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.

Relational Frame Theory (RFT; Hayes, Barnes-Holmes, and Roche, 2001) describes verbal contingencies as networks of relations between overt and covert stimuli. RFT posits that the ability to form these relational networks is a key component of language and cognition. These relations can become problematic when they result in an individual rigidly responding to verbal contingencies even when environmental contingencies produce more adaptive outcomes. RFT has given rise to an intervention program called Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) that is designed to help people see past maladaptive verbal contingencies. ACT's utility in the area of OBM is still in the early stages of exploration. Experiment 1 examined the effect of a verbal and written performance feedback system with a low cost probabilistic contingency reward program and an eight hour ACT training program on the percentage of time Direct Support Professionals (DSPs) spent engaged in active treatment and the technical competence of active treatment provided to people with disabilities. The experiment used a pretest/posttest design with a waitlist control group and two intervention groups. DSPs serving children and adults with developmental disabilities in a residential and small group home settings participated in the experiment. The first intervention group received only the feedback intervention while the second intervention group received the feedback intervention and the ACT training. After attrition the group sizes were control N = 12, feedback only N = 12, and feedback plus ACT N = 17. Both intervention groups performed significantly better than the control group. The feedback plus ACT group outperformed the feedback only group by 27.8% in percentage of observation time engaged in active treatment at posttest. The result was statistically significantly at the .05 level of significance. The feedback plus ACT group also exhibited superior but nonsignificant improvements over the feedback only group in the areas of competency of operant teaching techniques (14.9%), percentage of clients engaged in purposeful activities (10.7%), and percentage of clients with learning or leisure materials within arm's reach (11.0%). Regression analyses found a weak positive correlation between age and frequency of active treatment (R2 = .11, F(1, 39) = 4.99, p < .05), a weak positive correlation between psychological flexibility as measured by the Acceptance and Action Questionnaire-2 (AAQ-2) and job satisfaction, a weak negative correlation between psychological flexibility and self-reported workplace stress, and a weak negative correlation between stress and job satisfaction. Self-reported levels of psychological flexibility, workplace stress, and job satisfaction remained stable for all three groups from pre to posttest despite the increased performance expectations on DSPs in the two intervention groups. Possible explanations for the differences in performance are discussed. Experiment 2 consisted of a small scale replication of the active treatment findings of experiment 1 while examining what impact, if any, higher frequency observations and verbal and written feedback would have on DSP self-reported workplace stress, job satisfaction, and psychological flexibility. Experiment 2 also used participants 25 years of age and under to further explore and possibly rule out the age-active treatment correlation found in experiment 1 as a significant variable impacting the frequency of active treatment. The intervention procedures used in experiment one were adapted for experiment two. The specific intervention components used were verbal performance feedback and a one-on-one daylong version of the eight-hour ACT training program used in experiment one. Two separate multiple baseline designs across participants were used. Group one consisted of three DSPs and group two contained 2 DSPs. The feedback intervention produced improvements in the percentage of time DSPs were engaged in active treatment during observations and in their operant teaching skills competency-based testing assessment scores. Three DSPs failed to meet the performance target after the feedback intervention was introduced but met or exceeded the performance target after the daylong ACT training was implemented.

This investigation evaluated the use of multiple exemplar instruction (MEI) to teach perspective-taking skills to adolescents with high-functioning autism. The first experiment used a multiple probe design to examine the use of MEI to teach participants to respond appropriately to the deictic frames of I-You, Here-There, and Now-Then. Participants were instructed and tested using developmentally appropriate perspective-taking protocols, and generalization of perspective-taking skills to a more natural social interaction format was also assessed. The second experiment used a multiple probe design to examine the use of MEI to facilitate defusion from negative thoughts and feelings related to social interaction. Participants were trained to discriminate between different aspects of their own perspective (i.e., self-as-content and self-as-context). Defusion was measured using ratings of the believability and comfort associated with negative thoughts, and the percentage of time engaged in appropriate social interaction was recorded for each participant. Results from Experiment 1 showed the emergence of deictic relational responding in the presence of novel relations for all participants following MEI, and varying degrees of generalization of perspective-taking skills to a natural presentation of social interaction were observed based on the complexity of the deictic relation. Results from Experiment 2 revealed a decrease in believability and an increase in comfort associated with problematic thoughts for all participants following MEI in the absence of directly observed changes in social interaction in the natural environment. These results support the use of MEI as an instructional strategy for teaching perspective-taking skills to individuals with autism. Findings are discussed according to a Relational Frame Theory analysis of perspective-taking.

Use of restraint during crisis intervention is of great concern as these situations evoke stress responses in the direct care staff that respond to them. This stress response often leads to non- neutral reactions. Acceptance and Commitment Therapy (ACT) has been used to effectively de- literalize task-related stimuli in individuals that share similar physiological symptoms of stress to those that direct care staff might experience during crisis. The purpose of this study was to evaluate how an ACT intervention would improve direct care staff performance during crisis interventions and increase accuracy of incident report writing. Results indicated that four out of the six participants improved their performance following ACT training, while the most improvement was observed in accuracy in incident report writing. This study expands upon the limited research available on the utility of ACT in the workplace. Implications of this study suggest that ACT may be a beneficial intervention to increase staff performance during crisis.

The current study examined the utility of an idiographic configuration of the Implicit Relational Assessment Procedure (IRAP) as a measure of psychological flexibility. Psychological flexibility is the overarching outcome variable of Acceptance and Commitment Therapy (ACT) and may be defined as the ability to make full contact with the present moment and persist in behavior that serves valued ends (Hayes, 2004). One hundred six participants first completed questionnaires assessing individual valued activities and distressing private events. These data were utilized to populate the IRAP. Depending on the administration order, the subjects either continued with the IRAP or with a series of self-report measures evaluating psychological functioning and ACT processes. Results indicated that IRAP scores modestly correlated with some self-reports of psychological flexibility and were also able to significantly predict symptomology. However, the study revealed inadequate internal consistency of the IRAP, which constitutes a limitation to the validity of the measure. This study represents one step in a long line of research examining a variety of procedural and contextual variables influencing the reliability of the IRAP, offering preliminary support for the utility of an idiographic IRAP as an implicit measure of psychological flexibility. Future additions to IRAP research similar to the current study will continue to enhance the field’s understanding of implicit cognitions and the effectiveness of the IRAP in psychological research.

The present study extends previous research on acceptance and commitment therapy (ACT) by using a new ACT protocol, the Fusion Management System (Dixon, 2013 in press) with a new population. Participants were 2 high functioning children with autism: an 8-year old boy and a 12 year-old girl. Using a multiple baseline design, 2 participants were exposed to 15 hours of therapy over the span of 12 weeks. Behavioral data was taken for each participant by their parent(s) on a problematic behavior that was of concern to them. Prior to and following the ACT intervention, both participants took three psychometric measures that were designed to measure ACT related processes: the Child and Adolescent Mindfulness Measure (CAMM), the Acceptance and Action Questionnaire-II (AAQ-II), and the Avoidance and Fusion Questionnaire for Youth (AFQ-Y). Following the intervention one participant improved on all measures of the ACT related processes and the other participant's score improved on the AFQ-Y and slightly deteriorated on the CAMM and AAQ-II. During the intervention phase of this study both participants' problematic behavior significantly improved. Implications of the study and future research are also discussed.

Therapist burnout is of primary concern for individuals who provide ABA therapy for those with autism or related disabilities. Prolonged high levels of work-related stress increase the risk of negative interactions and emotional exhaustion among workers. Acceptance and Commitment Therapy (ACT) may alleviate this problem. ACT has been found to decrease levels of perceived work-related stress among direct care staff. The primary purpose of the study was to evaluate whether ACT would improve positive interactions among therapists for children with autism spectrum disorder. The results indicated that the percentage of positive interactions had improved an average of 23.1% and procedural fidelity improved an average of 7% across all three participants. This study extends that of previous research by supporting the efficacy of ACT in work environments. One implication of the current study is that it could benefit the psychological well-being of ABA therapists. Future studies should examine whether ACT-exercises influence the way therapists address challenging behavior as it pertains to the quality of services delivered.

This study aimed to investigate the use of values based training with typically developing adults to affect levels of physical activity recorded by FitBit Flex technology in the form of step count. Traditional approaches have shown promise but with mixed results. Interestingly, one must look outside of behavior analysis for interventions attempting to affect control by an individual’s covert verbal behavior. Acceptance and Commitment Therapy (ACT) has been shown to be effective in various behavior change areas by using a values based approach that focuses on the control of rules and their motivative functions. An ACT training protocol (ACTr) consisting of values identification, present moment training, and committed action (goal setting) was implemented across four sessions to teach various tools in an effort to relate personal values to physical activity and create short-term and long-term goals with respect to those values. Results show small to moderate increases in physical activity during intervention with continued increases seen in follow-up. These results support the potential of using values based training to increase physical activity levels.

Det finns lite forskning kring metoder och arbete med par såväl internationellt som i Sverige. Syftet med denna studie har varit att undersöka om tillägg av upplevelsebaserade övningar med fokus på defusion bidrar till ytterligare ökning av den relationella tillfredsställelsen jämfört med traditionell familjerådgivning. Defusion är en av processerna i Acceptance and Commitment Therapy. Studien har bestått av en undersökningsgrupp (n=16, 8 par) som erhållit en work-shop med upplevelsebaserade övningar med fokus på defusion samt en kontrollgrupp (n=16, 8 par). Vi valde att undersöka följande: Finns det en skillnad i utfall vad gäller relationell tillfredsställelse mellan grupperna efter tre sessioner? Finns det en skillnad mellan grupperna vad gäller utfall efter tre sessioner vad gäller: anpassningsförmåga rörande områdena enighet, sammanhållning, tillfredsställelse samt känslouttryck, frekvens av valideringsbeteenden samt grad av kognitiv sammanblandning och upplevelsebaserat undvikande. Resultatet visar på en signifikant skillnad i undersökningsgrupp jämfört med kontrollgrupp avseende sammanhållning samt tillfredsställelse i relationen. Måttliga effektstorlekar har också kunnat påvisas. Slutsatsen som drogs var att denna typ av tillägg vid behandling av par visar lovande resultat och bör väcka intresse för ytterligare forskning och metodutveckling.

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.