     

A Pilot Study of Acceptance and Commitment Therapy as a Workshop Intervention for Body Dissatisfaction and Disordered Eating Attitudes

Body image dissatisfaction is a source of significant distress among non-eating-disordered women, but because it is subclinical it is generally not treated. It remains stable throughout adulthood, and has proven resistant to many prevention interventions. This study presents a pilot test of a practical alternative: a 1-day Acceptance and Commitment Therapy (ACT) workshop targeting body dissatisfaction and disordered eating attitudes. Women with body dissatisfaction (N = 73) were randomly assigned to the workshop or to a wait list. Participants in both conditions also completed appetite awareness self-monitoring of hunger and satiety. After a brief 2-week follow-up, wait-list participants were also offered the workshop. Eating attitudes, body anxiety, and preoccupation with eating, weight, and shape improved in both arms of the study following the workshop. Participants in the ACT group showed significant reductions in body-related anxiety and significant increases in acceptance when compared to the wait-list control condition. ACT presented as a brief workshop intervention may be applicable for a broad range of women experiencing disordered eating attitudes and distress related to eating and body image; however, larger studies with longer follow-ups are needed.     

Acceptance and values-based action in chronic pain: a three-year follow-up analysis of treatment effectiveness and process

Recent developments in CBT emphasize the promotion of psychological flexibility to improve daily functioning for people with a wide range of health conditions. In particular, one of these approaches, Acceptance and Commitment Therapy (ACT), has been studied for treatment of chronic pain. While trials have provided good support for treatment effectiveness through follow-ups of as long as seven months, the longer-term impact is not known. The present study of 108 participants with chronic pain examined outcomes three years after treatment completion and included analyses of two key treatment processes, acceptance of pain and values-based action. Overall, results indicated significant improvements in emotional and physical functioning relative to the start of treatment, as well as good maintenance of treatment gains relative to an earlier follow-up assessment. Effect size statistics were generally medium or large. At the three-year follow-up, 64.8% of patients had reliably improved in at least one key domain. Improvements in acceptance of pain and values-based action were associated with improvements in outcome measures. A “treatment responder” analysis, using variables collected at pre-treatment and shorter term follow-up, failed to identify any salient predictors of response. This study adds to the growing literature supporting the effectiveness of ACT for chronic pain and yields evidence for both statistical and clinical significance of improvements over a three-year period.     

Acute treatment of inpatients with psychotic symptoms using Acceptance and Commitment Therapy: pilot results

Cognitive behavior therapy (CBT) has been demonstrated in a number of randomized controlled trials to be efficacious as an adjunctive treatment for psychotic disorders. Emerging evidence suggests the usefulness of CBT interventions that incorporate acceptance/mindfulness-based approaches for this population. The current study extended previous research by Bach and Hayes (2002. The use of Acceptance and Commitment Therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129-1139) using Acceptance and Commitment Therapy (ACT) in the treatment of psychosis. Psychiatric inpatients with psychotic symptoms were randomly assigned to enhanced treatment as usual (ETAU) or ETAU plus individual sessions of ACT. At discharge from the hospital, results suggested short-term advantages in the ACT group in affective symptoms, overall improvement, social impairment, and distress associated with hallucinations. In addition, more participants in the ACT condition reached clinically significant symptom improvement at discharge. Although 4-month rehospitalization rates were lower in the ACT group, these differences did not reach statistical significance. Decreases in the believability of hallucinations during treatment were observed only in the ACT condition, and change in believability was strongly associated with change in distress after controlling for change in the frequency of hallucinations. Results are interpreted as largely consistent with the findings of Bach and Hayes and warrant further investigations with larger samples.     

Long-term outcomes of Acceptance and Commitment Therapy in drug-dependent female inmates: A randomized controlled trial

The general aim of this randomized controlled trial was to test the long-term efficacy of acceptance and commitment therapy (ACT) compared to a cognitive behavioural therapy (CBT) condition in the treatment of drug abuse. Participants were 37 polydrug incarcerated females assessed with Mini International Neuropsychiatric Interview, Addiction Severity Index-6, Anxiety Sensitivity Index (ASI) and Acceptance and Action Questionnaire II at pre, post, and at 6-, 12- and 18-months follow-ups. The mixed lineal model analyses showed reductions in drug abuse, ASI levels and avoidance repertoire in both conditions, without any differences between groups. However, the percentages of mental disorders were reduced only in ACT participants. At the 18-month follow-up, ACT was better than CBT in the maintaining of abstinence rates. This data support the incubation pattern showed in previous ACT studies. To conclude, the ACT intervention seems to be an adequate treatment option for addictive behaviours and co-occurring disorders in incarcerated women.     

A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania

This randomized trial compared a combined Acceptance and Commitment Therapy/Habit Reversal Training (ACT/HRT) to a waitlist control in the treatment of adults with trichotillomania (TTM). Twenty-five participants (12 treatment and 13 waitlist) completed the trial. Results demonstrated a significant reduction in hair pulling severity, impairment ratings, and hairs pulled, along with significant reductions in experiential avoidance and both anxiety and depressive symptoms in the ACT/HRT group compared to the waitlist control. Reductions generally were maintained at a 3-month follow-up. Decreases in experiential avoidance and greater treatment compliance were significantly correlated with reductions in TTM severity, implying that targeting experiential avoidance may be useful in the treatment of TTM. Other implications and suggestions for future research are noted.     

The relationship between acceptance,fatigue, and subjective cognitive impairment in hematologic cancer survivors

Background/Objective: Cancer and its treatment can have a detrimental impact on psychological well-being. Acceptance as the basis of acceptance and commitment therapy (ACT) has shown beneficial effects on depression and anxiety. However, its relationship to fatigue and cognitive impairment has not been investigated. A protective effect of acceptance may open up a new target for psychological intervention.Method: A cross-sectional postal survey was undertaken. 922 hematological cancer survivors (≥ 2.5 years post diagnosis) were recruited through two regional cancer registries in Germany. Acceptance (AAQ-II), fatigue (BFI) and subjective cognitive impairment (AFI) were assessed.Results: Higher levels of acceptance were negatively associated with fatigue and subjective cognitive impairment (R²= .34 and R²= .26, respectively). The relationship between fatigue and fatigue-related impairment of daily life was weaker for survivors with high acceptance.Conclusions: Acceptance is strongly associated with fatigue and subjective cognitive impairment. ACT may be useful to reduce symptoms of fatigue and subjective cognitive impairment in cancer survivors.     

I Am > Trauma: Experimentally Reducing Event Centrality and PTSD Symptoms in a Clinical Trial

Event centrality has been one of the strongest predictors of PTSD symptoms. We attempted to experimentally reduce event centrality using a modified version of Acceptance and Commitment Therapy (ACT) in a sample of traumatized participants from a community outreach center. Relative to a control group, participants who received ACT evidenced significant decreases in PTSD symptoms, depression, and event centrality. A mediation analysis revealed that the effect of condition on PTSD symptoms was mediated by decreases in event centrality. Only the effect of condition on depression was still significant at six weeks posttreatment. This study is the first to manipulate event centrality and suggests that components of ACT may be effective at reducing event centrality.     

Measuring Experiential Avoidance: Reliability and Validity of the Dutch 9-item Acceptance and Action Questionnaire (AAQ)

Three studies evaluated psychometric properties of the Dutch version of the 9-item Acceptance and Action Questionnaire (AAQ)—a self-report measure designed to assess experiential avoidance as conceptualized in Acceptance and Commitment Therapy (ACT). Study 1, among bereaved adults, showed that a one-factor model, with AAQ-items constituting a single dimension of experiential avoidance, fitted the data well. The internal consistency and temporal stability of the AAQ were satisfactory. In Study 2, among undergraduate students, and Study 3, among 60 outpatients, higher AAQ scores were found to be significantly associated with psychopathology, maladaptive coping strategies, and neuroticism, attesting to the validity of the measure. In support of its incremental validity, Study 3 showed that the AAQ remained significantly associated with depression and anxiety after controlling for neuroticism and thought suppression. The current studies complement prior research supporting the psychometric properties of the AAQ and the ACT conceptualization of experiential avoidance.

Examining associations among factor-analytically derived components of mental health stigma, distress, and psychological flexibility

Mental health stigma can be detrimental not only for the recipient, but also for the stigmatizer. As mental health stigma is often conceptualized as a multidimensional construct, Study 1 first examined the factor structure of mental health stigma as assessed by the Stigmatizing Attitudes-Believability (SAB; Masuda, Price, Anderson, Schmertz, & Calamaras, 2009). Study 2 investigated differential relations between the factor-analytically derived components of mental health stigma and psychological distress and psychological flexibility. Results of Study 1 revealed that mental health stigma consisted of two related, yet separable components: Exclusion and Course/Origin. The Exclusion component was characterized by negative emotions and cognitions associated with an increased desire for social distance. Course/Origin was marked by pessimistic views toward treatment prognosis and recovery. Results of Study 2 suggested that these two components have differential associations with psychological distress and flexibility. The Course/Origin component of stigma, but not Exclusion, was associated with psychological distress of the stigmatizer. Furthermore, this association was fully mediated by lower levels of psychological flexibility. These findings suggest the importance of conceptualizing mental health stigma multidimensionally.     

Effectiveness of an ACT‐based rehabilitation program for the treatment of chronic fatigue: Results from a 12‐months longitudinal study

Acceptance and Commitment Therapy (ACT) is potentially effective for treating chronic fatigue. Given the paucity of studies on this topic, we aimed to assess long‐term trajectories of primary (fatigue, quality of life and functional abilities) and secondary outcomes (anxious and depressive symptoms) of an ACT‐based rehabilitation program for patients with chronic fatigue. Further, we examined if changes in potential process variables (psychological inflexibility, metacognitive beliefs, and cognitive and behavioral responses to symptoms) during ACT predicted change in all outcomes across follow‐up. One‐hundred ninety‐five workers on sick leave (mean age: 43.61 ± 9.33 years; 80.5% females) with a diagnosis of chronic fatigue were enrolled in a manualized, 3.5‐week intensive return‐to‐work rehabilitation program based on ACT. All completed a battery of questionnaires at pre‐, post‐treatment, 6 and 12 months follow‐up. We found significant longitudinal changes in most primary and secondary outcomes from pre‐ up to 12 months follow‐up. All process variables significantly decreased from pre‐ up to 12 months follow‐up, and pre‐to‐post changes in fear avoidance beliefs were most often associated with a greater change in outcomes across follow‐up. Depressive symptomatology showed a similar trajectory of change to fatigue, meaning that scores were correlated at each time point and tended to converge over time. This suggests that both symptoms influence each other substantially over a year following the treatment. Concluding, results lend support to the effectiveness of an ACT‐based rehabilitation program for patients with chronic fatigue and provide preliminary evidence for the role of process variables and depressive symptomatology on subsequent change in outcomes.     

Psychological distance reduces the effect of internalized stigma on mental health treatment decisions

Although stigma is a major barrier to treatment for those with mental health concerns, it is poorly understood when stigma is more or less influential in mental health treatment decisions. In the current work, we examined whether psychological distance—the removal of an event from direct experience—reduced the influence of internalized stigma on willingness to seek treatment. Specifically, we tested the hypothesis that psychological distance versus proximity (e.g., seeking treatment in three months vs. in two days, respectively) decreases the negative influence of stigma on willingness to seek treatment. We focused on a population for whom mental health treatment decisions are personally-relevant: individuals who had previously sought mental health treatment. Experiment 1 showed that the extent to which these individuals internalized (i.e., personally endorsed) stigma about mental illness predicted lower intentions to make an appointment with a mental health care provider for themselves (but not another person). Experiment 2 replicated this result using a different measure of psychological distance (temporal distance) and extended this finding to behavior (time spent reading mental health resources). Overall, this research demonstrated that internalized stigma disrupts mental health treatment-seeking intentions and behaviors when they are psychologically proximal, but not when they are distant. Potential applications of these results are discussed.     

Acceptance and Commitment Therapy for adults who stutter: Psychosocial adjustment and speech fluency

The aim of the present study was to assess the effectiveness of an Acceptance and Commitment Therapy group intervention program for adults who stutter (N = 20). The program consisted of 2-h therapeutic sessions conducted weekly for eight consecutive weeks. It was an integrated program designed to improve: (a) psychosocial functioning, (b) readiness for therapy and change, (c) utilisation of mindfulness skills and psychological flexibility, and (d) frequency of stuttering. The findings provide innovative evidence for Acceptance and Commitment Therapy as an effective intervention with statistically significant improvements in psychosocial functioning, preparation for change and therapy, utilisation of mindfulness skills, and overall speech fluency. Follow-up data collected at three months post-treatment revealed that therapeutic gains were successfully maintained over time. These findings enhance the understanding of the impact of stuttering on psychological wellbeing and offer a new perspective on what might constitute successful stuttering treatment. Further, clinical research support is provided for Acceptance and Commitment Therapy delivered in a group format as a promising and novel intervention for adults who stutter.Educational objectives: The reader will be able to: (a) appreciate the potential for Acceptance and Commitment Therapy for adults who stutter; (b) identify the improvements participants experienced in psychosocial functioning and frequency of stuttered speech; (c) appreciate the six core processes of Acceptance and Commitment Therapy; and (d) appreciate the differences between an ACT model of intervention for adults who stutter compared to a CBT approach.     

Disengagement and Engagement Coping with HIV/AIDS Stigma and Psychological Well-Being of People with HIV/AIDS

The stigma associated with HIV/AIDS poses a psychological challenge to people living with HIV/AIDS. We hypothesized that that the consequences of stigma-related stressors on psychological well-being would depend on how people cope with the stress of HIV/AIDS stigma. Two hundred participants with HIV/AIDS completed a self-report measure of enacted stigma and felt stigma, a measure of how they coped with HIV/AIDS stigma, and measures of depression and anxiety, and self-esteem. In general, increases in felt stigma (concerns with public attitudes, negative self-image, and disclosure concerns) coupled with how participants reported coping with stigma (by disengaging from or engaging with the stigma stressor) predicted self-reported depression, anxiety, and self-esteem. Increases in felt stigma were associated with increases in anxiety and depression among participants who reported relatively high levels of disengagement coping compared to participants who reported relatively low levels of disengagement coping. Increases in felt stigma were associated with decreased self-esteem, but this association was attenuated among participants who reported relatively high levels of engagement control coping. The data also suggested a trend that increases in enacted stigma predicted increases in anxiety, but not depression, among participants who reported using more disengagement coping. Mental health professionals working with people who are HIV positive should consider how their clients cope with HIV/AIDS stigma and consider tailoring current therapies to address the relationship between stigma, coping, and psychological well-being.