Muscle disorders are chronic, progressive conditions, the majority of which are without disease modifying treatments. Quality of life (QoL) is reduced in these conditions, and alternative methods, such as psychological intervention, may offer ways to improve QoL. Previous work has suggested that aberrant illness perceptions may be influential targets for psychological interventions; however, emerging evidence suggests that psychological flexibility might offer another treatment target. This thesis first presents a longitudinal investigation of the role of these two variables, alongside disability level, in explaining life satisfaction and mood measured four months later. Participants were recruited from charities and online communities, with data collected via online questionnaires. Here, illness perceptions and psychological flexibility, but not disability level, were cross-sectionally associated with all dependent variables. In prospective analyses psychological flexibility accounted for greater variance in life satisfaction and anxiety; while illness perceptions explained more variance in depression. However, after controlling for variance in time one dependent variables, psychological flexibility alone was predictive of life satisfaction and anxiety at time two. Therefore, psychological flexibility represents a possible influential target for psychological intervention in muscle disorders. Acceptance and Commitment Therapy (ACT) is a psychological intervention specifically designed to improve psychological flexibility. Subsequently, the results of the empirical study imply that ACT is worthy of trial with muscle disorders. However, there has been no comprehensive review of the use of ACT in chronic disease or long-term conditions. Therefore, Chapter 2 presents a systematic review of ACT as applied to chronic disease/long-term conditions. The aims were to collate all ACT interventions with chronic disease/long-term conditions; evaluate their quality and comment on efficacy. Ovid MEDLINE, EMBASE and Psych Info were searched, with a further search of citing articles undertaken using Google Scholar. Studies with mental health or chronic pain populations were excluded. Study quality was then rated, with a proportion re-rated by a second researcher. Seventeen studies were included, of which: eight were randomised controlled trials (RCTs), three used pre-post designs, and seven were case studies. A broad range of applications were observed (e.g. improving quality of life and symptom control, reducing distress) across many diseases/conditions (e.g. HIV, cancer, epilepsy). However, study quality was generally low, and many interventions were of low intensity. The small number of RCTs per application and lower study quality emphasise that ACT is not yet a well-established intervention for chronic disease/long-term conditions. However, there was promising evidence for certain applications: the parenting of children with long-term conditions, seizure-control in epilepsy, psychological flexibility and possibly self-management/lifestyle. The studies comprising this thesis suggest that, whilst psychological flexibility appears influential in muscle disorders, high-quality research into ACT interventions for chronic disease/long-term conditions is generally lacking. Therefore one cannot confidently generalise from existing studies that ACT will improve outcomes in muscle disorders. Thus an evaluation of ACT in the context of muscle disorders is now required. This should adhere to the methodological suggestions provided in the systematic review.

The relevance of individuals' values to clinical situations is increasingly recognised in political and clinical contexts. Enhancing an individual's capacity to live consistently with their values is assumed to facilitate mental well-being and quality of life (QoL). However, little research has empirically investigated whether this focus is appropriate. This collection of studies will examine the relationship between values, well-being and QoL. "Valued living" is a core aim of Acceptance and Commitment Therapy (ACT) but it has received little empirical attention. The values identified within ACT may not be equally applicable to all clinical populations. Encouraging value-consistent action is often assumed to be inappropriate to offender populations. Schwartz‟s universal model of human values is introduced to inform understanding of the relationship between values and well-being and whether mentally disordered offenders (MDOs) have similar values to a non-psychologically distressed comparison group. Method Study 1 investigated the relationship between values, quality of life (QoL), psychological distress and psychological inflexibility (cognitive fusion and experiential avoidance) amongst a sample from the non-clinical sample (N = 109) using an online survey. Study 2 compared a subsample from study 1 with MDOs detained in medium security (N = 15) on the same measures. Study 3 explored participants‟ beliefs about the origin and maintenance of meaningful values. Responses were coded according to ACT literature and analysed using content analysis. Results Amongst the non-clinical population, QoL was positively correlated with „valued living‟, and negatively correlated with psychological inflexibility and distress. Psychological distress and psychological inflexibility correlated positively with the Openness to Change value domain and conservatism correlated negatively with psychological distress. No other relationships were observed between psychological flexibility or distress and value domain in the non-clinical population. MDOs had higher rates of psychological distress and lower psychological flexibility and QoL than the non-distressed population; they also attributed less importance to the self-transcendence value domain and more to self-enhancement. Benevolence was ranked significantly lower by the MDO sample. Other large effect sizes were detected reflecting differences between the samples, but they were not statistically significant. Intrinsic reinforcement was considered an important factor that maintained values as meaningful to all participants. Self-report data suggests that there are similarities and differences to how each sample conceptualises values. Discussion A clinical focus on values appears to be justified. The addition of Schwartz‟s model provided insight into the values of MDOs. The clinical and theoretical implications of the results are discussed as are the strengths and limitations of the study.

Background: Research in psychological adjustment to multiple sclerosis (MS) suggests that the way individuals appraise their condition can have an impact upon their psychological well-being and adjustment to their condition. Such research has influenced the development of Cognitive Behavioural Therapy (CBT) interventions in this population. In recent years, Acceptance and Commitment Therapy (ACT) has gathered increasing interest in relation to chronic health conditions. ACT does not target the content of thought, but rather focuses on the contexts in which thought occurs (i.e. how individuals relate to their experiences). Aim and Primary Hypothesis: A cross sectional design was used to compare the extent to which cognitive appraisals and ACT constructs (‘acceptance’ and ‘cognitive fusion’), mediate the relationship between physical symptoms of MS and psychological adjustment outcomes. It was hypothesised that in comparison to cognitive appraisals, ACT constructs would serve as stronger mediators of the relationship between physical symptoms of MS and outcome measures. This study also piloted a newly adapted measure of MS related acceptance, the Multiple Sclerosis Acceptance Questionnaire (MSAQ). Method and Results: Participants (N = 133) completed self-report measures of: MS symptom severity, various cognitive constructs (cognitive appraisals and ACT constructs), symptoms of psychological distress, and satisfaction with life. Multiple mediation analysis was then used to compare competing mediational hypotheses. In comparison to all measures of cognitive appraisals, the ACT constructs tended to be stronger mediators of the relationship between symptoms and outcome measures (both psychological distress, and satisfaction with life). There was also some evidence for appraisals of personal control mediating the relationship between symptoms of MS and psychological distress. Conclusions: This research suggests that ACT constructs may be relevant to the process of psychological adjustment to MS, and that ACT based interventions may be worthy of investigation in this population. The newly adapted MSAQ also shows preliminary promise as a measure of MS related acceptance.

Background: There are significant psychological challenges faced by people throughout their lives and many of these challenges can be readily understood from a contextual behavioural science perspective, and Acceptance and Commitment Therapy (ACT) shows promise as a theoretically and practically relevant intervention. Some problems faced in delivering such an intervention are volume and access to healthcare. A potential solution to this is to design theoretically driven interventions which can be delivered through technology. These need to be interactive, individually shaped and will combine mindfulness, acceptance and values. Such interventions need to be evaluated scientifically according to acceptability, quality, safety and effectiveness. Aims: This thesis has two sections. Firstly, a systematic review aiming to assess the acceptability and effectiveness of using technology to deliver ACT. Secondly, an empirical research study aiming to analyse the experiences of using an ACT based app for young people with type 1 diabetes (TD1). Methods: The review searched 11 databases, and a related website. Included studies were required to use a form of technology to deliver ACT, with no real-time therapist. Two independent researchers determined inclusion of articles into the review and rated the studies according to the quality criteria. Where there was uncertainty a third reviewer was used. For the empirical study, individual interviews of 9 young people aged 13-22 years with TD1 were asked about their experiences of using the ACT based app. Framework analysis was used to determine themes. Results: The review search yielded 18 studies which met inclusion criteria. Findings highlighted that generally these interventions were seen as acceptable and satisfactory. All of these interventions were conducted in an adult population, and qualitative data was not robustly accounted for. The empirical research found two main themes: ‘Desire for apps to represent my needs’ and ‘How diabetes impacts me and how this could potentially be addressed in an app’. Discussion: Both the review and empirical study found that participants were positive about the use of technology to deliver ACT. Developmental progress needs to be made in the app to truly represent the needs of young people with TD1. These interventions could enhance the availability of psychological therapies. This has been highlighted as a government objective in several countries. Methodological weaknesses limit conclusions, such as underpowered studies. As this is a fast growing body of research it is hoped that future studies could be more similar methodologically. It would still be interesting to determine whether asynchronous contact enhances the cost-effectiveness of this form treatment. This thesis has provided me with the opportunity to design an ACT protocol for young people with type 1 diabetes (TD1). It has helped me to fully understand the undertaking which goes into designing apps and the scope of how responsive apps can be. It has given me the chance to communicate with people from different professional backgrounds to create a shared language, an opportunity to lead and manage a project and much more. With the help of my supervisor in my first year of training, we established links with the informatics department to see if students would be able to help with the programming of such an app. We had to create a synopsis of the proposed study to entice students to undertake the project as part of their degree. An interested student was assigned the project and meetings were held to determine our expectations and to establish the scope of what could be created. A second student took on the project during my second year or training. During this time my supervisor and I created a protocol of the content for the app. This was based on previous ACT protocols and tools we were aware of, which we thought might be helpful. A lot of thought had to go into trying to keep the content concise, including different modes of delivery (MP3s, video, animation etc), making the content applicable to young people with TD1 based on previous literature, and thinking about how interactive the app could be. Friends were also relied on to create graphics for the app. I went to different health boards across Scotland to meet with Diabetes teams to inform them about the project and to gather advice on the appropriateness of the diabetes information within the content of the app, and to determine whether they were interested in taking part in the study. I tested the initial prototype and glitches were ironed out. The next stage was to test the app on professionals working in the field, and to gather their feedback through focus groups. Adaptations to the app were made based on this. The app was initially made for Android phone devices based on general market research indicating that there was little evidence that one platform was more popular in adolescents. The diabetes teams and I tried to recruit young people with TD1 from their usual diabetes clinics. Initial barriers to recruitment were that at least 50% of young people had iPhones so could not download the app, and others did not seem interested in downloading the app to take part in the study. Funding of 10 Android tablets was agreed by the University. I attended the usual diabetes clinics in NHS Lothian and young people with TD1 started to volunteer to take part in the study. Originally it was hoped a trial of the effectiveness of the app would be carried out, but the difficulties in recruitment meant that instead I decided to use a qualitative methodology to explore young people’s experiences of using the app.

Background: Acceptance and Commitment Therapy (ACT) has shown promise as an effective intervention in the treatment of mental health disorders. In the last decade, the delivery of ACT has expanded to include various formats (e.g. groups, self-help, online and phone apps). Further research is needed to evaluate whether such delivery formats are a viable extension of ACT. Furthermore, the existing evidence base of certain alternative delivery formats have yet to be reviewed. This thesis portfolio sought to contribute to this area of research. Methods: A systematic review of the literature was conducted to investigate the efficacy of group-based interventions for mental health disorders using ACT. Five databases were systematically searched, manual searches were conducted and corresponding authors were contacted. Studies which used a randomised-controlled design, with adult samples and investigated group-based ACT interventions for mental health disorders were included. A meta-analysis of the included studies was conducted for post-intervention and follow-up data. In the empirical study, an ACT manual was trialled using a randomised-controlled design to investigate the efficacy of using ACT in a guided self-help context. Participants with anxiety/depression were randomly assigned to receive either the ACT intervention or treatment as usual (TAU). Those in the ACT group were posted an ACT manual and received two telephone calls. Outcome measures were analysed after the six-week intervention. Results: From the meta-analysis, 18 randomised-controlled trials were identified, 14 of which focussed on anxiety and depression. The findings suggest that ACT-based groups have a large effect on symptom reduction when compared to non-active comparisons at post-treatment and a moderate effect when compared to non-active comparisons at follow-up. Additionally, there was a small effect in favour of ACT when compared to active treatment controls at post-treatment and equivalent effects when comparing ACT to active treatment controls at follow-up. Similar effects were found when separately comparing the 14 studies which focussed primarily on anxiety and depression. The empirical study revealed that guided self-help was found to be no more effective in improving quality of life or reducing psychological distress than the TAU group. However, such results should be interpreted with caution as the small sample size and high attrition rate indicates that further research with larger samples and follow-up are needed before strong conclusions can be made. Conclusions: The findings of this research indicate that group-based ACT interventions may be a suitable alternative delivery format for service providers in the provision of common mental health disorders, particularly anxiety and depression. Further research is needed before any strong conclusions can be made regarding the efficacy of guided self-help for anxiety/depression.

Objectives. Mindfulness and acceptance-based therapies are becoming increasingly popular in practise and meta-analyses have been conducted to evaluate their effects on a range of mental health difficulties. The purpose of this review was to evaluate the evidence base for mindfulness and acceptance-based therapies in the treatment of distressing auditory hallucinations. Method. Five electronic databases were searched in addition to an internet search engine. Authors of included studies were contacted and reference lists were reviewed. Quality criteria were developed and studies were rated independently by three raters. Results. Nine studies met the inclusion criteria; four controlled studies and five case studies. There was substantial variation in study design and outcomes. Overall, the quality of the studies was poor. Reductions in hallucination-related distress, belief conviction, cognitive appraisals and hallucination proneness were noted. Participants’ ability to respond mindfully to hallucinations increased. Conclusion. Although the results of this review suggest that mindfulness and acceptance-based therapies may result in several beneficial effects, the quality of these studies was poor and the results are likely to have been subject to considerable bias. More research is needed before such therapies can be considered evidence-based treatments for distressing hallucinations. Suggestions for future research are made.

Freely choosing a life direction, or flexible valuing, is a core component of acceptance and commitment therapy (ACT). Initial research suggests that valuing behavior may contribute to psychological well-being, but has been stymied by a lack of an efficient measure. The current study examined the psychometric characteristics of a new measure of flexible valuing, the Meta-Valuing Measure (MVM), in a sample of 532 undergraduates. Exploratory factors analysis revealed 3 orthogonal factors, Valuing (α = .94), Freedom from Values Conflict (α = .92), and Flexibility in Valuing (α = .73). The majority of expected relationships with other constructs were significant including those with measures of values, mindfulness, quality of life, experiential avoidance, and psychological distress.

Purpose: The systematic review summarised the research investigating Acceptance and Commitment Therapy (ACT) with older adults. The empirical study explored psychosocial adjustment patterns to a diagnosis of mild cognitive impairment, a condition characterised by memory or thinking problems. Method: The review included 14 studies identified through database searches using predefined eligibility criteria. The empirical study employed a cross-sectional design. Thirty-five participants completed a short cognitive assessment and a series of questionnaires measuring perceptions of MCI, cognitive fusion (i.e. how caught up someone is with their thoughts), anxiety, depression and quality of life. Results: The review found initial evidence to suggest that ACT is an acceptable and effective intervention for reducing distress in older adults. The empirical study found that threatening perceptions of MCI were more strongly related to psychosocial adjustment outcomes than objective level of cognitive impairment. The study also found evidence to suggest that cognitive fusion is associated with adjustment outcomes in an MCI population. Conclusions: The systematic review highlights the limited, but promising evidence-base for the application of ACT with older adults. The review emphasises the need for further research with improved methodological rigor. Findings from the empirical study need to be replicated with a larger sample, however the results indicate that psychological interventions such like ACT could have utility for MCI patients with adjustment difficulties.

Il presente elaborato ha come tema il ruolo dello psicologo clinico nella riabilitazione cardiologica, con una particolare attenzione alle sfide poste nel sostenere e facilitare il cambiamento dello stile di vita del paziente affetto da cardiopatia ischemica. La tesi si articola in tre sezioni, ognuna delle quali comprende un’introduzione teorica, con spunti sia di natura clinica che riferimenti al contesto della riabilitazione, e un contributo empirico che intende fornire una prospettiva innovativa al campo di riferimento. Il primo capitolo si apre con una breve descrizione della cardiopatia ischemica e dei fenomeni ad essa clinicamente legati. Queste informazioni introduttive si riveleranno preziose nello svolgersi dei capitoli successivi, in quanto consentono di approfondire il contesto della riabilitazione cardiologica, i suoi principali obiettivi e il razionale alla base dell'intervento clinico proposto. A questo proposito, verrà sottolineata la centralità dell’esercizio fisico come outcome funzionale della riabilitazione. In linea con questo affondo teorico, il primo contributo empirico è volto a indagare la relazione tra ridotta capacità di esercizio e sintomatologia ansiosa e depressiva, e a valutare la direzione di questa associazione attraverso un Cross-Lagged Panel Design che ha incluso 212 pazienti afferenti all’Unità di Riabilitazione Cardiovascolare dell’Ospedale S. Luca di Milano. I risultati sono discussi alla luce del ruolo che lo psicologo può svolgere per massimizzare il beneficio che il paziente può ottenere dalla riabilitazione, anche nei termini di capacità d’esercizio. Questo tema, accennato nella discussione del primo studio, viene ampliato nel secondo capitolo. Il secondo capitolo introduce infatti il modello dell’Acceptance and Commitment Therapy (ACT), riferimento teorico che costituisce l’ossatura dell’intervento presentato nella terza parte dell’elaborato. In particolare viene approfondito il ruolo della flessibilità psicologica, che rappresenta il cuore clinico del modello ACT, in quanto meccanismo primario di azione terapeutica. Per quanto esistano diversi strumenti per misurare questo costrutto, nessuno di essi è stato pensato e validato per il contesto cardiovascolare. La sezione empirica del secondo capitolo si riferisce allo sviluppo di un nuovo questionario per la misurazione della flessibilità psicologica adatto al contesto in esame - il CVD-AAQ, ovvero CardioVascular Disease Acceptance and Action Questionnaire - di cui vengono valutate le proprietà psicometriche. Lo studio si è avvalso di un secondo campione di 275 pazienti, arruolati nella medesima Unità Operativa. Il CVD-AAQ viene proposto e descritto in quanto misura di outcome dello studio presentato nella terza e ultima parte dell’elaborato. 8 Il terzo capitolo presenta lo studio ACTonHEART, un trial clinico randomizzato finalizzato a valutare l’efficacia e la fattibilità di un protocollo di intervento basato sull’ACT, cui scopo è migliorare il benessere e sostenere il cambiamento dello stile di vita dei pazienti ischemici in riabilitazione, aumentandone la flessibilità psicologica. Novantadue pazienti sono stati arruolati e allocati al gruppo sperimentale (N= 59) e di controllo (N= 33), seguendo uno schema di randomizzazione sbilanciata 2:1. Il gruppo di controllo ha svolto la sola riabilitazione, quello sperimentale in aggiunta ha partecipato all’intervento di gruppo ACTonHEART, il cui manuale è presentato integralmente in forma manualizzata. Il protocollo ha una durata di sei ore, suddivise in tre sedute, ognuna delle quali è incentrata su un principio clinico dell’ACT e affronta un aspetto diverso del cambiamento dello stile di vita richiesto al paziente ischemico in un’ottica di prevenzione secondaria. Gli outcome dell’ACTonHEART sono i seguenti: Body Mass Index, flessibilità psicologica e benessere. Ognuno di essi è stato misurato in tre occasioni: prima della riabilitazione (t0), al suo termine (t1) e in un follow-up a sei mesi (t2). Considerata la presenza di tre misurazioni e il fatto che solo i pazienti assegnati al gruppo sperimentale hanno partecipato a un trattamento di gruppo, da un punto di vista metodologico l’ACTonHEART si configura come un Partially Nested Design a tre livelli, un disegno di ricerca la cui struttura verrà brevemente descritta in una sezione dedicata. Per valutare l’efficacia del trattamento è stata infine svolta un’analisi multilivello, i cui risultati sono presentati e discussi nella sezione finale dell’elaborato. / The thematic core of the present paper consists in the role of clinical psychology in cardiac rehabilitation, with a specific focus on the challenges faced when supporting the changes in lifestyle required to patients suffering from ischemic heart disease. This thesis is divided into three broad sections. Every section includes a theoretical introduction, describing both clinical and rehabilitation state-of-the art practices and research results, and an empirical contribution aiming to provide an innovative perspective on the topics considered. The first chapter includes a brief description of ischemic heart disease and its clinically related phenomena. This introductory information will prove valuable in the subsequent chapters, as it deepens the context of cardiovascular rehabilitation, describing its main goals and the rationale behind its mode of intervention, as well as the centrality of exercise capacity as functional outcome. Starting from this theoretical background, the first empirical contribution aims at investigating the relationship between reduced exercise capacity and symptoms of anxiety and depression. The direction of this association will be evaluated through a Cross-Lagged Panel Design that included 212 patients recruited in the Cardiovascular Rehabilitation Unit of S. Luca Hospital in Milan. Results are discussed in light of the role the psychologist plays in order to maximize the impact the rehabilitation has on the patient, even in terms of exercise capacity. This theme, introduced in the discussion of the first study, is further explored in the second chapter. The second chapter introduces Acceptance and Commitment Therapy (ACT), the theoretical framework of ACTonHEART, which is the intervention presented in the third part of the thesis. In particular, psychological flexibility will be discussed as the primary mechanism of therapeutic action proposed by the ACT model. While there are several tools to measure this construct, none of them have been validated for the cardiovascular context. The empirical section of the second chapter presents a disease-specific new questionnaire for measuring the psychological flexibility, the Cardiovascular Disease Acceptance and Action Questionnaire (CVD-AAQ), whose psychometric properties are evaluated. The validation study examined a second sample of 275 patients enrolled in the same hospital. The CVD-AAQ will be used as a measure of outcome for the intervention presented in the third and last part of the elaborate. The third chapter presents the ACTonHEART study, a RCT aimed at evaluating the effectiveness and feasibility of an ACT-based intervention protocol, whose purpose is to improve well-being and support the change in lifestyle of ischemic patients, through an increase in psychological flexibility. 10 Ninety-two patients were enrolled and randomized, following an unbalanced randomization ratio of 2:1, to the experimental group (N= 59) and the control group (N= 33). The control group was administered Treatment-as-Usual (TAU), while experimental subjects participated in the ACTonHEART group intervention in addition to the cardiac rehabilitation process. In this section the ACTonHEART protocol will be entirely presented in its manualized form. The ACTonHEART protocol consists in three sessions for a total of six hours. Each session focuses on an ACT clinical principle and addresses a different aspect of the lifestyle changes asked to the ischemic patient for secondary prevention. The outcomes considered for the ACTonHEART are the following: Body Mass Index, Psychological Flexibility and Well-Being. Participants were assessed at baseline (t0), at the end of the rehabilitation period (t1), and at a six-month follow-up (t2). The ACTonHEART is a Partially nested Design with three levels, a research methodology whose structure will be briefly outlined in this section. An appropriate multilevel analysis was carried out to evaluate the effectiveness of the intervention, whose results are presented and discussed in the final section of the thesis.

<p>Among some researchers, there is an emerging conceptualization of chronic tic disorders (CTDs) as conditions that are partially rooted in avoidance of tic-related private experiences (i.e., painful or difficult thoughts and feelings) and internal sensations (i.e., premonitory urges to tic). The first specific aim of the present research was to investigate the possibility that experiential avoidance is related to tic severity and perceived quality of life in individuals with CTDs. The second aim was to determine whether the efficacy of Habit Reversal Training (HRT), the most prevalent and effective behavioral intervention for CTDs to date, might be enhanced by combining it with Acceptance and Commitment Therapy (ACT), an intervention that directly targets experiential avoidance. These aims were addressed by conducting two related studies. Study I, an online survey, included 239 adults (<italic>M</italic> = 37.6 years; <italic>SD</italic> = 13.8 years) who reported having been previously diagnosed with a CTD. Results showed that levels of premonitory urges, as well as both general and tic-specific experiential avoidance, were significantly positively related to tic severity. General and tic-specific experiential avoidance were also significantly negatively related to perceived quality of life. Psychometric analyses of two novel measures developed for Study I (i.e., the Yale Global Tic Severity Scale-Self-Report Version and the Acceptance and Action Questionnaire-Tic-Specific Version) demonstrated excellent internal consistency and convergent validity. Study II, a multi-site pilot investigation, involved 13 adolescents (<italic>M</italic> = 15.4 years; <italic>SD</italic> = 1.3 years) who were treated with either HRT alone or a novel HRT+ACT intervention. Results suggest that the HRT+ACT treatment is feasible, highly acceptable to both patients and parents, and as effective as HRT alone at reducing tic severity from pre-treatment through week 22 follow-up. Participants in both groups reported clinically significant post-treatment decreases in general and tic-specific experiential avoidance and improvements in overall functioning. Researchers concluded that experiential avoidance plays an important role in tic expression and overall functioning for individuals with CTDs. Results support additional development and testing of the promising HRT+ACT intervention, to evaluate its efficacy alone and in comparison to other relevant psychosocial and pharmacological interventions.</p> / Dissertation