Background: In recent years Acceptance and Commitment Therapy (ACT) has gained increasing status as a promising approach to treating chronic pain physical functioning and psychological well-being. The basic premise of ACT as applied to chronic pain is that while pain hurts, it is the struggle with pain that causes suffering. This approach aims to restore effective and adaptive functioning for an individual within a context of continuing pain so that the individual can live a more vital and meaningful life. There is a growing empirical support for the effectiveness of ACT however research has relied on self-reported quantitative outcomes, focused on addressing changes in pain intensity and the physical and psychological impact of chronic pain. There appears to be a gap in the literature on the exploration of the experience of attending an ACT programme for chronic pain from the patient’s perspective. Aim: This study sought to explore the experience of attending an ACT programme for chronic pain within an outpatient NHS hospital setting. Furthermore the study sought to explore the modulating factors influencing clients learning and understanding of the construct of acceptance from the perspective of the participants. Additionally, the experience of attending a group based ACT intervention was explored. Methodology: A qualitative methodology was chosen for the project. The study used a purposive sample of twelve participants, who had all attended the Luton & Dunstable Hospital ACT 8 week outpatient programme for chronic pain. The participants were interviewed through the use of a semi structured interviews, and the transcripts were transcribed and then analysed using Thematic Analysis. Identified themes were further organised using the tool of Thematic Network Analysis. Results: Three global themes emerged from the analysis of the data. The first global theme encompassed the participant’s pre-programme expectations and this theme highlighted the participant’s feelings of hope and hopelessness prior to attending the programme. The second global theme demonstrated the on-going process of living with chronic pain and highlighted the benefits and barriers to adopting and ACT based approach to chronic pain. Finally the third global theme addressed the experience of a group based intervention and included the positive and negative aspects of this experience for the participants. Clinical Implications & Conclusion: Based on the results of this study a number of clinical implications were highlighted in relation to the future development of ACT programmes for chronic pain. These included suggestions in relation to engaging participants in such programmes. Notably, timing issues, validation of physical symptoms, and consideration of the potential barriers to acceptance and understanding of the benefits of adopting and ACT group based pain management approach were discussed.

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.

The term emerging adulthood was coined during the 21st century to describe human development between adolescence and adulthood, during the ages of 18-25 (Arnett, 2000). During this stage, individuals can explore life areas. Emerging adults beginning college have a unique opportunity to form their identities and develop value systems (Hauser & Greene, 1991). With increasing autonomy, college students have possibilities for positive development and risk; values may be imperative in that differentiation. Furthermore, value systems are believed to play a major role in decision-making (Schwartz, 1992). Parents are influential in values development (Simpson, 2001; Steinberg & Sheffield Morris, 2001). During emerging adulthood, individuals have opportunities to notice discrepancies between their parents’ value system and society. Thus, emerging adults evaluate and choose personal values, which may or may not be similar to those of their parents, peers, or broader culture. Findings from this study indicate female caregivers’ parenting styles and closeness of the parent-child relationship have significant direct effects on the degree to which values are freely chosen. Specifically, Authoritarian parenting style (β = -.43 B = -1.70, p < .001), Authoritative parenting style (β = .12, B = .53, p < .001), and Emotional Support (β = .30, B = 6.80, p < .001) significantly predicted the degree to which values are intrinsically chosen. Only one significant relationship was found for male caregivers; there was a significant positive relationship between the authoritative parenting style and quality of the parent-child relationship (β = .64, B = .10, p < .001).

The present study used a basic behavioral paradigm derived from Relational Frame Theory (RFT), a contemporary behavioral account of language and cognition, to validate principle-based definitions of the cognitive interventions of defusion and reappraisal. Ninety-one participants first underwent an RFT learning paradigm that established symbolically generalized avoidance. Participants were then randomized to a defusion, reappraisal, or control condition. The main outcomes were equivalence responding—indicative of the trained relational network and analogous to the content of cognition—and avoidance—analogous to the behavioral impact of cognition. Defusion and reappraisal significantly reduced avoidance responding, providing support for the hypothesis that these interventions target the behavior of relational framing. Mediation analyses, conducted on an exploratory basis, revealed differences between the mechanisms of defusion and reappraisal and provided preliminary support for the classification of these interventions as a functional context intervention and a relational context intervention, respectively.

Abstract

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.

Mental health professionals are at high risk of experiencing work-related stress and burnout due to the challenging and highly emotive environments in which they work. This may lead to a range of physical and psychological symptomology which may affect them and also the quality of care provided to patients. This thesis presents a systematic review of the literature regarding the effectiveness of workplace interventions designed to reduce or prevent work-related stress and burnout when compared to no intervention or alternative interventions for mental health professionals working in adult mental health settings. The thesis then presents an empirical study, using the Job Demands-Resources model of burnout. Personal resources (styles of coping, self-compassion, cognitive fusion and valued living) were tested as (a) moderators of the relationship between job demands and exhaustion and (b) mediators of the relationship between job resources and disengagement within a sample of mental health nurses. Methods: A systematic review and meta-analysis of randomised controlled trials (RCTs), non-randomised controlled trials (N-RCTs), controlled before and after (CBA) and interrupted time series workplace (ITS) interventions were conducted. Primary outcomes were occupational stress and burnout. An assessment of strength of evidence was made using GRADE criteria. A quantitative cross-sectional survey of 214 mental health nurses was used to examine the role of: self-compassion, cognitive fusion, engaged living and coping in the development of burnout. Results Thirteen eligible studies were identified comprising 11 RCTs and 2 CBA’s. Overall, there was no beneficial effect of organisational and relaxations intervention was found for reducing burnout or work-related stress. There are some promising findings for the effectiveness of staff training and psychosocial interventions in the short and medium-term. Overall, the quality of studies was low due to risk of bias and a lack of precision due to low number of participants in each study. In the empirical paper, the moderating role of personal resources in the development of exhaustion was not supported. By contrast the mediating role of personal resource between job resources and disengagement was supported. Discussion At present, there is limited evidence for the effectiveness of workplace interventions. This is influenced by the low number of intervention studies and the quality of interventions to date for mental health professionals. There is preliminary evidence for the potential for third-wave cognitive behavioural interventions such as acceptance commitment therapy in reducing disengagement in mental health nurses. Interventions to reduce exhaustion need to include strategies to reduce job demands.

Background Dementia has been a global priority for over a decade, with a recognition that it presents a growing challenge for all those directly affected, as well as for health and social care services. For those who are caring for a relative at home, carer burden has been found to be predictive of physical and mental health problems, and can impact on the decision to place a relative in fulltime residential care. Gaining a fuller understanding of factors that impact on caregiver burden may help inform the development of effective interventions for this population. This thesis comprises a systematic review of the literature on individual behavioural and psychological symptoms of dementia (BPSD) and their impact on carer burden, a cross-sectional study of one hundred and ten dementia caregivers, exploring the impact of executive functioning deficits, and potential mediating mechanisms, on carer burden and positive gain, and a development and feasibility study of an Acceptance and Commitment Therapy (ACT) group intervention for dementia caregivers. Systematic Review Twenty-one studies measured the association between at least one individual symptom, or symptom cluster, and carer burden, and are included in the review. All studies found at least one symptom to be significantly associated with burden. However, due to the heterogeneity of studies in this field, there was insufficient evidence to establish whether any symptoms are more closely associated than others. Issues regarding the conceptualisation of burden and measurement of BPSD are highlighted and suggestions for addressing this in future studies proposed. Method One hundred and ten dementia caregivers completed five self-report questionnaires as part of a cross-sectional design, aiming to explore the role of executive functioning deficits, dementia management strategies and experiential avoidance in 2 the development of carer burden and positive gain. Drawing on these findings, a group intervention, based on ACT, was developed and delivered to twenty-three dementia caregivers. Data on attendance, attrition and qualitative feedback was collected as an indication of acceptability, and a quasi-experimental design, involving four pre, post and follow-up measures was employed to provide preliminary data on effectiveness. The measures used in both studies were the Dysexecutive Questionnaire (DEX) (study 1 only), Zarit Burden Interview (ZBI), Positive Aspects of Caregiving Questionnaire (PAC), Dementia Management Strategies Scale (DMSS) and Experiential Avoidance in Caregiving Questionnaire (EACQ). Results & Conclusions In study one, executive functioning deficits were found to account for most variance in burden. The use of negative management strategies and Active Avoidant Behaviour (a subscale of the EACQ), were also associated with higher levels of burden, while positive management strategies were associated with positive gain. The results suggest that management strategies and experiential avoidance could be potential mediating mechanisms in the development of carer burden, and so were targeted in the ACT group intervention in study two. Findings from study two indicate that the group intervention was feasible and acceptable to caregivers, with subjective change reported in understanding of behavioural changes in the care-recipient, ability to handle negative emotions and valued living. Suggestions are made regarding alternative outcome measures for future studies in order to capture participants’ experience more fully, as there was little statistically significant change in this study. Suggestions are also made regarding future directions for the intervention.

Denna studie har undersökt hur behandlare anpassar Acceptance and Commitment Therapy (ACT) i arbetet med unga samt deras upplevelser av att utöva metoden med målgruppen. Intervjuer genomfördes med sju psykologer och data bearbetades genom tematisk analys. Resultaten visar att behandlarna utförde generella barnterapeutiska anpassningar, kombinerade ACT med traditionell kognitiv beteendeterapi (tKBT) och modifierade arbetet med ACT-principerna. Vidare beskrevs utmaningar i arbetet vara: att arbeta med en omgivning med annan agenda, ständigt vara flexibel, våga vara aktiv och släppa kontrollen samt att arbeta med en behandlingsmetod som inte var implementerad på arbetsplatsen och som hade en oviss framtid. Möjligheter i arbetet innefattade: att använda ACT på sig själv, arbeta med positiva mål och ha roligt. Därtill presenterades en syn på ACT som livsfilosofi snarare än arbetsmetod och dilemman med att använda en metod med bristande evidens. Vidare forskning föreslås på olika ACT-principers inverkan på psykologisk flexibilitet hos unga samt hur utmaningar i behandlingsarbetet kan avhjälpas. / This study has examined therapists’ adjustments of ACT with children and adolescents and experiences of practicing the method with said group. Interviews were conducted with seven psychologists and data was analyzed using thematic analysis. Results showed general child-therapeutic adjustments, combining ACT with tCBT and modifications of the ACT principles. Challenges were working with a context with a different agenda, to be flexible and daring to be active and weird. Another challenge was working with a method that isn’t implemented in the workplace and has an uncertain future. Possibilities included using ACT for oneself, working towards positive goals and having fun. Additionally, a view of ACT as a philosophy of life was presented. Dilemmas concerning the use of a method lacking evidence were also presented. Future research can examine the impact of the different ACT principles on psychological flexibility in youths and how challenges in treatment can be overcome.

In the tradition of acceptance and commitment therapy (ACT), cognitive fusion is a transdiagnostic risk factor and occurs when one becomes overly attached to or "caught up" in their thoughts, leading to a more narrowed behavioral repertoire and difficulty taking effective action in response to life's demands. Cognitive defusion is ACT's curative answer to fusion, and denotes the process of taking a step back, seeing thoughts as "simply thoughts," thereby reducing the negative impact of distressing or anxiety-provoking thoughts. While these components have been widely studied in neurotypical (NT) samples, the purpose of this study was to extend findings to people diagnosed on the autism spectrum (AS). Specifically, this study aimed to examine the impact of cognitive fusion in this population and the effectiveness of a brief defusion technique. Forty-two AS participants and fifty-five neurotypical participants were given a battery of questionnaires measuring psychological distress and dispositional levels of cognitive fusion. Participants were then randomized into either a brief cognitive fusion technique or a brief active distraction technique. In both conditions participants chose a distressing thought and rated it on a visual analogue scale (VAS) in terms of thought discomfort and believability. They were then read a rationale regarding their assigned technique, practiced the technique, and applied the technique to their chosen distressing thought. After the intervention participants immediately re-rated the thought on the same VAS. Throughout the study, participants' heart rate and skin conductance were monitored to determine physiological effects of the conditions. Finally, a follow-up survey was sent at a one-week and two-week follow-up, where participants re-rated the believability and discomfort of their thoughts. Results of this study showed that the AS group had higher overall levels of fusion than the NT group, and that fusion was moderately to strongly related to psychological distress in the AS group and the NT group. In terms of the intervention effects, all interpretation statements must be taken with caution, as there were significant pre-group differences despite randomization. Both defusion and distraction worked equally well in immediately reducing thought believability and thought discomfort for AS and NT groups. Furthermore, treatment effects were maintained at the two-week follow-up period for all groups except for the AS group in the defusion condition. There were no treatment effects for physiology. The current study provides evidence that cognitive fusion may be an important factor in the psychiatric comorbidity that people with AS experience, and a brief technique can be effectively used.