The role of psychological inflexibility and self-compassion in acceptance and commitment therapy for clinical perfectionism

Acceptance and Commitment Therapy Processes and Mediation: Challenges and How to Address Them

Acceptance and commitment therapy (ACT) emphasizes a focus on theory-driven processes and mediating variables, a laudable approach. The implementation of this approach would be advanced by addressing five challenges, including (a) distinguishing ACT processes in measurement contexts, (b) developing and rigorously validating measures of ACT processes, (c) the wide use of psychometrically weaker ACT process measures and the more limited use of stronger measures in earlier work, (d) the inconsistency of past evidence that ACT processes are sensitive or specific to ACT or mediate ACT outcomes specifically, and (e) improving statistical power and transparency. Drawing on the existing literature, we characterize and provide evidence for each of these challenges. We then offer detailed recommendations for how to address each challenge in ongoing and future work. Given ACT's core focus on theorized processes, improving the measurement and evaluation of these processes would significantly advance the field's understanding of ACT.

Serially mediated effects of psychological inflexibility on quality of life of refugees in Uganda during coronavirus pandemic

The unexpected outbreak and rapid spread of COVID-19 necessitated radical and stringent control measures, consequently changing how people live globally. To vulnerable populations like refugees, who were already living a disrupted life, the outbreak of COVID-19 and accompanying control measures complicated their living conditions and drastically affected their mental health and, consequently, their quality of life. The current study aimed to test whether psychological inflexibility was a factor in lowering the quality of life of refugees in Uganda during the COVID-19 pandemic. The study further examines whether the effects of psychological inflexibility on quality of life were serially mediated by avoidance coping, perceived threat, adherence to COVID-19 control measures, and general mental health states. The study was conducted among refugees living in Kampala city suburbs and Bidibidi refugee settlement in Uganda. Data was collected using a survey questionnaire during the partial reopening of the economy in mid-2020, after the first lockdown. The analysis assesses a serial mediation model of the effects of psychological inflexibility on the quality of life of refugees through avoidance coping, perceived threat, adherence to COVID-19 control measures, and mental health using PROCESS Macro. The study involved 353 participants. Our analyses revealed that psychological inflexibility was negatively associated with the perceived threat, adherence, and quality of life. Psychological inflexibility was positively associated with avoidance coping and poor mental health. The data supported all hypothesized mediation paths. These findings support literature suggesting that psychological inflexibility is a maladaptive attribute that thwarts positive coping and behavior adjustment in times of crisis. Consequently, psychological inflexibility can worsen mental health problems and quality of life, especially in populations such as refugees in low-income countries who live in precarious conditions. Incorporating interventions that reduce psychological inflexibility in crisis management efforts can help refugees maintain good psychological functioning and quality of life.

The effectiveness and cost-effectiveness of Acceptance and Commitment Therapy as a transdiagnostic intervention for transitional-age youth: study protocol of a randomized controlled trial

BACKGROUND

Although the prevalence of psychological problems in transitional-age youth (i.e., youth aged 15 to 25; TAY) is high, TAY are much less likely to receive age-appropriate treatments for their psychological problems compared to younger adolescents or older adults. Hence, effective interventions for TAY seem warranted. ACT your way is a transdiagnostic treatment, specifically developed for TAY, based on the principles of Acceptance and Commitment Therapy (ACT). ACT your way is not directed primarily at symptom reduction, but mainly aims to change the underlying mechanism of psychopathology, namely increasing TAY's psychological flexibility. Meta-analyses show that ACT is an effective treatment for adults with diverse types of psychopathology. Less is known about the effectiveness of ACT for TAY. Therefore, the goal of this study is to examine the effectiveness and cost-effectiveness of ACT your way. In addition, we will investigate for whom and under what circumstances (i.e., moderators) and how (i.e., mediators) the intervention is (most) effective.

METHOD

The study is designed as a multi-centre, randomized controlled trial. In total, 140 TAY diagnosed with any psychological disorder will be randomly assigned to either the ACT your way or treatment as usual (TAU) condition. In total, six assessments will be conducted: at baseline, after 3, 6 and 9 sessions, at post-intervention and at 6-month follow-up, using multiple informants (TAY, parents/caregivers, therapists). Assessments will include diagnostic interviews and questionnaires. The primary outcomes are psychological flexibility and number of DSM-5 diagnoses; the secondary outcomes are the presence of the primary DSM-5 diagnosis, psychopathology, personality problems, global, individual and societal functioning, quality of life, stress, treatment satisfaction, treatment drop-out and therapeutic alliance. We will also assess costs and various moderators (i.e., demographic characteristics, type and severity of problems, psychopathology of parents/caregivers, treatment expectancy and previous treatments) and mediators (i.e., psychological flexibility, emotion regulation, self-compassion, autonomy, perfectionism, self-esteem and group cohesion).

DISCUSSION

To our knowledge, this is the first study investigating the (cost-)effectiveness of ACT compared to TAU in clinically referred TAY with various types of psychopathology, using a rigorous design.

TRIAL REGISTRATION

The research project is registered in the Dutch Trial Register (Trial NL9642).

Mechanisms of action and processes of yoga-based group intervention for inpatients with schizophrenia spectrum disorders-A longitudinal qualitative study

BACKGROUND

Research exploring the effects of yoga therapy (YT) on individuals with schizophrenia spectrum disorders (SSD) is scarce. Therefore, the current study aimed to explore possible mechanisms of actions and processes, as well as adverse effects of a novel yoga-based group intervention (YoGI) for in-patients with SSD in a German university hospital setting.

MATERIAL AND METHODS

A longitudinal qualitative study was integrated into a rater-blinded randomized controlled trial, exploring the impact of a 4-week YoGI as add-on treatment. In-depth interviews were conducted with participants receiving YoGI (n = 19) in addition to treatment as usual (TAU) and a control group (n = 14) which only received TAU. Interviews were conducted at baseline (n = 33) and 4 weeks post-intervention (N = 28) to assess the participant's experiences and how they changed over time. The interviews (N = 61) were audio-taped, translated, coded, and analyzed by means of inductive thematic analysis. Separate case summaries were prepared for each participant to analyze longitudinal changes within subjects. The research team members collaboratively discussed the final list of themes and subcodes. Rater-based questionnaires, such as the Positive and Negative Syndrome Scale (PANSS), Calgary Depression Scale for Schizophrenia (CDSS), and Personal and Social Performance Scale (PSP) were administered at baseline to assess clinical outcomes.

RESULTS

At baseline, participants reported a desire to improve their stress- and symptom management. A minority of participants expressed reservations toward yoga, and several psychosocial barriers were named, including worries about symptom exacerbation. At post-intervention, four mechanisms of change became evident from the interviews: (1) acquiring competence in relaxation, (2) increased interoceptive awareness, (3) feeling connected, and (4) a sense of spiritual wellbeing. A small number of participants reported difficulties with YoGI.

CONCLUSION

Generally, YoGI positively influenced participants' experiences of their inpatient stay, regarding distress, self- and body awareness, social connectedness, and spiritual wellbeing. However, participants also illuminated necessary adjustments to improve the intervention. YoGI will therefore be adapted and further developed in an iterative process based on a participant involvement approach. The efficacy regarding outcomes and processes needs to be investigated in a future larger-scaled randomized controlled trial.

Attention, flexibility, and imagery in misophonia: Does attention exacerbate everyday disliking of sound?

INTRODUCTION

Misophonia is an unusually strong aversion to everyday sounds, such as chewing, crunching, or breathing. Here, we ask whether misophonia might be tied to an unusual profile of attention (and related traits), which serves to substantially heighten an otherwise everyday disliking of sounds.

METHODS

In Study 1, we tested 136 misophonics and 203 non-misophonics on self-report measures of attention to detail, cognitive inflexibility, and auditory imagery, as well as collecting details about their misophonia. In Study 2, we administered the Embedded Figures task to 20 misophonics and 36 non-misophonics.

RESULTS

We first showed that the degree to which sounds trigger misophonia reflects the pattern by which they are (more mildly) disliked by everyone. This suggests that misophonia is scaffolded onto existing mechanisms rather than qualitatively different ones. Compared to non-misophonics, we also found that misophonics self-reported greater attention to detail, cognitive inflexibility, and auditory imagery. As their symptoms worsen, they also become more accurate in an attentional task (Embedded Figures).

CONCLUSIONS

Our findings provide a better understanding of misophonia and support the hypothesis that dispositional traits of attention to detail may be key to elevating everyday disliking of sound into the more troubling aversions of misophonia.

Early shaming experiences and psychological distress: The role of experiential avoidance and self-compassion

OBJECTIVES

Early shaming experiences have been suggested to be associated with later psychopathological symptoms. Understanding this relationship is complex, due to a number of psychological processes potentially influencing this. Therefore, the aim of the current study was to further explore the nature of the mediating effect of experiential avoidance in the association between early shame experiences and psychological distress, and whether self-compassion moderates this relationship by mitigating the effects of this.

DESIGN

A cross-sectional design was conducted using self-report measures of early shaming experiences, experiential avoidance, self-compassion, and psychological distress.

METHOD

An online study of 556 participants, comprised of participants from the general population and university students participated within this online study.

RESULTS

The moderated mediation model explained 51% of variance within depressive symptoms. Experiential avoidance was found to mediate the association between early shaming experiences and depressive symptoms. This mediating relationship was shown to be moderated by self-compassion, with higher levels of self-compassion being associated with lower levels of depressive symptoms across all levels of experiential avoidance levels (low, medium, and high).

CONCLUSION

These findings suggest that self-compassion may play a significant buffering role within attenuating the effects of experiential avoidance associated with depressive symptoms. Such findings present important clinical and theoretical implications in further understanding the protective role of self-compassion within early shaming experiences and the relationship between depressive symptoms.

PRACTITIONER POINTS

Early shaming experiences have been linked to later psychological distress. Experiential avoidance identified a core underlying psychological process in the relationship between early shaming experiences and psychological distress. Self-compassion offers a range of protective features that may alleviate the effects of experiential avoidance and depressive symptoms. Self-compassion-based interventions that target experiential avoidance may offer greater reductions within depressive symptoms.

"Third-wave" cognitive and behavioral therapies and the emergence of a process-based approach to intervention in psychiatry

For decades, cognitive and behavioral therapies (CBTs) have been tested in randomized controlled trials for specific psychiatric syndromes that were assumed to represent expressions of latent diseases. Although these protocols were more effective as compared to psychological control conditions, placebo treatments, and even active pharmacotherapies, further advancement in efficacy and dissemination has been inhibited by a failure to focus on processes of change. This picture appears now to be evolving, due both to a collapse of the idea that mental disorders can be classified into distinct, discrete categories, and to the more central attention given to processes of change in newer, so-called "third-wave" CBTs. Here we review the context for this historic progress and evaluate the impact of these newer methods and models, not as protocols for treating syndromes, but as ways of targeting an expanded range of processes of change. Five key features of "third-wave" therapies are underlined: a focus on context and function; the view that new models and methods should build on other strands of CBT; a focus on broad and flexible repertoires vs. an approach to signs and symptoms; applying processes to the clinician, not just the client; and expanding into more complex issues historically more characteristic of humanistic, existential, analytic, or system-oriented approaches. We argue that these newer methods can be considered in the context of an idiographic approach to process-based functional analysis. Psychological processes of change can be organized into six dimensions: cognition, affect, attention, self, motivation and overt behavior. Several important processes of change combine two or more of these dimensions. Tailoring intervention strategies to target the appropriate processes in a given individual would be a major advance in psychiatry and an important step toward precision mental health care.

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.

Unburdening the Weight of Stigma: Findings From a Compassion-Focused Group Program for Women With Overweight and Obesity

OBJECTIVE

The aim of this study was to develop a 2-day intensive-format, Compassion-Focused Therapy (CFT) based group program targeting weight stigma in women with overweight and obesity, and to conduct a pilot study to determine the feasibility and acceptability of the intervention.

METHOD

Participants were 15 females aged 18-62 years (mean [M] = 43.60, standard deviation [SD] = 12.38), who participated in the program and completed measures of self-compassion, internalized weight stigma, psychological distress, life-satisfaction, loneliness, eating self-efficacy, body dissatisfaction, and body shame, at pre-treatment, post-treatment, and 3-month follow-up.

RESULTS

Significant improvements were found from pre-treatment to post-treatment for self-compassion and internalized weight stigma, with gains maintained at 3-month follow-up. Significant improvements were also found on measures of psychological distress, life satisfaction, loneliness, eating self-efficacy, and body dissatisfaction at the post-treatment assessment. Credibility ratings of the program were high.

CONCLUSIONS

This study has contributed to existing stigma research, being the first proof-of-concept study to demonstrate support for an intensive, CFT based group approach targeting the effects of weight stigma for women with overweight and obesity. The findings are discussed in terms of the potential of CFT to assist women develop resilience to the harmful effects of weight stigma, and possible future research directions to further develop and evaluate this approach.