The impact of treatment components suggested by the psychological flexibility model: a meta-analysis of laboratory-based component studies

Acceptance and Commitment Therapy as a Treatment for Anxiety and Depression: A Review

Acceptance and commitment therapy (ACT) is a modern form of cognitive behavioral therapy based on a distinct philosophy and basic science of cognition. This article reviews the core features of ACT's theoretic model of psychopathology and treatment and its therapeutic approach. It provides a systematic review of randomized controlled trials (RCTs) evaluating ACT for depression and anxiety disorders. Summarizing 36 RCTs, ACT appears to be more efficacious than waitlist conditions and treatment-as-usual, with largely equivalent effects relative to traditional cognitive behavioral therapy. Evidence indicates that ACT treatment outcomes are mediated through increases in psychological flexibility, its theorized process of change.

Analyzing Change Processes Resulting from a Smartphone Maintenance Intervention Based on Acceptance and Commitment Therapy for Women with Chronic Widespread Pain

PURPOSE

This study investigated change processes resulting from a randomized controlled trial smartphone-delivered maintenance intervention with daily electronic diaries and personalized written feedback based on acceptance and commitment therapy (ACT) following a rehabilitation program for patients with chronic widespread pain.

METHOD

This study included 48 women who during a 5-week period completed electronic diaries three times daily, totaling 3372 entries. In response to the completed diaries, they received daily feedback from a therapist for 4 weeks (excluding weekends), totaling 799 feedback messages. To analyze the change processes, we explored the associations between feedback and daily ratings of participants' physical activities, positive emotions, pain fear and avoidance, pain acceptance, and self-management. Commitment to physical activities and the participants' evaluation of feedback were also analyzed. Multilevel models were used in the statistical analyses.

RESULTS

Participants' average pain fear and avoidance decreased over the intervention period (mean -0.019, P = 0.05). Self-management, pain acceptance, and positive feelings increased (mean -0.030, P < 0.01; mean -0.015, P < 0.01; and mean -0.011, P = 0.01, respectively). Participants' performance of physical activities decreased slightly over time, but the level of commitment was high and they evaluated the feedback as supportive for staying sufficiently active. No correlation between diary contents and feedback messages was found, even though most of the participants evaluated the feedback as supportive.

CONCLUSION

No support was found for an association between diary content and feedback based on ACT. However, diary measures were consistent with the ACT model and may have influenced positively the change processes.

Ultra-Brief Mindfulness Training Reduces Alcohol Consumption in At-Risk Drinkers: A Randomized Double-Blind Active-Controlled Experiment

Background

Like other complex psychosocial interventions, mindfulness-based treatments comprise various modality-specific components as well as nonspecific therapeutic ingredients that collectively contribute to efficacy. Consequently, the isolated effects of mindfulness strategies per se remain unclear.

Methods

Using a randomized double-blind design, we compared the isolated effects of 11-minutes of "supervised" mindfulness instruction against a closely matched active control (relaxation) on subjective, physiological, and behavioral indices of maladaptive alcohol responding in drinkers at risk of harm from alcohol use (n = 68). Simple follow-up instructions on strategy use were provided, but practice was unsupervised and not formally monitored.

Results

Both groups showed acute reductions in craving after training, although a trend group x time interaction (P = .056) suggested that this reduction was greater in the relaxation group (d = 0.722 P < .001) compared with the mindfulness group (d = 0.317, P = .004). Furthermore, upregulation of parasympathetic activity was found after relaxation (d = 0.562; P < .001) but not mindfulness instructions (d = 0.08; P > .1; group x time interaction: P = .009). By contrast, only the mindfulness group showed a reduction in past-week alcohol consumption at 7-day follow-up (-9.31 units, d = 0.593, P < .001), whereas no significant reduction was seen in the relaxation group (-3.00 units, d = 0.268, P > .1; group x time interaction: P = .026).

Conclusion

Very brief mindfulness practice can significantly reduce alcohol consumption among at-risk drinkers, even with minimal encouragement to use this strategy outside of the experimental context. The effects on consumption may therefore represent a lower bound of efficacy of "ultra-brief" mindfulness instructions in hazardous drinkers, at least at short follow-up intervals.

Psychoneuroendocrine evaluation of an acceptance and commitment based stress management training

BACKGROUND AND OBJECTIVES

Acceptance and Commitment Therapy (ACT), a behavioral therapy that targets psychological flexibility (PF), has been shown to be efficacious across a wide range of problems, including chronic work-related stress and perceived stress. ACT's effect on the multiple levels of the acute stress response (i.e., subjective and biological) is less well understood. The aim of the current study was to test whether ACT, by working toward PF, would reduce both the endocrine and subjective evaluations of participants' acute stress response.

METHODS

Participants (n = 35) were randomized to an ACT condition or waitlist (WL). Participants in the ACT condition received a two-day ACT workshop on how to flexibly deal with stress. All participants completed a standardized laboratory stress test.

RESULTS

The ACT and WL groups did not differ on main comparisons of the endocrine response (i.e., cortisol) or subjective evaluation. Baseline levels of PF moderated some outcomes. Avoidant participants had a stronger endocrine stress reaction if they received the ACT intervention.

LIMITATIONS

The control condition was a WL and not an active intervention comparison.

CONCLUSIONS

ACT is not useful in reducing the acute stress response and may even be iatrogenic, at least during tasks with little real-world impact for their personal values. Clinical or methodological significance of this article: This was one of the first studies to investigate the impact of an ACT intervention on biological parameters. The short-term intervention did not attenuate acute endocrine stress levels or subjective stress appraisals. Future studies should investigate which interventions and under which conditions attenuate acute and long-term stress responses.

Mindfulness, Acceptance and Defusion Strategies in Smokers: a Systematic Review of Laboratory Studies

The psychological flexibility model (PFM) provides a framework for understanding and treating behavioural dysregulation in addictions. Rather than modulating the intensity of subjective experience, interventions based on, or consistent with, the PFM (PFM interventions) seek to alter the individual's relationship to internal states, such as craving, negative affect and drug-related thoughts, using mindfulness, acceptance and related strategies. Experimental (non-clinical) studies in smokers have examined the effects of specific isolated strategies informed by or consistent with the PFM (PFM strategies). Here, we systematically review these studies and determine the extent to which they conform to methodological standards indicative of high levels of internal validity. Eligible studies were identified through electronic database searches and assessed for the presence of specific methodological features. Provisional aggregate effect sizes were determined depending on availability of data. Of 1499 screened publications, 12 met the criteria. All examined aspects of private subjective experience relevant to abstinence (craving n = 12; negative affect n = 10), demonstrating effects favouring PFM strategies relative to inactive control conditions. However, only six assessed outcome domains consistent with the PFM and provided no consistent evidence favouring PFM strategies. Overall, most studies had methodological limitations. As such, high-quality experimental studies continue to be needed to improve our understanding of necessary and/or sufficient constituents of PFM-guided smoking cessation interventions. Recommendations for future research are discussed.

Evaluating an Adjunctive Mobile App to Enhance Psychological Flexibility in Acceptance and Commitment Therapy

The primary aims of this study were to evaluate the feasibility and potential efficacy of a novel adjunctive mobile app designed to enhance the acquisition, strengthening, and generalization of acceptance and commitment therapy (ACT) skills being taught in therapy. A sample of 14 depressed/anxious clients receiving ACT used the ACT Daily app for 2 weeks in a pre-post, open trial design. Participants reported a high degree of program satisfaction. Clients significantly improved over the 2-week period on depression and anxiety symptoms as well as a range of psychological inflexibility measures. Analyses of mobile app data indicated effects of ACT Daily skill coaching on in-the-moment measures of inflexibility and symptoms, with unique effects found for acceptance and mindfulness. Adjunctive ACT mobile apps appear promising in enhancing therapy effects on psychological inflexibility and outcomes. A tailored skill coaching approach like ACT Daily based on randomly prompted assessments may be especially promising.

Departing from the essential features of a high quality systematic review of psychotherapy: A response to Öst (2014) and recommendations for improvement

Öst's (2014) systematic review and meta-analysis of Acceptance and Commitment Therapy (ACT) has received wide attention. On the basis of his review, Öst argued that ACT research was not increasing in its quality and that, in contradiction to the views of Division 12 of the American Psychological Association (APA), ACT is "not yet well-established for any disorder" (2014, p. 105). We conducted a careful examination of the methods, approach, and data used in the meta-analysis. Based in part on examinations by the authors of the studies involved, which were then independently checked, 91 factual or interpretive errors were documented, touching upon 80% of the studies reviewed. Comparisons of Öst's quality ratings with independent teams rating the same studies with the same scale suggest that Ost's ratings were unreliable. In all of these areas (factual errors; interpretive errors; quality ratings) mistakes and differences were not random: Ost's data were dominantly more negative toward ACT. The seriousness, range, and distribution of errors, and a wider pattern of misinterpreting the purpose of studies and ignoring positive results, suggest that Öst's review should be set aside in future considerations of the evidence base for ACT. We argue that future published reviews and meta-analyses should rely upon diverse groups of scholars rather than a single individual; that resulting raw data should be made available for inspection and independent analysis; that well-crafted committees rather than individuals should design, apply and interpret quality criteria; that the intent of transdiagnostic studies need to be more seriously considered as the field shifts away from a purely syndromal approach; and that data that demonstrate theoretically consistent mediating processes should be given greater weight in evaluating specific interventions. Finally, in order to examine substantive progress since Öst's review, recent outcome and process evidence was briefly examined.

Considering Meta-Analysis, Meaning, and Metaphor: A Systematic Review and Critical Examination of "Third Wave" Cognitive and Behavioral Therapies

In this review, we examine common usage of the term "third wave" in the scientific literature, systematically review published meta-analyses of identified "third wave" therapies, and consider the implications and options for the use of "third wave" as a metaphor to describe the nature of and relationships among cognitive and behavioral therapies. We demonstrate that the "third wave" term has grown in its use over time, that it is commonly linked with specific therapies, and that the majority of such therapies have amassed a compelling evidence base attesting to their clinical and public health value. We also consider the extent to which the "third wave" designation is an effective guide for the future, and we encourage scientific inquiry and self-reflection among those concerned with cognitive and behavioral therapies and the scientific basis of psychotherapy more broadly.

Contextual Positive Psychology: Policy Recommendations for Implementing Positive Psychology into Schools

There has been a rapid growth in positive psychology, a research and intervention approach that focuses on promoting optimal functioning and well-being. Positive psychology interventions are now making their way into classrooms all over the world. However, positive psychology has been criticized for being decontextualized and coercive, and for putting an excessive emphasis on positive states, whilst failing to adequately consider negative experiences. Given this, how should policy be used to regulate and evaluate these interventions? We review evidence that suggests these criticisms may be valid, but only for those interventions that focus almost exclusively on changing the content of people's inner experience (e.g., make it more positive) and personality (improving character strength), and overemphasize the idea that inner experience causes action. We describe a contextualized form of positive psychology that not only deals with the criticisms, but also has clear policy implications for how to best implement and evaluate positive education programs so that they do not do more harm than good.

Model and Processes of Acceptance and Commitment Therapy (ACT) for Chronic Pain Including a Closer Look at the Self

Acceptance and commitment therapy (ACT) is one of the so called "third-wave" cognitive behavioral therapies. It has been increasingly applied to chronic pain, and there is accumulating evidence to support its effectiveness. ACT is based on a model of general human functioning called the psychological flexibility (PF) model. Most facets of the PF model have been examined in chronic pain. However, a potential key facet related to "self" appears underappreciated. Indeed, a positive or healthy sense of self seems essential to our well-being, and there have been numerous studies of the self in chronic pain. At the same time, these studies are not currently well organized or easy to summarize. This lack of clarity and integration creates barriers to progress in this area of research. PF with its explicit inclusion of self-related therapeutic processes within a broad, integrative, theoretical model may help. The current review summarizes the PF model in the context of chronic pain with a specific emphasis on the parts of the model that address self-related processes.

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.

Cognitive-behavioral therapies for depression and substance use disorders: An overview of traditional, third-wave, and transdiagnostic approaches

BACKGROUND

The co-occurrence of depression and substance use disorders (SUD) is highly prevalent and associated with poor treatment outcomes for both disorders. As compared to individuals suffering from either disorder alone, individuals with both conditions are likely to endure a more severe and chronic clinical course with worse treatment outcomes. Thus, current practice guidelines recommend treating these co-occurring disorders simultaneously.

OBJECTIVES

The overarching aims of this narrative are two-fold: (1) to provide an updated review of the current empirical status of integrated psychotherapy approaches for SUD and depression comorbidity, based on models of traditional cognitive-behavioral therapy (CBT) and newer third-wave CBT approaches, including acceptance- and mindfulness-based interventions and behavioral activation (BA); and (2) to propose a novel theoretical framework for transdiagnostic CBT for SUD-depression, based upon empirically grounded psychological mechanisms underlying this highly prevalent comorbidity.

RESULTS

Traditional CBT approaches for the treatment of SUD-depression are well-studied. Despite advances in the development and evaluation of various third-wave psychotherapies, more work needs to be done to evaluate the efficacy of such approaches for SUD-depression.

CONCLUSION

Informed by this summary of the evidence, we propose a transdiagnostic therapy approach that aims to integrate treatment elements found in empirically supported CBT-based interventions for SUD and depression. By targeting shared cognitive-affective processes underlying SUD-depression, transdiagnostic treatment models have the potential to offer a novel clinical approach to treating this difficult-to-treat comorbidity and relevant, co-occurring psychiatric disturbances, such as posttraumatic stress.

Evaluating the Effectiveness of ACT for Anxiety Disorders in a Self-Help Context: Outcomes From a Randomized Wait-List Controlled Trial

Rigorous evaluations of cognitive behavioral self-help books for anxiety in pure self-help contexts are lacking. The present study evaluated the effectiveness of an Acceptance and Commitment Therapy (ACT) self-help workbook for anxiety-related concerns, with no therapist contact, in an international sample. Participants (N=503; 94% mental health diagnosis) were randomized to an immediate workbook (n=256) or wait-list condition (n=247). Assessments at pretreatment, 12weeks, 6months, and 9months evaluated anxiety and related symptoms, quality of life, and ACT treatment processes (e.g., psychological flexibility). Participants in the wait-list arm crossed over to the workbook following the 12-week assessment. The workbook condition yielded significant improvements on all assessments from pre- to posttreatment relative to wait-list, and these gains were maintained at follow-ups. The pattern observed in the wait-list condition was virtually identical to the active treatment arm after receiving the workbook, but not before. Attrition was notable, but supplemental analyses suggested dropout did not influence treatment effects for all but one measure. Overall, findings provide preliminary support for the effectiveness of this self-help workbook and suggest ACT-based self-help bibliotherapy might be a promising low-cost intervention for people experiencing significant anxiety-related concerns.

The role of mindfulness in distress and quality of life for men with advanced prostate cancer

Objective

To examine the extent to which mindfulness skills influence psychological distress and health-related quality of life (HRQOL) in men with metastatic or castration-resistant biochemical progression of prostate cancer.

Patients and methods

A cross-sectional survey of 190 men (46 % response; mean age 71 years, SD = 8.7, range 40–91 years) with advanced prostate cancer, assessed psychological and cancer-specific distress, HRQOL. Mindfulness skills were assessed as potential predictors of adjustment outcomes.

Results

Overall, 39 % of men reported high psychological distress. One third had accessed psychological support previously although only 10 % were under current psychological care. One quarter had accessed a prostate cancer support group in the past six months.

Higher HRQOL and lower cancer-specific and global psychological distress were related to non-judging of inner experience (p < 0.001).

Higher HRQOL and lower psychological distress were related to acting with awareness (p < 0.001). Lower distress was also related to higher non-reactivity to inner experience and a lower level of observing (p < 0.05).

Conclusions

Men with advanced prostate cancer are at risk of poor psychological outcomes. Psychological flexibility may be a promising target for interventions to improve adjustment outcomes in this patient group.

Clinical Trial Registry

Trial Registration: ACTRN12612000306819

Acceptance and Commitment Therapy for Problematic Internet Pornography Use: A Randomized Trial

Problematic Internet pornography use is the inability to control the use of pornography, the experience of negative cognitions or emotions regarding pornography use, and the resulting negative effects on quality of life or general functioning. This study compared a 12-session individual protocol of acceptance and commitment therapy (ACT) for problematic Internet pornography use to a waitlist control condition with 28 adult males, all but 1 of whom were members of the Church of Jesus Christ of Latter-day Saints. Measures of self-reported pornography viewing, standardized measures of compulsive sexual behavior and related cognitions, and quality of life occurred at pretreatment, posttreatment, and 3-month follow-up. Results demonstrate significant between-condition reductions in pornography viewing compared to the waitlist condition (93% reduction ACT vs. 21% waitlist). When combining all participants (N=26), a 92% reduction was seen at posttreatment and an 86% reduction at 3-month follow-up. Complete cessation was seen in 54% of participants at posttreatment and at least a 70% reduction was seen in 93% of participants. At the 3-month follow-up assessment, 35% of participants showed complete cessation, with 74% of participants showing at least 70% reduction in viewing. Treatment suggestions and future directions are discussed.

Screening for Psychological Inflexibility: Initial Validation of the Avoidance and Fusion Questionnaire for Youth as a School Mental Health Screener

The present study reports on the initial validation of the eight-item version of the Avoidance and Fusion Questionnaire for Youth (AFQ-Y8) as a school mental health screener for identifying clinical-level depression and anxiety caseness within a sample of urban high school students ( N = 219). Results indicated that responses to the AFQ-Y8 yielded better data–model fit and comparable internal consistency and convergent validity in relation to responses to the longer, 17-item version of the measure. Findings from receiver operating curve (ROC) analyses showed that scores derived from the AFQ-Y8 had excellent discrimination ability for correctly classifying students with and without clinical-level depression (area under the curve [AUC] = .91) and anxiety (AUC = .92), and that a cutoff score of ≥15 yielded optimal sensitivity (.86, .92) and specificity (.88, .87) for accomplishing these purposes. Taken together, findings suggest the AFQ-Y8 is a technically adequate instrument for both measuring psychological inflexibility and classifying students with clinical-level internalizing problems. Implications for future research and practice are discussed.

The Take Control Course: Conceptual Rationale for the Development of a Transdiagnostic Group for Common Mental Health Problems

BACKGROUND

Increasingly, research supports the utility of a transdiagnostic understanding of psychopathology. However, there is no consensus regarding the theoretical approach that best explains this. Transdiagnostic interventions can offer service delivery advantages; this is explored in the current review, focusing on group modalities and primary care settings.

OBJECTIVE

This review seeks to explore whether a Perceptual Control Theory (PCT) explanation of psychopathology across disorders is a valid one. Further, this review illustrates the process of developing a novel transdiagnostic intervention (Take Control Course; TCC) from a PCT theory of functioning.

METHOD

Narrative review.

RESULTS AND CONCLUSIONS

Considerable evidence supports key tenets of PCT. Further, PCT offers a novel perspective regarding the mechanisms by which a number of familiar techniques, such as exposure and awareness, are effective. However, additional research is required to directly test the relative contribution of some PCT mechanisms predicted to underlie psychopathology. Directions for future research are considered.

Web-Based Self-Help for Preventing Mental Health Problems in Universities: Comparing Acceptance and Commitment Training to Mental Health Education

OBJECTIVE

This study sought to test the feasibility of a web-based Acceptance and Commitment Training (ACT) prototype prevention program called ACT on College Life (ACT-CL).

METHOD

A sample of 234 university students was randomized to either the ACT-CL website or a mental health education (MHE) website.

RESULTS

Findings indicated a lower level of user engagement and satisfaction ratings with the prototype of ACT-CL than the MHE website. There were no significant differences between conditions on outcome measures at post or follow-up. However, statistical trends suggested the MHE condition actually led to greater remission of severe symptoms than the ACT-CL condition among those with severe symptoms at baseline. There were no differences between conditions on ACT process of change measures. Changes in psychological flexibility were predictive of changes in mental health across conditions, but relations dissipated over time. Furthermore, greater engagement in some components of ACT-CL predicted improvements in psychological flexibility, though not on mental health outcomes.

CONCLUSIONS

The effects of the ACT-CL program on mental health outcomes and ACT process measures were largely equivalent to those of an education website, although there was a lower level of program engagement with ACT-CL. Findings are discussed in the context of feasibility issues and lessons learned for program revisions.

Does the Theoretical Perspective of Exposure Framing Matter? Acceptance, Fear Reduction/Cognitive Reappraisal, and Values-Framing of Exposure for Social Anxiety

Exposure-based therapy represents a first line treatment for anxiety disorders, but it is often underused. One target for improving client engagement is manipulating the theoretical perspective from which exposure is framed. Ninety-six adults with elevated social anxiety were enrolled in a two-session exposure therapy intervention. Participants were randomized to one of four conditions: (a) fear reduction/cognitive reappraisal, (b) acceptance, (c) personal values, or (d) experimental control. The first three included brief psychoeducation and condition-specific experiential exercises and rationale; all four included in-session speech exposure and between-session exposure for homework. Results revealed that compared to the experimental control, the three active conditions reported significantly higher treatment credibility, initial in-vivo exposure engagement, and improvement in social anxiety symptoms. The three active conditions showed few differences among themselves. This study demonstrates that a brief exposure intervention using a credible rationale led to initial engagement in exposure therapy and improvement in social anxiety symptoms.

Testing of the coping flexibility hypothesis based on the dual-process theory: Relationships between coping flexibility and depressive Symptoms

According to the dual-process theory of coping flexibility (Kato, 2012), coping flexibility is the ability to discontinue an ineffective coping strategy (i.e., evaluation coping process) and implement an alternative strategy (i.e., adaptive coping process). The coping flexibility hypothesis (CFH) proposes that the ability to engage in flexible coping is related to better psychological functioning and physical health, including less depression. I the present study, participants were 393 American Whites, 429 Australian Whites, and 496 Chinese, selected from the data pool of the 2013 Coping and Health Survey (see Kato, 2014b). They completed both the Coping Flexibility Scale (Kato, 2012), which is based on the dual-process theory of coping flexibility, and the Center for Epidemiologic Studies Depression Scale (CES-D). For all nationalities and genders, evaluation coping and adaptive coping were significantly correlated with lower levels of depressive symptoms. Structural equation modeling revealed that evaluation coping was associated with lower depressive symptoms for all nationalities and genders, whereas no significant relationships between adaptive coping and depressive symptoms were found for any nationalities. Our results partially supported that the CFH fits with the dual-process theory of coping flexibility.

Acceptance and Commitment Therapy modules: Differential impact on treatment processes and outcomes

A modular, transdiagnostic approach to treatment design and implementation may increase the public health impact of evidence-based psychosocial interventions. Such an approach relies on algorithms for selecting and implementing treatment components intended to have a specific therapeutic effect, yet there is little evidence for how components function independent of their treatment packages when employed in clinical service settings. This study aimed to demonstrate the specificity of treatment effects for two components of Acceptance and Commitment Therapy (ACT), a promising candidate for modularization. A randomized, nonconcurrent, multiple-baseline across participants design was used to examine component effects on treatment processes and outcomes in 15 adults seeking mental health treatment. The ACT OPEN module targeted acceptance and cognitive defusion; the ACT ENGAGED module targeted values-based activation and persistence. According to Tau-U analyses, both modules produced significant improvements in psychiatric symptoms, quality of life, and targeted therapeutic processes. ACT ENGAGED demonstrated greater improvements in quality of life and values-based activation. ACT OPEN showed greater improvements in symptom severity, acceptance, and defusion. Both modules improved awareness and non-reactivity, which were mutually targeted, though using distinct intervention procedures. Both interventions demonstrated high treatment acceptability, completion, and patient satisfaction. Treatment effects were maintained at 3-month follow up. ACT components should be considered for inclusion in a modular approach to implementing evidence-based psychosocial interventions for adults.

Decoupling as a Mechanism of Change in Mindfulness and Acceptance

A growing body of research within the acceptance and mindfulness-based therapies suggests that these treatments may function in part by reducing or eliminating (i.e., decoupling) the normative relationships between internal experiences and other internal/overt behavior. Examples of decoupling effects found in this review include reduced relationships between urges to smoke and smoking behavior, between dysphoric mood and depressive cognitions, and between pain intensity and persistence in a painful task. A literature review identified 44 studies on acceptance and mindfulness that demonstrated decoupling effects. Overall, preliminary evidence for decoupling effects were found across a broad range of problem areas, including substance abuse, depression, eating disorders, overeating, chronic pain, anxiety, relationships, anger, avoidance behavior, and self-harm, with the strongest evidence currently available in the area of substance abuse. However, the review also notes a general lack of replication studies on decoupling effects and the need for more well-powered and controlled research testing specific decoupling hypotheses.

A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems

BACKGROUND

The current study presents the results of a meta-analysis of 39 randomized controlled trials on the efficacy of acceptance and commitment therapy (ACT), including 1,821 patients with mental disorders or somatic health problems.

METHODS

We searched PsycINFO, MEDLINE and the Cochrane Central Register of Controlled Trials. Information provided by the ACBS (Association of Contextual Behavioral Science) community was also included. Statistical calculations were conducted using Comprehensive Meta-Analysis software. Study quality was rated using a methodology rating form.

RESULTS

ACT outperformed control conditions (Hedges' g = 0.57) at posttreatment and follow-up assessments in completer and intent-to-treat analyses for primary outcomes. ACT was superior to waitlist (Hedges' g = 0.82), to psychological placebo (Hedges' g = 0.51) and to treatment as usual (TAU) (we defined TAU as the standard treatment as usual; Hedges' g = 0.64). ACT was also superior on secondary outcomes (Hedges' g = 0.30), life satisfaction/quality measures (Hedges' g = 0.37) and process measures (Hedges' g = 0. 56) compared to control conditions. The comparison between ACT and established treatments (cognitive behavioral therapy) did not reveal any significant differences between these treatments (p = 0.140).

CONCLUSIONS

Our findings indicate that ACT is more effective than treatment as usual or placebo and that ACT may be as effective in treating anxiety disorders, depression, addiction, and somatic health problems as established psychological interventions. More research that focuses on quality of life and processes of change is needed to understand the added value of ACT and its transdiagnostic nature.

A Functional and Cohesive Treatment of Tourette’s Disorder and Chewing Tobacco Use

Acceptance and commitment therapy (ACT) is a function-based treatment that can be applied to multiple clinical concerns where psychological inflexibility is a mediating issue. This case study describes the use of ACT in combination with habit reversal training for a man with a primary concern of Tourette’s disorder and a secondary concern of chewing tobacco use. Large reductions were seen in the primary outcomes of motor and vocal tics (measured by behavioral tracking and a semi-structured assessment) and chewing tobacco use after 19 individual sessions. Furthermore, increases in psychological flexibility and quality of life and decreases in overall symptomatology were seen at posttreatment. This article conceptualizes this case from a cohesive theory, describes the details of the presenting concerns, and explains the treatment used and treatment outcomes. A description of barriers and suggestions for further treatment and research are also presented.

5HTT is associated with the phenotype psychological flexibility: results from a randomized clinical trial

Adaption to changing environments is evolutionarily advantageous. Studies that link genetic and phenotypic expression of flexible adjustment to one's context are largely lacking. In this study, we tested the importance of psychological flexibility, or goal-related context sensitivity, in an interaction between psychotherapy outcome for panic disorder with agoraphobia (PD/AG) and a genetic polymorphism. Given the established role of the 5HTT-LPR polymorphism in behavioral flexibility, we tested whether this polymorphism (short group vs. long group) impacted therapy response as a function of various endophenotypes (i.e., psychological flexibility, panic, agoraphobic avoidance, and anxiety sensitivity). Patients with PD/AG were recruited from a large multicenter randomized controlled clinical trial on cognitive-behavioral therapy. Pre- to post-treatment changes by 5HTT polymorphism were analyzed. 5HTT polymorphism status differentiated pre- to post-treatment changes in the endophenotype psychological flexibility (effect size difference d = 0.4, p < 0.05), but none of the specific symptom-related endophenotypes consistently for both the intent-to-treat sample (n = 228) and the treatment completers (n = 194). Based on the consistency of these findings with existing theory on behavioral flexibility, the specificity of the results across phenotypes, and the consistency of results across analyses (i.e., completer and intent to treat), we conclude that 5HTT polymorphism and the endophenotype psychological flexibility are important variables for the treatment of PD/AG. The endophenotype psychological flexibility may help bridge genetic and psychological literatures. Despite the limitation of the post hoc nature of these analyses, further study is clearly warranted.

Cognitive and psychological flexibility after a traumatic brain injury and the implications for treatment in acceptance-based therapies: A conceptual review

This paper provides a selective review of cognitive and psychological flexibility in the context of treatment for psychological distress after traumatic brain injury, with a focus on acceptance-based therapies. Cognitive flexibility is a component of executive function that is referred to mostly in the context of neuropsychological research and practice. Psychological flexibility, from a clinical psychology perspective, is linked to health and well-being and is an identified treatment outcome for therapies such as acceptance and commitment therapy (ACT). There are a number of overlaps between the constructs. They both manifest in the ability to change behaviour (either a thought or an action) in response to environmental change, with similarities in neural substrate and mental processes. Impairments in both show a strong association with psychopathology. People with a traumatic brain injury (TBI) often suffer impairments in their cognitive flexibility as a result of damage to areas controlling executive processes but have a positive response to therapies that promote psychological flexibility. Overall, psychological flexibility appears a more overarching construct and cognitive flexibility may be a subcomponent of it but not necessarily a pre-requisite. Further research into therapies which claim to improve psychological flexibility, such as ACT, needs to be undertaken in TBI populations in order to clarify its utility in this group.

Depression and disability in migraine: the role of pain acceptance and values-based action

BACKGROUND

Migraine is a complex neurological disorder that substantially impairs a person's functioning and is often comorbid with depression. Currently, little is known about psychological coping strategies that may underlie disability and depression in patients with migraine.

PURPOSE

This study examines concurrent relations between depression and disability on the one hand and pain acceptance and values-based action on the other hand in patients with migraine.

METHOD

Ninety-three patients with migraine and depressive symptoms-being evaluated for a larger project examining the impact of a behavioral intervention on depression in patients with migraine-completed measures of depression, disability, pain acceptance, and values-based action. Using multiple regression analyses, the contributions of pain acceptance and values-based action to depression and disability were assessed.

RESULTS

Low pain acceptance was strongly associated with depression and disability (r s(2) = .15-.37) in these patients. Low pain acceptance also explained unique variance in disability, beyond that of depression. Values-based action related modestly to depression and disability (r s(2) = .02-.07).

CONCLUSION

Pain acceptance can contribute to our understanding of psychological health and functioning. An important next step would be to examine whether targeting acceptance in treatment of patients with migraine would lead to improvements in their mental health and functioning.

Building Psychological Flexibility to Mitigate Adjustment Disorder

Clients who present to psychotherapy reporting diffuse and/or sub-clinical concerns may provide a puzzling treatment decision for providers of evidence-based practice. The current case study illustrates the implementation of an evidence-based treatment, Acceptance and Commitment Therapy (ACT), for a client diagnosed with adjustment disorder with mixed anxiety and depressive symptoms. ACT targets a dimensional, transdiagnostic construct known as psychological flexibility, currently conceptualized as involving six inter-related behavioral repertoires. The client was a Caucasian woman in her 30s who self-referred to therapy. She reported feeling anxious and depressed, especially in regard to interpersonal difficulties with her mother and her ex-husband. Fourteen sessions of an ACT protocol emphasizing a modular approach to the repertoires emphasized by the psychological flexibility model were provided. Each modular session consisted of psychoeducation, metaphors, experiential exercises, and daily practice assignments for one of the repertoires. The client completed pre-treatment, post-treatment, and 6-month follow-up outcome measures and weekly process measures to track change throughout treatment. One process measure assessed each of the six repertoires. The client’s data revealed substantial increases in psychological flexibility and decreases in psychological distress from pre- to post-treatment, which remained stable at follow-up. This case report suggests that ACT may be a desirable treatment option for clients bearing ambiguous or sub-clinical presentations, including interpersonal conflicts. The report also provides a model for monitoring change with individual psychological flexibility repertoires with respect to a modular approach to teaching those repertoires.