The role of psychological flexibility in a self-help acceptance and commitment therapy intervention for psychological distress in a randomized controlled trial

Internet-based acceptance and commitment therapy for obsessive-compulsive symptoms: A randomized controlled trial

Subthreshold obsessive-compulsive symptoms (OCS) are associated with increased distress, help seeking behaviours, and functional problems, and may predict progression into further mental health problems. This study investigated the effectiveness of a four-module internet-based acceptance and commitment therapy (iACT) for adults with OCS compared to internet-based progressive relaxation training (iPRT). Eighty-nine adults with OCS participated in a single-blinded randomised controlled trial of iACT or iPRT. Self-report assessments of OCS, psychological flexibility, and quality of life, among others, were measured at baseline, post-treatment, and at three-month follow-up. Both iACT and iPRT showed large pre-post improvements in OCS (b = 6.32, p < 0.001, d = 0.8) and medium improvements in psychological flexibility (b = -0.38, p = 0.011, d = 0.47) and quality of life (b = -5.26, p = 0.008, d = 0.58), with no significant differences in effects between groups. All improvements were maintained at follow-up. There were no differences in attrition or adherence between groups. iACT was rated more favourably by participants at post-treatment, and there were some differences in qualitative feedback across groups. These findings suggest both iPRT and iACT may be helpful in improving mental health in adults with OCS, but that iACT may be more acceptable.

Examining domains of psychological flexibility and inflexibility as treatment mechanisms in acceptance and commitment therapy: A comprehensive systematic and meta-analytic review

The current systematic and meta-analytic review sought to integrate a growing number of studies examining dimensions of psychological flexibility as treatment mechanisms for Acceptance and Commitment Therapy (ACT). Analyses of 77 records (67 unique studies; Ntotal = 9123 participants) from comprehensive searches of multiple databases suggested that ACT interventions led to reduced inflexibility (i.e., lowered global inflexibility, lack of present moment awareness, cognitive fusion, experiential avoidance, self-as-content, & inaction) and increased flexibility (i.e., committed action/contact with values, global flexibility/acceptance, & defusion). Those changes remained significant when ACT was compared with waitlist or active treatments and were significantly linked to corresponding drops in psychological distress, supporting their roles as ACT treatment mechanisms. Moderation analyses revealed that the use of student samples, exclusion of clinically symptomatic individuals, and comparisons of ACT with other active treatments weakened these effects whereas offering ACT as an individual therapy and excluding individuals in extreme crisis (i.e., with suicidal ideation) strengthened them. The meta-analytic findings and systematic review suggested specific recommendations for future clinical work and research on ACT mechanisms: (1) Evaluate both psychological flexibility and inflexibility as distinct treatment mechanisms, (2) Evaluate specific dimensions of psychological flexibility/inflexibility as mechanisms with multidimensional scales (CompACT, MPFI), (3) Broaden treatment outcomes to include forms of wellbeing (peace of mind, vitality, connectedness), (4) Assess mechanisms and outcomes repeatedly throughout treatment to model the process of therapeutic change, (5) Investigate non-specific factors (therapeutic alliance, treatment adherence) as mechanisms, and (6) Explore treatment mechanisms in effectiveness studies.

Cross-cultural validity and reliability of the comprehensive assessment of acceptance and commitment therapy processes (CompACT) in people with multiple sclerosis

PURPOSE

The Comprehensive assessment of Acceptance and Commitment Therapy (CompACT) is a 23-item questionnaire measuring psychological flexibility, a quality of life protective factor. An 18-item version was recently produced. We assessed validity and reliability of CompACT, and equivalence of paper and electronic (eCompACT) versions in people with multiple sclerosis (PwMS) in Italy, Germany and Spain.

METHODS

We used confirmatory factor analysis and assessed CompACT-23 and CompACT-18 measurement invariance between the three language versions. We assessed construct validity (Spearman's correlations) and internal consistency (Cronbach's alpha). Test-retest reliability (intraclass correlation coefficient, ICC) and equivalence of paper and eCompACT (ICC and linear regression model for repeated measures) were assessed in subsamples of PwMS.

RESULTS

A total of 725 PwMS completed the study. The three-factor structure of the CompACT-23 showed poor fit (RMSEA 0.07; CFI 0.82; SRMR 0.08), while the fit of the CompACT-18 was good (RMSEA 0.05; CFI 0.93; SRMR 0.05). Configural and partial metric invariance were confirmed, as well as partial scalar invariance (reached when five items were allowed to vary freely). The CompACT-18 showed good internal consistency (all alpha ≥ 0.78); and test-retest reliability (all ICCs ≥ 0.86). Equivalence between paper and eCompACT was excellent (all ICCs ≥ 0.86), with no mode, order, or interaction effects.

CONCLUSION

Results support using the refined CompACT-18 as a three-factor measure of psychological flexibility in PwMS. Paper and eCompACT-18 versions are equivalent. CompACT-18 can be used cross-culturally, but sub-optimal scalar invariance suggests that direct comparison between the three language versions should be interpreted with caution.

The illusion of inclusion: contextual behavioral science and the Black community

Anti-racism approaches require an honest examination of cause, impact, and committed action to change, despite discomfort and without experiential avoidance. While contextual behavioral science (CBS) and third wave cognitive-behavioral modalities demonstrate efficacy among samples composed of primarily White individuals, data regarding their efficacy with people of color, and Black Americans in particular, is lacking. It is important to consider the possible effects of racial stress and trauma on Black clients, and to tailor approaches and techniques grounded in CBS accordingly. We describe how CBS has not done enough to address the needs of Black American communities, using Acceptance and Commitment Therapy (ACT) and Functional Analytic Psychotherapy (FAP) as examples. We also provide examples at the level of research representation, organizational practices, and personal experiences to illuminate covert racist policy tools that maintain inequities. Towards eradicating existing racism in the field, we conclude with suggestions for researchers and leadership in professional psychological organizations.

Effect of group-based acceptance and commitment therapy on older stroke survivors: study protocol for a randomized controlled trial

INTRODUCTION

Older stroke survivors usually experience various psychology disorders, such as post-stroke depression (PSD), which may be associated with high experiential avoidance (EA) and can seriously affect their quality of life. To date, the efficacy of group-based acceptance and commitment therapy (ACT) for older stroke survivors has not been established. The aim of this study is to investigate the effectiveness of group-based ACT on EA, PSD, psychological distress, and quality of life in older stroke survivors after group-based ACT.

METHODS AND ANALYSIS

This study is a randomized, single-blind, wait-list controlled, parallel-arm trial. A total of 66 stroke survivors will be randomly assigned to wait-list control group or intervention group. Participants in wait-list control group will receive treatment as usual (TAU), while the intervention group will receive group-based ACT once a week for eight weeks. The primary outcome measure being EA, and the secondary outcome measures being PSD, psychological distress, and quality of life. Results of the two groups will be blindly assessed by professional evaluators at baseline (T0), post-treatment (T1), and one-month follow up (T2).

DISCUSSION

The results of this study will provide the first evidence for the effectiveness of a group-based ACT intervention in reducing EA, PSD, psychological stress, and improving quality of life for post-stroke survivors.

TRIAL REGISTRATION

ChiCTR2200066361.

Acceptance and Commitment Therapy Processes Differentially Predict Aspects of Mental Health

Psychological flexibility relates to various aspects of mental health, including psychological distress and adaptive mental health. The CompACT has been developed to assess psychological flexibility by quantifying psychological flexibility as a multidimensional whole, and by three processes of psychological flexibility including, Openness to Experience (OE), Behavioral Awareness (BA), and Valued Action (VA). The current study examined the unique predictive property of each three process of the CompACT with aspects of mental health. Participants (N = 593) were a diverse sample of United States adults. Our results found OE and BA significantly predicted depression, anxiety, and stress. OE and VA significantly predicted satisfaction with life, and all three processes significantly predicted resilience. Our results support multidimensional assessment of psychological flexibility when examining aspects of mental health.

The Effectiveness of Mindful Hypnotherapy on Depression, Self-Compassion, and Psychological Inflexibility in Females with Major Depressive Disorder: A Single-Blind, Randomized Clinical Trial

The effectiveness of the novel intervention mindful hypnotherapy on depression, self-compassion, and psychological inflexibility in females with major depressive disorder was examined in a randomized, clinical trial. Thirty-four participants were randomly allocated into mindful hypnotherapy and waitlist control groups. The intervention group was treated in 8 face-to-face, 60-minute weekly therapy sessions along with mindful hypnosis audio tapes to be used daily. The results of analysis of covariance indicated that there were significant differences between the mindful hypnotherapy and waitlist control groups after intervention and at 2-month follow-up (p < .001). The between-subject test of repeated measures ANOVAs also indicated a clinically significant difference between groups across time (baseline, postintervention, and 2-month follow-up) in depression, F = 53.86, p < .001, effect size = .65, and in self-compassion, F = 33.18, p < .001, effect size = .53, as well as psychological inflexibility, F = 26.84, p < .001, effect size = .48. In conclusion, this study indicates that mindful hypnotherapy is an effective intervention for treating depression as well as reducing psychological inflexibility and improving self-compassion for patients with major depressive disorder.

Trait Acceptance Buffers Aggressive Tendency by the Regulation of Anger during Social Exclusion

Social exclusion has led to increased negative emotions and aggressive behaviors, two outcomes that are correlated with each other. Thus, the down-regulation of negative emotions appears to play a crucial role in reducing the tendency for aggressive behavior. However, this assumption has not yet been tested. To this end, a total of 397 undergraduates reported their aggressive tendencies, state emotions and trait acceptance by completing corresponding questionnaires, and a recall paradigm was used to induce experiences of social exclusion. The results showed that in the context of social exclusion, (1) trait acceptance was negatively correlated with negative emotions and aggressive tendency but was positively correlated with positive emotions; (2) negative emotions, rather than positive emotions, were positively correlated with aggressive tendency; (3) increased trait acceptance buffered the experience of anger, which is, in turn, related to reduced aggressive tendency; (4) trait acceptance also downregulated the feeling of sadness, which is, however, related to increased aggression; (5) the mediator of sadness was smaller in effect size than that of anger. Taken together, these results suggest that negative emotions are associated with aggression in the context of social exclusion, and the habitual use of an acceptance strategy was conductive to decreasing aggressive tendencies by decreasing anger.

The impact of psychological flexibility on family dynamics amidst the COVID-19 pandemic: A longitudinal perspective

Background

Health risks associated with contracting COVID-19, stay-at-home orders, and pandemic-related economic and social hardships created unique challenges for individuals throughout the pandemic, and in particular for families whose daily routines were disrupted at the start of the pandemic. This study applied a contextual behavioral science lens to Family Systems Theory to examine the impact of COVID-19 stressors on family and individual functioning.

Methods

A sample of 742 coparents (86% married/engaged; 84% Caucasian; 71% female; M = 40.7 years old, SD = 8.1; M _income = $82,435, SD _income = $27,604) of school-aged children (5-18 years old) completed a baseline survey from late March to late April 2020. Of the initial sample, 556 coparents completed weekly diaries for 8 weeks.

Results

Mediation models were tested within a multilevel path modeling framework to evaluate both the stable, between-family differences (i.e., at level 2) and the within-family changes from week to week (i.e., at level 1). Across both levels of the model, parent psychological inflexibility was robustly linked to poorer functioning across all levels of the family system, showing direct links to a majority of the processes assessed. The results further supported a top-down spillover cascade in which parent inflexibility was proximally linked to greater COVID-19 related stress and parent depressive symptoms, which were proximally linked to poorer romantic functioning (greater negative conflict, lower satisfaction), which were proximally linked to poorer family functioning (greater coparent discord and family chaos), which were proximally linked to poorer parenting (greater angry/reactive parenting), which was proximally linked to greater child distress. Multi-group models suggested that the results were largely stable across (1) parent race (white vs non-white), (2) family size (1 child vs 2 or more), (3) child age (less than 10 years old vs 10 or older), (4) parent age (under 40 vs. 40 or older), (5) perceived COVID-19 risk, (6) parent gender (mothers vs fathers), (7) household income groups (less than $100k vs $100k or more), and (8) perceived economic stress/uncertainty (low vs high). However, a handful of moderated effects emerged from those multi-group models suggesting that fathers might be slightly more prone to negative spillover effects across the family systems and that wealthier families might have experienced the stress of new demands (e.g., homeschooling, remote working) as more disruptive.

Conclusions

Results highlight the crucial role parental psychological flexibility and inflexibility play in families managing the stress of COVID-19, as well as key mechanisms for how those stressors may either reverberate or become dampened throughout the family system.

Effects of internet-based acceptance and commitment therapy on process measures: A systematic review and meta-analysis (Preprint)

Background

Acceptance and commitment therapy (ACT) is based on a psychological flexibility model that encompasses 6 processes: acceptance, cognitive defusion, self-as-context, being present, values, and committed action.

Objective

This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to examine the effects of internet-based ACT (iACT) on process measures.

Methods

A comprehensive search was conducted using 4 databases. The quality of the included RCTs was assessed using the Cochrane Collaboration Risk of Bias Tool. A random-effects or fixed-effects model was used. Subgroup analyses for each outcome were conducted according to the type of control group, use of therapist guidance, delivery modes, and use of targeted participants, when applicable.

Results

A total of 34 RCTs met the inclusion criteria. This meta-analysis found that iACT had a medium effect on psychological flexibility and small effects on mindfulness, valued living, and cognitive defusion at the immediate posttest. In addition, iACT had a small effect on psychological flexibility at follow-up. The overall risk of bias across studies was unclear.

Conclusions

Relatively few studies have compared the effects of iACT with active control groups and measured the effects on mindfulness, valued living, and cognitive defusion. These findings support the processes of change in iACT, which mental health practitioners can use to support the use of iACT.

The Role of Distress Tolerance in the Relationship Between Affect and NSSI

OBJECTIVE

Non-suicidal self-injury (NSSI), the deliberate and self-inflicted damage of body tissue, typically serves an emotion regulation function. Both negative and positive affectivity have been associated with NSSI, as has low distress tolerance. In the current study, we tested whether relationships between both negative and positive affectivity and NSSI are moderated by the four facets of distress tolerance (tolerance, absorption, appraisal, regulation) captured by the Distress Tolerance Scale.

METHODS

A sample of 531 university students completed well-validated measures of NSSI, negative affectivity, positive affectivity, and distress tolerance.

RESULTS

Findings indicate that negative and positive affectivity, as well as the appraisal (i.e. negative perceptions of distress) and absorption (i.e. allocation of attention to distress) facets of distress tolerance, were directly associated with NSSI. Positive affectivity and appraisal also interacted in differentiating participants with recent, lifetime and no history of NSSI. Specifically, the association between negative perceptions of distress and self-injury was weaker at high levels of positive affectivity. Positive affectivity and absorption also interacted to differentiate between individuals with no history of NSSI and individuals who recently engaged in NSSI. Specifically, positive affectivity was negatively associated with self-injury, but only among individuals who allocate less attention to their distress.

CONCLUSIONS

Considering the independent roles of negative and positive affectivity alongside specific facets of distress tolerance and their interactions with emotional experience, may enhance understanding of NSSI. Prevention and intervention initiatives that assist regulation of negative affectivity, increase positive affectivity, and improve distress tolerance, may reduce the likelihood of engaging in self-injury.HighlightsNegative and positive affectivity are independently associated with NSSIAppraisal and absorption facets of distress tolerance are associated with NSSIPositive affectivity moderates associations between appraisal and absorption and NSSI.

Deconstructing recovery: A prospective study on well-being, symptom severity and acceptance in patients with major depressive disorders

BACKGROUND

Perceived well-being is key in the recovery from major depressive disorder (MDD). It is however unclear how well-being relates to other aspects of recovery, like depressive symptom severity, acceptance, disease identification and social participation. In patients with MDD we investigated 1) changes in these five concepts over time, 2) which concepts associate with well-being, and 3) whether a relationship between depressive symptoms and well-being is moderated by acceptance, disease identification and social participation.

METHODS

Adult outpatients with MDD (n=77) were administered the Mental Health Continuum-Short Form, the Inventory of Depressive Symptomatology, the Acceptance and Action Questionnaire-II, the Pictorial Representation of Illness and Self Measure, and the Scale Functional Remission before treatment and six months later. Changes over time were tested using paired samples t-tests, associations between concepts were tested with correlations. Regression analyses were used to test moderation effects.

RESULTS

Participants improved on all outcome measures. Well-being correlated moderately with depressive symptom severity (negative correlation) and acceptance at baseline, and strongly at follow-up. At follow-up well-being also correlated moderately with disease identification and social participation. No evidence for moderation was found.

LIMITATIONS

Recruitment in one regional mental health center might limit generalizability. Furthermore, confounding effects of psychiatric comorbidity on recovery and well-being cannot be ruled out.

CONCLUSION

Recovery in patients with MDD is associated with improvement on multiple outcome domains. Symptom severity and acceptance showed the strongest association with perceived well-being. Future studies should explore whether treatments targeting symptom severity and acceptance have the strongest impact on recovery.

Therapeutic processes in digital interventions for anxiety: A systematic review and meta-analytic structural equation modeling of randomized controlled trials

While the efficacy of Internet- and mobile-based interventions (IMIs) for treating anxiety disorders is well established, there is no comprehensive overview about the underlying therapeutic processes so far. Thus, this systematic review and meta-analysis evaluated research on mediators and mechanisms of change in IMIs for adult anxiety disorders (PROSPERO: CRD42020185545). A systematic literature search was performed in five databases (i.e., CENTRAL, Embase, MEDLINE, PsycINFO and ClinicalTrials.gov). Two reviewers independently screened studies for inclusion, assessed the risk of bias and adherence to quality criteria for process research. Overall, 26 studies (N = 6042) investigating 64 mediators were included. Samples consisted predominantly of participants with clinically relevant symptoms of generalized anxiety disorder and severe health anxiety, as well as of participants with non-clinically relevant anxiety symptoms. The largest group of examined mediators (45%) were cognitive variables, evincing also the second highest proportion of significance (19/29); followed in numbers by skills (examined: 22%; significant: 10/14) and a wide range of other (19%; 7/12), emotional/affective (11%; 2/7) and behavioral mediators (3%; 1/2). Meta-analytical synthesis of mediators, limited by a small number of eligible studies, was conducted by deploying a two-stage structural equation modeling approach, resulting in a significant indirect effect for negative thinking (k = 3 studies) and non-significant indirect effects for combined cognitive variables, both in clinical (k = 5) and non-clinical samples (k = 3). The findings of this review might further the understanding on presumed change mechanisms in IMIs for anxiety, informing intervention development and the concurrent optimization of outcomes. Furthermore, by reviewing eligible mediation studies, we discuss methodological implications and recommendations for future process research, striving for causally robust findings. Future studies should investigate a broader range of variables as potential mediators, as well as to develop and apply original (digital) process and engagement measures to gather qualitative and high-resolution data on therapeutic processes.

Behind the masks: A cross-sectional study on intolerance of uncertainty, perceived vulnerability to disease and psychological flexibility in relation to state anxiety and wellbeing during the COVID-19 pandemic

Early findings suggest the COVID-19 pandemic and related containment measures negatively impact mental wellbeing. This study compared the contribution and relations of three factors to anxiety and wellbeing during the pandemic in June 2020. These factors were: i) Contextual factors (e.g. exposure to COVID-19, being a keyworker, feeling lonely); ii) Cognitive appraisals: perceived vulnerability to disease (PVD) and intolerance of uncertainty (IU); and iii) psychological flexibility (PF). 603 participants aged 18 or older completed an online survey of self-report measures. Hierarchical regression analyses demonstrated PVD, IU and PF predicted state anxiety, and IU and PF predicted mental wellbeing. Some, but not all of the contextual factors also predicted state anxiety and wellbeing. The findings support cognitive appraisal theories and the PF model, lending support to an acceptance and commitment therapy (ACT) approach to public health during pandemics.

A randomized controlled trial of a mindfulness-based intervention in social workers working during the COVID-19 crisis

As one of the frontline professionals during the coronavirus (COVID-19) pandemic, social workers can face tremendous pressure, which can lead to mental health problems. The objective of this study was to investigate whether a brief mindfulness-based intervention had short- and middle-term effects on social workers working during the COVID-19 pandemic. In a randomized controlled trial, 49 social workers were assigned to an experimental group (n = 28) or a waitlist control group (n = 21). The intervention was a four-week mindfulness-based program. The outcome variables were measured at pre- and post-test, and at one-month follow-up test. At post-test and follow-up, the workers in the experimental group reported higher mean scores in psychological flexibility and self-compassion and lower mean scores in depression compared to the workers in the waitlist control group. Although the experimental group also showed lower mean scores than the waitlist control group in anxiety and stress at both post-test and follow, the differences were not statistically significant. The findings suggest that a brief mindfulness-based intervention can improve psychological flexibility, self-compassion, and depression in social workers working during the COVID-19 crisis, leading to protected mental health, adding support to continuing development of such efficient mindfulness-based programs. Future studies should use larger samples and examine brief interventions’ working mechanisms.

Reducing drug-use harms among higher education students: MyUSE contextual-behaviour change digital intervention development using the Behaviour Change Wheel

BACKGROUND

Digital harm-reduction interventions typically focus on people with severe drug-use problems, yet these interventions have moderate effectiveness on drug-users with lower levels of risk of harm. The difference in effectiveness may be explained by differences in behavioural patterns between the two groupings. Harnessing behavioural theories to understand what is at the core of drug-use behaviours and mapping the content of new interventions, may improve upon the effectiveness of interventions for lower-risk drug-users. To the best of our knowledge, this is the first study to systematically apply the Behaviour Change Wheel (BCW) approach to understand the components, influencing capabilities, opportunities, and motivations (COM-B) of higher education students to change their drug-use behaviors. It is also the first study which identifies specific patterns of behaviours that are more responsive to harm reduction practices through the use of the Theoretical Domain Framework (TDF).

METHODS

We employed an explanatory sequential mix-method design. We first conducted an on-line survey and a Delphi exercise to understand the factors influencing COM-B components of higher education students to change their drug-use. Subsequently, we mapped all evidence onto the COM-B components and the TDF domains to identify clusters of behaviours to target for change, using a pattern-based discourse analysis. Finally, a series of multidisciplinary group meetings identified the intervention functions-the means by which the intervention change targeted behaviours and the Behavioural Change Techniques (BCTs) involved using the behaviour change technique taxonomy (v.1).

RESULTS

Twenty-nine BCTs relevant to harm-reduction practices were identified and mapped across five intervention functions (education, modelling, persuasion, incentivization, and training) and five policy categories (communication/marketing, guidelines, regulation, service provision, and environmental/social planning). These BCTs were distributed across eight identified saturated clusters of behaviours MyUSE intervention attempts to change.

CONCLUSIONS

The BCTs, identified, will inform the development of a digitally delivered behaviour change intervention that focuses on increasing mindful decision-making with respect to drug-use and promotes alternatives to drug-use activities. The findings can also inform implementation scientists in applying context-specific harm-reduction practices in higher education. We present examples of how the eight identified clusters of target behaviours are mapped across the COM-B components and the TDF, along with suggestions of implementation practices for harm reduction at student population level.

Validation of the Chinese Version of the Body Image Acceptance and Action Questionnaire and the Mediating Role of Body Image Flexibility in the Relationship Between Body Dissatisfaction and Psychological Distress

The psychometric properties of the Chinese version of the Body Image Acceptance and Action Questionnaire (C-BI-AAQ) and its short form (C-BI-AAQ-5) were examined with a sample of Chinese undergraduates (n =1,068, 52.6% female). The factor structure, measurement reliability, measurement invariance across gender, and latent gender mean difference of the two scales were explored. Confirmatory factor analysis was used to examine the factor structure of the C-BI-AAQ and the C-BI-AAQ-5. The original one-factor structure was replicated for both the C-BI-AAQ and the C-BI-AAQ-5. Both the C-BI-AAQ and C-BI-AAQ-5 showed good internal consistency, test-retest reliability, and convergent and discriminant validity (e.g., relationship patterns in the expected directions with theoretically similar psychological flexibility, and with theoretically dissimilar body dissatisfaction, and psychological distress). The C-BI-AAQ-5 was shown to be equivalent to the C-BI-AAQ. Furthermore, strict measurement invariance across gender was confirmed for both the C-BI-AAQ and C-BI-AAQ-5, and latent mean difference tests showed that men had higher levels of body image flexibility than women. Thus, both the C-BI-AAQ and C-BI-AAQ-5 appear to be psychometrically sound instruments for use in the Chinese young adult population. In addition, body image flexibility measured by both the C-BI-AAQ and the C-BI-AAQ-5 fully mediated the relationship between body dissatisfaction and psychological distress.

Internet-Based Acceptance and Commitment Therapy: A Transdiagnostic Systematic Review and Meta-Analysis for Mental Health Outcomes

Internet-based acceptance and commitment therapy (iACT) primarily targets the process of psychological flexibility. Its accessibility and low-intensity delivery are applicable across different treatment and prevention scenarios. This transdiagnostic meta-analysis reviews the effectiveness of iACT on anxiety, depression, quality of life, and psychological flexibility across individuals with different psychological and somatic conditions/complaints, or undiagnosed complaints. Seven databases were searched for randomized controlled trials that reported on anxiety, depression, quality of life, and psychological flexibility outcomes from iACT in any adult population. Engagement with iACT was summarized and methodological and population-related variables were investigated as potential moderators of effectiveness. Across 25 studies, small pooled effects were found for all outcomes at post-assessment and maintained at follow-up time-points. Interventions with therapist guidance demonstrated greater effectiveness in improving depression and psychological flexibility outcomes compared to nonguided iACT, and populations defined by a psychological condition or symptoms (e.g., depressed samples) demonstrated greater improvements in anxiety compared to nonclinical or somatic populations (e.g., chronic pain samples or students). Participants completed on average 75.77% of iACT treatments. While we found iACT to be effective in improving and maintaining mental health outcomes across diverse populations, there was limited evidence of reliable, clinically significant effects. PROSPERO registration number: CRD42020140086.

One year follow-up and mediation in cognitive behavioral therapy and acceptance and commitment therapy for adult depression

BACKGROUND

Existing therapies for depression are effective, but many patients fail to recover or relapse. To improve care for patients, more research into the effectiveness and working mechanisms of treatments is needed. We examined the long-term efficacy of Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) for Major Depressive Disorder (MDD), testing the hypothesis that CBT outperforms ACT and that both therapies work through their designated mechanisms of change.

METHODS

We conducted a randomized controlled trial with 82 patients suffering from MDD. Data were collected before, during and after treatment, and at 12-month follow-up, assessing symptoms of depression, quality of life, dysfunctional attitudes, decentering, and experiential avoidance.

RESULTS

Patients in both conditions reported significant and large reductions of depressive symptoms (d = - 1.26 to - 1.60) and improvement in quality of life (d = 0.91 to - 1.28) 12 months following treatment. Our findings indicated no significant differences between the two interventions. Dysfunctional attitudes and decentering mediated treatment effects of depressive symptoms in both CBT and ACT, whereas experiential avoidance mediated treatment effects in ACT only.

CONCLUSIONS

Our results indicate that CBT is not more effective in treating depression than ACT. Both treatments seem to work through changes in dysfunctional attitudes and decentering, even though the treatments differ substantially. Change in experiential avoidance as an underlying mechanism seems to be an ACT-specific process. Further research is needed to investigate whether ACT and CBT may work differently for different groups of patients with depression.

TRIAL REGISTRATION

clinicaltrials.gov; NCT01517503 . Registered 25 January 2012 - Retrospectively registered.

Knowledge of COVID-19 and Its Influence on Mindfulness, Cognitive Emotion Regulation and Psychological Flexibility in the Indian Community

The current global pandemic caused by COVID-19 has brought about an immense effect on the mental health of the general public. Considering the escalation in number of cases, mankind is facing a myriad of psychological problems, ranging from those related to taking precautions and maintaining safety to the ones caused by separation and bereavement. The current study aims to explore whether there is a significant difference between individuals with excellent, good, fair and vague knowledge of COVID-19 with respect to depression, anxiety, stress, level of mindfulness, specific cognitive emotion regulation strategies and psychological flexibility; to find out whether there is any significant relationship among these variables; and to determine whether knowledge of COVID-19, level of mindfulness, specific cognitive emotion regulation strategies and psychological flexibility are significant predictors of depression, anxiety and stress in the sample of the current study. The sample consisted of 402 individuals selected from the community following the research criteria. Data was collected using digital consent form, information schedule and questionnaires, from 3rd May to 13th May, 2020. The questionnaires consisted of a semi-structured interview schedule to assess knowledge of COVID-19, Depression, Anxiety and Stress Scale - 21, Five Facet Mindfulness Questionnaire-Short Form, Cognitive Emotion Regulation Questionnaire-Short version and Acceptance and Action Questionnaire-II. The data was statistically analyzed using analysis of variance test, correlational analysis and linear regression. The findings show that significant differences were present among individuals having varying degrees of knowledge of COVID-19 with respect to anxiety, level of mindfulness and psychological flexibility. Significant relationships were found to be present among the variables of the present study, having differing trends brought forward by the COVID-19 crisis. Certain socio-demographic characteristics and study variables were found to significantly predict the existing levels of depression, anxiety and stress in the current sample. The study suggests the necessity to formulate and implement appropriate mindfulness-based therapeutic interventions to address the mental health concerns arising as a result of the pandemic.

Psychological flexibility and inflexibility as sources of resiliency and risk during a pandemic: Modeling the cascade of COVID-19 stress on family systems with a contextual behavioral science lens

BACKGROUND

The coronavirus disease (COVID-19) pandemic and the historic economic shutdown and stay-at-home efforts to slow its spread have radically impacted the lives of families across the world, completely disrupting routines and challenging them to adjust to new health risks as well as to new work and family demands. The current study applied a contextual behavioral science lens to the spillover hypothesis of Family Systems Theory to develop a multi-stage mechanistic model for how COVID-19 stress could impact family and child functioning and how parents' psychological flexibility could shape those processes.

METHODS

A total of 742 coparents (71% female; 84% Caucasian, 85% married, M = 41 years old) of children (ages 5-18, M = 9.4 years old, 50% male) completed an online survey from March 27th to the end of April 2020.

RESULTS

Path analyses highlighted robust links from parent inflexibility to all components of the model, predicting: greater COVID-19 stress, greater coparenting discord and family discord, greater caustic parenting, and greater parent and child distress. Parent flexibility was associated with greater family cohesion, lower family discord and greater use of constructive parenting strategies (inductive, democratic/autonomy supportive, positive). Results further suggested that COVID-19 stressors predicted greater family and coparent discord, which in turn predicted greater use of caustic parenting (reactive, inconsistent, aggressive), which in turn predicted greater child and parent distress.

CONCLUSIONS

The current results highlight parental flexibility and inflexibility as key points of intervention for helping families navigate the current global health crisis, highlighting the crucial role they play in the lives of families.

Examining mediators of change in wellbeing, stress, and depression in a blended, Internet-based, ACT intervention for university students

A coach-guided Acceptance and Commitment Therapy (ACT) intervention that uses a blended approach of two face-to-face and five online sessions (iACT; N = 33) has been found to be more effective than a waiting-list control condition (WLC; N = 35) at enhancing the wellbeing of university students while also reducing stress and depression. The present study explored possible mediators of change that may account for the outcomes of the study. Mediation analyses revealed that changes in the non-reactivity subscale of mindfulness mediated changes in wellbeing, depression, and stress in the iACT group. In addition, changes in the sense of coherence subscale of meaningfulness mediated changes in all outcomes. Psychological flexibility and cognitive defusion did not mediate changes in outcomes. The results suggest that the use of practices focusing on non-reactivity, meaning the ability to allow thoughts and feelings to come and go without getting carried away by them, is especially important for enhancing the wellbeing of university students. A focus on enhancing meaningfulness also plays a significant role in reducing psychological distress. These findings provide a first step toward understanding the potential mechanisms of change taking place in brief, Internet-supported, blended ACT programs.

Psychological Flexibility in Depression Relapse Prevention: Processes of Change and Positive Mental Health in Group-Based ACT for Residual Symptoms

Relapse rates following a depressive episode are high, with limited treatments available aimed at reducing such risk. Acceptance and commitment therapy (ACT) is a cognitive-behavioral approach that has gained increased empirical support in treatment of depression, and thus represents an alternative in relapse prevention. Psychological flexibility (PF) plays an important role in mental health according to the model on which ACT is based. This study aimed to investigate the role of PF and its subprocesses in reducing residual symptoms of depression and in improving positive mental health following an 8-week group-based ACT treatment. Adult participants (75.7% female) with a history of depression, but currently exhibiting residual symptoms (N = 106) completed measures before and after intervention, and at 6 and 12-month follow-up. A growth curve model showed that positive mental health increased over 12-months. Multilevel mediation modeling revealed that PF significantly mediated these changes as well as the reduction of depressive symptoms, and that processes of acceptance, cognitive defusion, values and committed action, in turn, mediated increased PF.

The pursuit of euthymia

Psychiatrists often consider the positive characteristics displayed by a patient in their clinical judgment, yet current assessment and treatment strategies are shifted on the side of psychological dysfunction. Euthymia is a transdiagnostic construct referring to the presence of positive affects and psychological well-being, i.e., balance and integration of psychic forces (flexibility), a unifying outlook on life which guides actions and feelings for shaping future accordingly (consistency), and resistance to stress (resilience and tolerance to anxiety or frustration). There is increasing evidence that the evaluation of euthymia and its components has major clinical implications. Specific instruments (clinical interviews and questionnaires) may be included in a clinimetric assessment strategy encompassing macro-analysis and staging. The pursuit of euthymia cannot be conceived as a therapeutic intervention for specific mental disorders, but as a transdiagnostic strategy to be incorporated in an individualized therapeutic plan. A number of psychotherapeutic techniques aiming to enhance positive affects and psychological well-being (such as well-being therapy, mindfulness-based cognitive therapy, and acceptance and commitment therapy) have been developed and validated in randomized controlled clinical trials. The findings indicate that flourishing and resilience can be promoted by specific interventions leading to a positive evaluation of one's self, a sense of continuing growth and development, the belief that life is purposeful and meaningful, satisfaction with one's relations with others, the capacity to manage effectively one's life, and a sense of self-determination.

Mediators in psychological and psychoeducational interventions for the prevention of depression and anxiety. A systematic review

Although efforts have been undertaken to determine how psychological interventions exert their effects, research on mediators and mechanisms of change remains limited, especially in the field of prevention. We aimed to assess available evidence on mediators of psychological and psychoeducational interventions for the prevention of depression and anxiety in varied populations. A systematic review using PubMed, PsycINFO, Web of Science, Embase, OpenGrey, and the Cochrane Central Register of Controlled Trials was performed. Two independent reviewers assessed the eligibility criteria of all articles, extracted data, determined the risk of bias in randomized controlled trials, and the requirements for mediators. The outcomes were mediators of the incidence of depression or anxiety and/or the reduction of symptoms of depression or anxiety. We identified 28 nested mediator studies within randomized controlled trials involving 7442 participants. Potential cognitive, behavioral, emotional and interpersonal mediators were evaluated in different psychological and psychoeducational interventions to prevent depression and anxiety. The effects were mediated mainly by cognitive variables, which were the most commonly assessed factors. For depression, the mediator with the strongest empirical support was negative thinking in adults. Cognitive change is an important mediator in preventive psychological and psychoeducational interventions for both anxiety and depression. REGISTRATION DETAILS: Registration number (PROSPERO): CRD42018092393.

The BrainACT study: acceptance and commitment therapy for depressive and anxiety symptoms following acquired brain injury: study protocol for a randomized controlled trial

BACKGROUND

Following an acquired brain injury, individuals frequently experience anxiety and/or depressive symptoms. However, current treatments for these symptoms are not very effective. A promising treatment is acceptance and commitment therapy (ACT), which is a third-wave behavioural therapy. The primary goal of this therapy is not to reduce symptoms, but to improve psychological flexibility and general well-being, which may be accompanied by a reduction in symptom severity. The aim of this study is to investigate the effectiveness of an adapted ACT intervention (BrainACT) in people with acquired brain injury who experience anxiety and/or depressive symptoms.

METHODS

The study is a multicenter, randomized, controlled, two-arm parallel trial. In total, 94 patients who survive a stroke or traumatic brain injury will be randomized into an ACT or control (i.e. psycho-education and relaxation) intervention. The primary outcome measures are the Hospital Anxiety and Depression Scale and the Depression Anxiety Stress Scale. Outcomes will be assessed by trained assessors, blinded to treatment condition, pre-treatment, during treatment, post-treatment, and at 7 and 12 months.

DISCUSSION

This study will contribute to the existing knowledge on how to treat psychological distress following acquired brain injury. If effective, BrainACT could be implemented in clinical practice and potentially help a large number of patients with acquired brain injury.

TRIAL REGISTRATION

Dutch Trial Register, NL691, NTR 7111. Registered on 26 March 2018. https://www.trialregister.nl/trial/6916.

[Intervention focused on resources to reduce anxiety and depression disorders in cancer patients: A pilot study]

INTRODUCTION

Cancer, a widespread chronic disease, represented 400,000 diagnoses in France in 2017. The diagnoses as well as the treatments are a major source of stress for most patients concerned. Secondary effects may be painful and disturbing (pain, nausea, fatigue, loss of social and/or professional status, anxiety of death), and may lead to maladaptive coping strategies (avoidant coping), psychological inflexibility, anxiety, depression, and suicide risks which are twice as important as in the general population. Research in the field of psychotherapy for cancer patients represents an important international target, in particular in what concerns enhanced patient quality of life during and after treatment. Cognitive Behavioral Therapy, Mindfulness-Based Stress Reduction, as well as adapted physical activity have shown promising results to enhance patients' quality of life at different stages of the process. However, results mainly show significant short-term effects and usually only for patients with high levels of anxiety and depression symptoms. With the development of third wave Cognitive Behavioral Therapy, more global interventions (not just aimed at anxiety and depression symptoms) have emerged. Research has underlined their efficacy on both symptom reduction (anxiety and depression) and quality of life enhancement through the development of more varied and adaptive responses to stressful situations. Positive psychology interventions, mindfulness, and Acceptance and Commitment Therapy have inspired third wave Cognitive Behavioral Therapy. Emotional acceptance, mindful awareness of thoughts and emotions, and engaging in actions that are coherent with one's values all form part of the means by which these interventions may help patients to find ways to better adjust to their stressful situation. The results of the efficacy trials carried out using these approaches were mixed, and effects were mainly modest. Furthermore, most of the studies only tested one approach at a time, while each approach activated mechanisms, which can be useful for these patients. Hence, the aim of the current study was to test an integrative program based on classical second wave Cognitive Behavioral Therapy as well as on practices from the third wave of Cognitive Behavioral Therapy. We aimed at carrying out a preliminary study assessing the potential effects of the program on cancer patients' anxiety, depression symptoms, well-being and psychological flexibility.

METHOD

Sixteen cancer patients were enrolled in a second and third wave Cognitive Behavioral Therapy workshop composed of six sessions. In-session practices were based on validated practices. Participants completed the following questionnaires before the first workshop (T1) and at the end of the sessions (T2) in order to assess anxiety, depression symptoms, well-being and psychological flexibility: HAD, WEMWBS, MPFI, AAQ-2. Qualitative data regarding acceptability were also collected at the end of the last session.

RESULTS

Among the sixteen participants, nine women (mean age=56.1years old) completed the questionnaires seven of whom had breast cancer. The results of this preliminary study showed a significant pre-to-post reduction in anxiety and depression symptoms (P=0.017) as well as on certain dimensions of psychological flexibility: reduced "self as content" (P=0.011), and enhanced cognitive diffusion (P=0.018). Only marginal differences were found on other dimensions: reduced inaction (P=0.074) and experiential avoidance (P=0.089), and enhanced "self as context" (P=0.062). Content analysis showed (1) increased positive perceptions about experiences with more serenity, (2) positive attitudes towards self (self-compassion), (3) enhanced positive relationships, and (4) ability to accept negative affect.

CONCLUSION

Patients' qualitative feedback highlighted the potential feasibility and adaptability of the program for this population. The results of this preliminary study show promising avenues for research in the field of cancer patients' adaptive coping enhancement as well as reduce anxiety and depression symptoms. This type of workshop can be considered as complementary to individual psychotherapies as they may tap into different mechanisms that help foster psychological flexibility as the group format enhances decentering processes. Further research avenues are proposed in order to assess the efficacy of such interventions in cancer patients compared to other types of interventions. Further research should also look into individual differences in order to orient patients towards practices that fit them best.

How is personality related to well-being in older and younger adults? The role of psychological flexibility

OBJECTIVES

Personality is known to be a reliable predictor of well-being. However, it is rather difficult to influence the personality of individuals in order to improve their well-being. Therefore, it is important to examine possible underlying mechanisms or indirect effects. Consequently, the aim of the current study was to investigate whether psychological flexibility is a mechanism explaining the relationship between personality and well-being. Given the evidence that age-related differences exist in personality, flexibility, and well-being, we also investigated whether our indirect effects model differed in both older and younger adults.

DESIGN

We used a cross-sectional design.

SETTING

Participants were asked to fill in questionnaires at home.

PARTICIPANTS

We recruited 138 younger (25-50 years) and 120 older (65+) adults from a community-dwelling population.

MEASUREMENTS

Self-report questionnaires were used to assess (mal)adaptive personality traits (Big Five), psychological flexibility, and affective and general subjective well-being.

RESULTS

Similar indirect effects were found in older and younger adults: Psychological flexibility is a mechanism explaining the link between personality and well-being. In nearly half of the models, psychological flexibility even fully accounted for the effect of personality on well-being.

CONCLUSION

These results have important implications for clinical practice, since psychological flexibility, contrary to personality traits, is malleable. Interventions to increase psychological flexibility already exist and are validated in both older and younger samples. They may hold promise to improve well-being.

Psychological Flexibility and Depression in New Mothers of Medically Vulnerable Infants: A Mediational Analysis

Objectives Maternal depression in the postpartum period is prevalent and associated with negative child outcomes, including behavior problems and cognitive delays. Mothers of children admitted directly after birth to the neonatal intensive care unit (NICU) are at even higher risk for depressive symptoms and infants born premature and/or at low birth weight may be more vulnerable to the adverse effects of maternal depression. Understanding mechanisms, particularly modifiable mechanisms, involved in the development or persistence of depressive symptoms is critically important for developing effective treatments. Methods The longitudinal, secondary analysis investigated the role of psychological inflexibility (rigidly avoiding or attempting to control distressing internal experiences, precluding present moment awareness of contingencies and engagement with important values) as a mediator of the relationship between early (1-2 weeks postpartum) and later (3 and 6 months postpartum) depressive symptoms among mothers with an infant in the NICU. Results Psychological inflexibility measured 2 weeks after infant discharge from the hospital fully mediated the relationship between early and later depressive symptoms at 3 months postpartum, with partial mediation at 6 months, while controlling for factors previously found predictive of postpartum depression. Conclusions for Practice Psychological inflexibility may be a mechanism by which postpartum depressive symptoms persist after hospital discharge among new mothers with a NICU infant. Acceptance and Mindfulness therapies which specifically target psychological inflexibility may be promising interventions to reduce depressive symptoms postpartum.

Evaluating ACT Processes in Relation to Outcome in Self-Help Treatment for Anxiety-Related Problems

Evaluating how, for whom, and under what conditions psychosocial treatments work is an important component of anxiety disorder treatment development. Yet, research regarding mediators and moderators of self-help interventions is sparse. The current project is a secondary analysis of mediators, moderators, and correlates of outcome of a randomized wait-list-controlled trial assessing acceptance and commitment therapy (ACT) self-help bibliotherapy for anxiety and related problems. Participants (n = 503) were randomized to an immediate workbook (n = 256) or wait-list condition (n = 247). Nonparametric bootstrapped mediation analyses showed that pre-post positive changes in ACT treatment processes accounted for the relation between treatment and pre-post improvement on the primary outcomes of anxiety symptoms, depressive symptoms, and quality of life. Results indicated no baseline variables were significant moderators. Finally, hierarchical regression analyses indicated that the degree of improvement for each primary outcome was positively correlated with the degree to which participants reported applying the workbook material to their day-to-day life, over and above how much of the book they reported reading. This study provided support for the ACT model of change in a self-help context and highlighted the importance of actively applying self-help material, addressing theoretical and practical questions about how and why ACT self-help works.

Coping with stress: A pilot study of a self-help stress management intervention for patients with epileptic or psychogenic nonepileptic seizures

PURPOSE

Many patients with epilepsy or psychogenic nonepileptic seizures (PNES) experience high levels of stress. Although psychological interventions have been developed for seizure disorders, few patients can currently access them. We aimed to assess the acceptability and feasibility of a self-help intervention targeting stress in patients with seizures, and to provide preliminary evidence for its effectiveness.

METHOD

Patients were recruited from outpatient neurology clinics and randomized to an immediate intervention group (n = 39), who received the intervention at baseline, or a delayed intervention group (n = 43), who received the intervention one-month postbaseline. Participants completed self-report questionnaires measuring stress (Smith Stress Symptom Inventory [SSSI]), anxiety (Generalized Anxiety Disorder 7-item Scale [GAD-7]), depression (Neurological Disorders Depression Inventory for Epilepsy [NDDI-E]), quality of life (European Quality of Life - 5 Dimensions [EQ-5D]), and seizure severity and frequency (Liverpool Seizure Severity Scale [LSSS-3]) at baseline, and at one- and two-month follow-up. Participants also provided telephone feedback. The intervention consisted of a self-help stress management workbook based on an integrative stress model framework.

RESULTS

Although the rate of participants failing to return follow-up information at two months was approximately 50%, those who completed the trial found the intervention acceptable; with the majority rating it as helpful (63.6%) and that they would recommend it to others with seizures (88.1%). A significant reduction in self-reported stress (P = .01) with a medium effect size (d_z = 0.51) was observed one-month postintervention. There were no significant changes in any other measures.

CONCLUSION

The intervention was perceived to be acceptable, safe, and helpful by participants. It could be a useful complementary treatment option for reducing stress experienced by patients living with seizure disorders. Further evaluation in a larger trial is warranted.

What protects at-risk postpartum women from developing depressive and anxiety symptoms? The role of acceptance-focused processes and self-compassion

BACKGROUND

Not all women presenting risk factors for postpartum depression (PPD) develop depressive symptoms. Research has shown that acceptance-focused processes (nonjudgmental appraisal of thought content, psychological flexibility) and self-compassion play an important protective role in the development of psychological symptoms. However, considering the perinatal period, little is known about what variables can modify the negative impact of risk.

METHODS

The sample consisted of 185 postpartum women at risk of developing PPD (Postpartum Depression Predictors Inventory-Revised > 5.5). Data were collected regarding depressive (Edinburgh Postnatal Depression Scale) and anxiety symptoms (Hospital Anxiety and Depression Scale), psychological flexibility (Acceptance and Action Questionnaire-II), nonjudgmental appraisal of thought content (Postnatal Negative Thoughts Questionnaire) and self-compassion (Self-Compassion Scale-Short Form).

RESULTS

Women not presenting depressive and anxiety symptoms reported significantly higher levels of psychological flexibility, nonjudgmental appraisal of thought content and self-compassion than women presenting depressive and anxiety symptoms. Hierarchical logistic regression showed that women with higher levels of psychological flexibility (OR = 1.06, CI: 1.01-1.12) and nonjudgmental appraisal of thought content (OR = 1.33, CI: 1.15-1.53) had a significantly higher likelihood of not presenting depressive and anxiety symptoms.

LIMITATIONS

The limitations of this study were the cross-sectional design, the use of self-report questionnaires and the self-selected bias in recruitment.

CONCLUSIONS

This study emphasizes the important role of acceptance-based processes, suggesting that at-risk women who are more accepting of their private events may be more protected from developing psychological symptoms. Preventive interventions should consider the promotion of these processes to improve women's adjustment to this period.

Profiles of Psychological Flexibility: A Latent Class Analysis of the Acceptance and Commitment Therapy Model

There exists uncertainty for clinicians over how the separate subcomponent processes of psychological flexibility, a core construct of the Acceptance and Commitment Therapy model, interact and influence distress experienced. The present study (N = 567) employed latent class analysis to (a) identify potential classes (i.e., subgroups) of psychological flexibility based on responses on measures of key subcomponent process and (b) examine whether such classes could reliably differentiate levels of self-reported psychological distress and positive and negative emotionality. We found three distinct classes: (a) High Psychological Flexibility, (b) Moderate Psychological Flexibility, and (c) Low Psychological Flexibility. Those in the Low Psychology Flexibility class reported highest levels of psychological distress, whereas those in the High Psychological Flexibility class reported lowest levels of psychological distress. This study provides a clearer view to clinicians of the profile of the broader spectrum of the psychological flexibility model to facilitate change in clients.

Riding the emotional roller coaster: The role of distress tolerance in non-suicidal self-injury

Non-Suicidal Self-Injury (NSSI) is the deliberate damage to one's bodily tissue without suicidal intent. The Emotional Cascade Model proposes NSSI functions as a distraction from 'cascades' of intense affect and rumination. Low distress tolerance is one factor thought to potentially amplify these cascades but has yet to be empirically tested. Using the Emotional Cascade Model as a framework, we investigated the moderating roles of rumination and distress tolerance in the relationship between affect intensity and NSSI. A sample of 400 university students between the ages of 17 and 62 years (M = 21.02, SD = 5.32) completed well-validated measures of NSSI, affect intensity, rumination, and distress tolerance. As expected, rumination was associated with history of NSSI but only among individuals who reported high levels of distress tolerance. Further, affect intensity was positively associated with NSSI frequency, but only at low levels of rumination and distress tolerance. These results provide promising insight into potential prevention and intervention initiatives that may target rumination and distress tolerance to reduce the likelihood and frequency of self-injury.

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.

The Flexibility Hypothesis of Healing

Theories of healing have attempted to identify general mechanisms that may work across different modalities. These include altering expectations, remoralization, and instilling hope. In this paper, we argue that many forms of healing and psychotherapy may work by inducing positive psychological states marked by flexibility or an enhanced ability to shift cognitive sets. Healing practices may induce these states of cognitive and emotional flexibility through specific symbolic interventions we term "flexibility primers" that can include images, metaphors, music, and other media. The flexibility hypothesis suggests that cognitive and emotional flexibility is represented, elicited, and enacted through multiple modalities in healing rituals. Identifying psychological processes and cultural forms that evoke and support cognitive and emotional flexibility provides a way to understand the cultural specificity and potential efficacy of particular healing practices and can guide the design of interventions that promote resilience and well-being.