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A crucial step in assessing the scientific basis of a psychotherapeutic intervention is examining the individual components of the treatment to determine if they are additive or important to treatment outcomes. The construct of self-as-context (S-A-C), a central process in the acceptance and commitment therapy (ACT) approach, has not yet been studied in a component analysis. A previous dismantling trial, however, has shown this process has an additive effect as part of an ACT package (Williams, 2006). The current study is a preliminary trial of feasibility and efficacy to determine a) the practicality of assessing S-A-C in isolation in a laboratory setting, and b) the impact of manipulating S-A-C on theoretically related variables, including theorized mechanisms of change in various clinical approaches. 68 participants (55 female, 13 male) were randomly assigned to receive either a brief S-A-C intervention employing a common therapeutic metaphor (the chessboard metaphor), or the control condition, which involved discussing a mildly positive topic with the researcher. Results from the main analyses showed that there was no group-by-time interaction on measures to assess immediate impact on the construct, previously validated therapeutic mediation measures, or symptom measures. Several possible explanations for the failure to identify significant findings are discussed, including limitations of construct measurement. When analyses were repeated using only those participants whose scores were in the mild range or higher for stress, anxiety, or depression, time by condition interactions were significant for stress and approached significance for depression, with participants in the S-A-C group doing better than those in the control group, offering tentative support for the utility of this process among individuals with clinical difficulties. Implications for future studies are reported. / Ph. D.

Tinnitus is a highly prevalent health condition creating moderate or severe interference on mood, sleep and daily functioning for a group of those affected. The aims of this thesis were 1) to explore the role of acceptance and psychological flexibility in understanding tinnitus interference both experimentally and with a longitudinal design 2) to evaluate the immediate and long-term outcomes of an acceptance based behaviour therapy (Acceptance and Commitment Therapy; ACT) in the treatment of people with tinnitus and, 3) to investigate the relationship between treatment outcome and processes assumed to be the active ingredients of treatment (acceptance and cognitive defusion). Study I (n=47) was an experiment comparing the impact of acceptance to that of thought suppression or a neutral instruction on the ability to maintain attention on an imagery task. Results indicated that participants could benefit from an acceptance strategy when performing the task. Study II (n=47) was a longitudinal trial studying the mediating role of acceptance on the relationship between tinnitus interference at baseline and tinnitus interference, anxiety, life quality, and depression at a seven-month follow-up. Full mediation was found for life quality and depression, and partial mediation for tinnitus interference. Study IV (n=64) was a randomised controlled trial evaluating the immediate and long-term effects of ACT in comparison to those of Tinnitus Retraining Therapy (TRT) and to a wait list control. Results showed that ACT had large immediate effects on tinnitus interference in comparison to wait list, and medium long-term effects in comparison to TRT. Results were also seen on secondary outcome. Self-reported tinnitus acceptance significantly mediated the immediate outcome of ACT. Study III (n=24) was a process study where the video recorded sessions of ACT from study IV were observed and rated with regard to client behaviour. Results showed that in-session acceptance and defusion behaviours rated early in therapy were predictors of sustained positive treatment effects of ACT. These associations continued to be substantial even when controlling for the prior improvement in outcome. This whereas prior symptom change could not predict process variables rated late in therapy. Participants in all trials were chronic tinnitus patients, mainly from different departments of audiology. These findings implicate that 1) acceptance and psychological flexibility may contribute to the understanding of tinnitus interference 2) ACT can reduce tinnitus interference in a group of normal hearing tinnitus patients and 3) acceptance and cognitive defusion are important processes in ACT, related to outcome. / Tinnitus är ett mycket vanligt hälsoproblem där en grupp av de drabbade upplever påtagliga besvär såsom påverkan på sömn, välbefinnande och funktionsnivå. Denna avhandlings syften var att 1) utforska den roll acceptans och psykologisk flexibilitet har för förståelsen av tinnitusbesvär såväl experimentellt som med en longitudinell design 2) utvärdera de omedelbara och långsiktiga effekterna av en acceptansinriktad beteendeterapi (Acceptance and Commitment Therapy; ACT) vid behandling av personer med tinnitus samt 3) undersöka relationen mellan behandlingsutfall och processer som antas utgöra behandlingens aktiva komponenter (acceptans och kognitiv defusion). Studie I (n=47) var ett experiment där man jämförde förmågan att bibehålla uppmärksamheten på en mental bild vid tre olika betingelser: acceptans, tankesuppression eller en neutral betingelse. Resultaten indikerade att deltagarna som slumpats till acceptans var hjälpta av denna strategi i genomförandet av uppgiften. Studie II (n=47) var en självrapportstudie med longitudinell design där det undersöktes om acceptans fungerade som en mediator i sambandet mellan tinnitusbesvär i baslinjen och livskvalitet, depression, ångest och tinnitusbesvär vid en uppföljning efter sju månader. För variablerna livskvalitet och depression visade resultaten en fullständig mediation och för tinnitusbesvär en partiell mediation. Studie IV (n=64) var en randomiserad kontrollerad prövning av de omedelbara och långsiktiga effekterna av ACT i jämförelse med Tinnitus Retraining Therapy (TRT) och en väntelistekontrollgrupp. Resultaten visade att ACT hade en stor omedelbar effekt på tinnitusbesvär i jämförelse med väntelistan och en medelstor effekt i jämförelse med TRT. Även sekundära utfallsmått visade på effekter. Utfallet i ACT medierades av självrapporterad acceptans av tinnitus. Studie III (n=24) studerade processer i ACT-behandlingen genom observation och skattning av klientbeteenden under de videoinspelade sessionerna. Resultaten visade att klienternas acceptans- och defusionbeteende under sessioner tidigt i terapin predicerade det långsiktiga utfallet i behandlingen. Dessa samband kvarstod även när man kontrollerade för symtomförbättring fram till den skattade sessionen. Detta medan tidigare symtomförbättring inte predicerade klientbeteende senare i behandling. Deltagare i samtliga studier var patienter med kronisk tinnitus, huvudsakligen rekryterade från reguljär hörselvård. Resultaten från dessa studier indikerar att 1) acceptans och psykologisk flexibilitet kan bidra till förståelsen av tinnitusbesvär 2) ACT kan minska tinnitusbesvär hos en grupp normalhörande patienter 3) acceptans och kognitiv defusion är viktiga processer i ACT vilka är relaterade till behandlingutfallet.

The psychological aspects of sports is crucial for performance and important for sustaining good mental health. Despite this, efforts to improve those aspects are surprisingly rare and partly due to stigmatization of help-seeking together with lack of time and economic resources. However, in recent decades much research on internet-based interventions have been conducted. Also, a growing body of empirical support for the Mindfulness-Acceptance-Commitment approach (MAC) related to enhancement in performance and mental health in sports has emerged. This study was the first to explore the effects of internet-based MAC, which was conducted with the digital self-care programme ACTSPORT with or without feedback. Of 193 participants (aged 18 - 71, from 40 different sports on a variety of levels) who were randomly assigned to feedback, non-feedback and waitlist group, 125 completed the study. The results showed that participants who completed ACTSPORT with feedback experienced significantly enhanced performance, reduced performance anxiety and improved mental health, which included higher quality of life and less symptoms of depression. These improvements were predicted by significant improvements in acceptance and dispositional mindfulness. A larger effect was found for participants with feedback which indicated that some support is preferable. In conclusion, the present study indicate that internet-based interventions in sport may be  effective, time-saving, cost-effective, flexible and available means for both enhancement in performance and aspects of mental health. / De psykologiska faktorerna inom idrott är avgörande för prestation och viktiga för att upprätthålla god mental hälsa. Trots detta är ansträngningar för att förbättra dessa faktorer förvånansvärt sällsynta. Det beror bland annat på att det råder ett stigma kring att söka hjälp samt brist på tid och ekonomiska resurser. De senaste decennierna har det genomförts en stor mängd forskning på internetbaserade interventioner. Dessutom har Mindfulness-Acceptance-Commitment approach (MAC) fått en ökad mängd empiriskt stöd gällande förbättring i prestation och mental hälsa inom idrott. Föreliggande studie är den första i sitt slag att undersöka effekten av internetbaserad MAC, vilken genomfördes med det digitala självhjälpsprogrammet ACTSPORT med eller utan feedback. Av 193 deltagare (ålder 18 - 71, i 40 olika sporter på alla nivåer) som randomiserades till tre grupper med feedback, utan feedback eller väntelista, fullföljde 125 deltagare studien. Resultaten visade att deltagare som fullföljde ACTSPORT med feedback upplevde signifikant förbättrad prestation, minskad prestationsångest såväl som förbättrad mental hälsa vilket inkluderade högre livskvalité och minskade depressionssymtom. Detta visade sig kunna prediceras av signifikanta förbättringar i acceptans och dispositionell mindfulness. En större effekt sågs för deltagarna i gruppen med feedback vilket indikerade att ett visst stöd är fördelaktigt. Slutsatser från studien är att internetbaserade interventioner inom idrott kan vara effektiva, tidsbesparande, kostnadseffektiva, flexibla och tillgängliga medel för att både öka prestation och aspekter av mental hälsa.

Pathologische Sorgen sind ungenau definiert. Für die Behandlungsplanung bleiben wichtige Fragen offen: Welche Merkmale sind für die Unterscheidung zwischen behandlungsbedürftigen und nicht behandlungsbedürftigen Sorgen relevant? Welche Art von Sorgen muss wie behandelt werden? Und: Welche Art von Sorgen gilt es eher zu akzeptieren? Wir machen praxisnahe Vorschläge dafür, wie Sorgen mittels einer einfachen Heuristik auch vom Patienten selbst als «pathologisch» identifiziert werden können. Im Sinne eines therapeutischen Arbeitsmodells ergeben sich differentielle Bearbeitungsstrategien, je nachdem, ob es sich um wichtige oder weniger wichtige, auf lösbare oder unlösbare Probleme bezogene sowie angemessene oder überzogene Sorgen handelt. Das vorgestellte Arbeitsblatt zu den Sorgen soll vor allem die wahrgenommene Kontrolle des Patienten stärken und die Psychoedukation zur Generalisierten Angststörung erleichtern. / Pathological worries have not yet been clearly defined. As a consequence, practically relevant questions remain open: Which characteristics distinguish worries relevant for treatment from those which are not? What kind of worries has to be treated in which way? And: What kind of worries is rather to be accepted? We propose a simple rationale which helps the therapist and the patient to identify pathological worries. According to this working model, different treatment strategies result depending on whether worries are central or not, whether they relate to a problem which can be solved or not, and whether they seem proportionate or exaggerated. The presented worksheet is meant to strengthen the perceived control of the patient and to help facilitate psychoeducation for generalised anxiety disorder. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Systematic Review: Healthcare professionals work in highly emotive environments and are considered to be at high risk of developing burnout due to the nature of their roles. There has been increased interest in applying mindfulness-based interventions for stress reduction in healthcare professionals. Previous reviews have tended to include a heterogeneous mix of patients, healthcare students and healthcare professionals. The inherent differences in these roles limits the conclusions that can be drawn regarding the effectiveness of mindfulness-based interventions for healthcare professionals. The current review aimed to address this gap in knowledge by reviewing mindfulness-based interventions specifically for healthcare professionals. Eight studies were included in the review. It was concluded that despite some methodological weaknesses there was promising evidence of the effectiveness of mindfulness-based interventions in reducing stress and improving well-being particularly when baseline levels of stress were high. The evidence in support of reducing burnout was less conclusive. Future studies employing larger samples using active controls and longitudinal designs will provide valuable information on the long-term efficacy of these interventions. Empirical Research Study: Several studies have identified psychological adjustment as one of the most important factors correlating with psychological distress and quality of life in people with cancer. Identifying ways to promote positive adjustment to cancer is an important goal in helping to alleviate distress and improve quality of life for this client group. This can be facilitated by identifying robust predictors of distress. Previous studies have identified a number of useful predictors, such as coping styles and psychological adjustment styles. The current study aimed to explore the predictive power of two newer constructs aligned to mindfulness-based processes: self-compassion and cognitive fusion - in determining adjustment to cancer. 114 adults with various cancer diagnoses completed the Mini Mental Adjustment to Cancer Scale, Brief COPE, the Self-Compassion Scale, Cognitive Fusion Questionnaire; and two outcome measures: the Hospital Anxiety and Depression Scale and the Functional Analysis of Cancer Therapy – General. Hierarchical multiple regression was used to explore relationships between predictor variables: mental adjustment, coping style, self-compassion and cognitive fusion, and outcome variables: distress and quality of life. Results showed that a known predictor, emotional avoidance coping and the newer construct, cognitive fusion were significant predictors of distress over and above other known predictors. Emotional avoidance coping was the only significant predictor of quality of life over and above known predictors and the newer constructs under examination. Self-compassion did not account for any significant incremental variance in distress or quality of life after controlling for other known predictors. The results of this study indicate that interventions focused on reducing cognitive fusion and emotional avoidance are warranted and potentially beneficial in reducing distress in this population.

Elite freestyle snowboarders often expose themselves to large risks while performing their sport. A natural response to risk is fear, and it is the aim of this study to explore how elite freestyle snowboarders experience and cope with emotions of fear in conjunction with performing their sport. When examining these mechanisms, Acceptance and Commitment Therapy (ACT) will be used as the theoretical framework. The aim is to try to determine if the riders accept or avoid situations, thoughts and emotions of fear. Data was collected through semi-structured interviews with seven elite freestyle snowboarders (six men and one woman). The content of the interviews where processed with theory driven thematic analysis and inductive thematic analysis. The analysis revealed eight themes related to the athletes’ experience of fear: (1) Sources of fear, (2) Fear inducing events and situations, (3) Physiological responses, (4) Cognitive changes, (5) Action tendencies, (6) Fear appraisal, (7) Fear and risk and (8) Fear as a problem. In the analysis of the participants’ coping strategies for fear two themes emerged: Coping strategies not related to ACT and ACT-related coping strategies. It can be concluded from this study that elite freestyle snowboarders at times experience fear when exposed to high risk of injury, and can interpret this experience both as a negative and positive for well-being and performance. Participants use a range of coping strategies for fear; some which are in line with traditional sport psychology with an avoidance approach. Despite no previous ACT training, some participants have developed an accepting approach to relate to fear. The complexity of ACT as a theoretical framework is also demonstrated in this study due to the difficulties in categorizing the distinction between processes and orientations of strategies.

It is widely accepted in the literature that adverse experiences in childhood, such as abuse and emotional invalidation, pose a major risk factor for the development of psychopathology later in life. What is less known, however, is what processes mediate these associations. This study investigated whether psychological inflexibility – that is, cognitive fusion and experiential avoidance - play a role in mediating these relationships. Although abuse and experiential avoidance have featured prominently in the literature, emotional invalidation and cognitive fusion have been comparatively neglected. 518 adults currently experiencing self-reported psychological distress were recruited from online mental health support forums. They completed questionnaires measuring experiences of abuse and maternal/paternal emotional invalidation in childhood and current levels of cognitive fusion, experiential avoidance and psychopathology in an online survey. Given the interpersonal nature of the childhood experiences, and the impact these may have on attachment relationships, participants were also asked to complete a measure of adult attachment. Regression and path analyses indicated that whilst childhood abuse had a direct impact on adult psychopathology, experiences of maternal and paternal emotional invalidation had indirect relationships with psychopathology via cognitive fusion and experiential avoidance. In terms of predicting current levels of psychopathology, cognitive fusion made the most significant contribution, both directly, and indirectly via experiential avoidance. No reliable predictive relationships were observed between adult attachment and any other variable. The results add novel findings to the literature regarding the role of childhood emotional invalidation and cognitive fusion in the development and/or maintenance of distress. They suggest that clinical interventions aimed at cognitive defusion may be of particular benefit to people currently experiencing psychological distress and, perhaps, those with a history of emotional invalidation. However, the cross-sectional nature of this study limits the causal conclusions that can be made and future research should consider the use of longitudinal designs to extend these findings.