Background: Nonresponsiveness to therapy is generally acknowledged, but only a few studies have tested switching to psychotherapy. This study is one of the first to examine the malleability of treatment-resistant patients using acceptance and commitment therapy (ACT). Methods: This was a randomized controlled trial that included 43 patients diagnosed with primary panic disorder and/or agoraphobia (PD/A) with prior unsuccessful state-of-the-art treatment (mean number of previous sessions = 42.2). Patients were treated with an ACT manual administered by novice therapists and followed up for 6 months. They were randomized to immediate treatment (n = 33) or a 4-week waiting list (n = 10) with delayed treatment (n = 8). Treatment consisted of eight sessions, implemented twice weekly over 4 weeks. Primary outcomes were measured with the Panic and Agoraphobia Scale (PAS), the Clinical Global Impression (CGI), and the Mobility Inventory (MI). Results: At post-treatment, patients who received ACT reported significantly more improvements on the PAS and CGI (d = 0.72 and 0.89, respectively) than those who were on the waiting list, while improvement on the MI (d = 0.50) was nearly significant. Secondary outcomes were consistent with ACT theory. Follow-up assessments indicated a stable and continued improvement after treatment. The dropout rate was low (9%). Conclusions: Despite a clinically challenging sample and brief treatment administered by novice therapists, patients who received ACT reported significantly greater changes in functioning and symptomatology than those on the waiting list, with medium-to-large effect sizes that were maintained for at least 6 months. These proof-ofprinciple data suggest that ACT is a viable treatment option for treatment-resistant PD/A patients. Further work on switching to psychotherapy for nonresponders is clearly needed.

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多くの肥満者は，生活習慣のセルフマネジメントが困難であると指摘される。これに対し本稿は，肥満者の行動的QOLの低さ，すなわち行動レパートリーの不足に着目し，それを拡大する援助方略を行動変動性の観点から検討した。その結果，行動変動性が回避場面で減少することが示され，行動変動性に対する強化手続きや，その応用であるアクセプタンス＆コミットメント・セラピーが行動的QOLの拡大に有効であることが示された。 / It has been argued that many individuals with obesity have difficulty managing their lifestyle. This study focused on lack of behavioral repertory as a cause of the difficulty and attempted to expand behavioral repertory and behavioral quality of life (QOL) from the viewpoint of behavioral variability. The result showed that the decrease in behavioral variability was related to avoidant behavior. Furthermore, the result showed that reinforcement of behavioral variability and Acceptance and Commitment Therapy (ACT) promoted behavioral QOL expansion and lifestyle improvement. / 博士(心理学) / Doctor of Philosophy in Psychology / 同志社大学 / Doshisha University

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<p>Examen i vårdadministration, YH-utbildning: 20 Yh-poäng</p>

Indiana University-Purdue University Indianapolis (IUPUI) / The presence of a chronic pain condition can have a profound impact on one’s self-concept. Some individuals may have had to make major lifestyle changes. As a result, some people may start to define themselves in terms of their pain, such that their self-schema and pain-schemas become intertwined in a process termed schema-enmeshment. It is thought that schema-enmeshment is related to psychological distress making it a prime target for intervention. Little research has been conducted on interventions to reduce schema-enmeshment. Acceptance-based interventions may be especially appropriate in reducing schema-enmeshment or the connection between self and illness symptoms as these interventions tend to emphasize learning to live with pain and other symptoms and to work toward important life goals rather than continually fighting against the condition and allowing it to control their life. This study is a randomized trial comparing Acceptance and Commitment Therapy (ACT) to education about pain management in a sample of women with Fibromyalgia Syndrome (FMS). The primary aim of this study was to assess the efficacy of ACT in reducing schema-enmeshment between self and pain, as well as enmeshment between self and other symptoms and FMS as a whole. In addition, this study also explored the role of pain acceptance, specifically activity engagement as a mediator of the relationship between treatment group membership and changes in schema-enmeshment. The data was analyzed as an intent-to-treat analysis using the “last measure carried forward” method. Results indicated that the ACT group reported statistically significant differences in self schema-enmeshment with FMS, fatigue, and cognitive symptoms, but not with pain, following the intervention, compared to the educational control group. In each of these cases, the ACT group experienced greater reductions in schema-enmeshment compared to the education group. Interestingly, no statistically significant differences were observed for schema-enmeshment with pain. Statistically significant group differences were also observed for acceptance of pain following the intervention. Finally, a mediational model in which changes in activity engagement (a form of pain acceptance) served as the mediator of the relationship between treatment group and changes in schema-enmeshment with FMS was tested. The model was tested using a bootstrapping method, and results revealed a trend toward a significant indirect effect of changes in activity engagement leading to changes in schema-enmeshment with FMS. Taken together, the results of this study indicate that ACT may be a promising intervention for targeting maladaptive beliefs about the self in relation to illness, especially schema-enmeshment of self with illness and illness symptoms. Additionally, there is evidence that ACT may target key constructs such as activity engagement, which may be related to other cognitive and behavioral changes. Future directions for research and clinical practice related to ACT as an intervention for FMS are discussed in depth.

As a whole, eating disorders have been characterised as having the following key features: a persistent over concern with body size and shape; and weight control behaviours such as fasting, exercise, and self-induced vomiting. However, there tends to be a blurred line between those that do and do not meet diagnostic thresholds as the level of psychological distress is comparably similar. This study examined whether psychological inflexibility (from an Acceptance and Commitment Therapy perspective) was associated with eating disorders and whether it mediated the relationship between childhood abuse and invalidation and eating disorders. This was considered to be important because high rates of abuse have consistently been found in this population, yet not everyone goes on to develop an eating disorder. In addition, the role of emotional abuse has been largely neglected. A clinical sample of 190 participants with a clinical or subclinical eating disorder were recruited from eating disorder charities and support forums; they completed a range of questionnaires measuring experiences of abuse and maternal/paternal emotional invalidation in childhood, current levels of cognitive fusion and experiential avoidance and current levels of eating pathology. The sample was split into three groups based on their Eating Disorder Risk Composite scores: elevated, typical and low clinical range. It was found that those in the elevated clinical range (most severe eating pathology) had the poorest emotional processing and significantly higher levels of psychological inflexibility, thought-shape-fusion, depression and anxiety than those in the low clinical range (least severe eating pathology). In terms of predicting current levels of eating pathology, three variables emerged as significant predictors: emotional processing, thought-shape fusion and depression. In terms of predicting current levels of psychological inflexibility, five variables emerged as significant predictors: childhood emotional abuse, emotional processing, thought-shape-fusion, depression and anxiety. The results add novel findings to the literature regarding the role of early experiences on the development of psychological inflexibility, and the role of psychological inflexibility in the maintenance of eating pathology and psychological distress. Clinical implications of these findings in relation to assessment, formulation, intervention and prevention are discussed.

Appendices were not supplied with the digital version of the thesis but are available in the print version. / The present research includes two studies. Study I was based on the research finding that exposure to nuclear radiation and other toxic chemicals results in those who were exposed not only believing their health to be affected, but experiencing significant and chronic stress. It was hypothesised that ongoing stress for New Zealand’s nuclear test veterans resulting from the inability to adapt to their past nuclear exposure would result in them experiencing greater depressive symptomatology, poorer perceived health, and poorer perceived memory performance than a control group. Psychological profiles of 50 nuclear test veterans and 50 age-matched Control participants were obtained through postal survey and face-to-face interview, using the Geriatric Depression Scale, Medical Outcomes Study Short Form-36, and the Memory Assessment Clinics Self-Rating Scale. As predicted, the nuclear veterans exhibited more depressive symptoms, and perceived their health and memory performance to be poorer than the Control group. A stress theory framework is applied to help conceptualise the experience of the nuclear veterans, and to provide an explanation for their lower scores and consequent poorer functioning. Through the pathway of poor perceived health leading to anxiety, health anxiety was considered a form of chronic stress the nuclear veterans were experiencing. Consequently, Study II aimed to examine whether Acceptance and Commitment Therapy (ACT) could be usefully applied to relieve this anxiety. Most psychotherapeutic approaches have been developed for problems that have an "irrational" or "pathological" foundation. However, these approaches often fit poorly with psychological distress that stems from cognitions that are reality-based and may need to be accepted rather than changed, such as in the case of nuclear exposure-related health anxiety. ACT may be particularly useful in these situations in which cognitive change is not warranted. Study II examined the use of ACT with 5 NZ nuclear test veterans (of either Māori or Pākehā descent) experiencing moderate to high levels of health anxiety. Results of self-report measures administered at baseline, during treatment, post-treatment, and at 6-week follow-up indicated varying results amongst these men. One participant showed clinically significant post-treatment reductions in health anxiety, experiential avoidance, and general psychological distress that were maintained at follow-up. Two participants showed clinically significant post- vi treatment reductions in health anxiety, experiential avoidance, and distress, despite not engaging in therapy as they did not wish to make changes. For the same reason, a fourth participant chose not to engage in therapy, despite high baseline scores on all measures, and showed no improvement during or after therapy. The fifth participant had low baseline scores on all measures, maintaining these throughout therapy, and at follow-up. Results are explained in terms of cohort and gender effects, with suggestions for adapting ACT with NZ older adults, particularly males. Implications for the utility of ACT with toxic exposure populations, older adults, and various cultures are discussed.

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