Långvarig stress ökar risk för ohälsa och sjukfrånvaro, med negativa konsekvenser för individ, organisation och samhälle. En preventiv metod för stresshantering är Acceptance and Commitment Training (ACT). Syftet var att med en randomiserad, kontrollerad studie undersöka huruvida en kortvarig ACT-intervention påverkar stress och generell psykisk hälsa hos socialsekreterare inom Stockholms stad (n=106). Bortfall hanterades med intent-to-treat-analys. Vid förmätning rapporterade två tredjedelar av deltagarna hög stressnivå (PSS≥25). Resultaten visade att de som genomgått interventionen (n=70) hade signifikant lägre skattningar av stress, generell psykisk ohälsa och utbrändhet jämfört med kontrollgrupp (n=36). Separata analyser visade att dessa skillnader fanns även för deltagare med hög stress vid förmätning, men inte för de med låg. Effektstorlekarna var små till måttliga. Ingen signifikant skillnad fanns för prestationsbaserad självkänsla, psykologisk flexibilitet eller krav och kontroll i arbetet. Genom randomisering kontrollerades även för gruppledarinflytande. Slutsatsen var att interventionen kan användas för att minska symtom på stress, utbrändhet och psykisk ohälsa hos socialsekreterare. Vidare forskning bör undersöka effekten över tid.

This thesis investigates a contextual behavioral approach for obesity surgery patients. In a contextual approach a behavior is interpreted as inseparable from its current and historical context. Candidates for bariatric surgery often have a history of self-stigma, body dissatisfaction and eating for emotional relief. Despite losing a large amount of weight post surgery, psychological problems may still be present for some patients. One possible common underlying process observed in body concerns and eating patterns is experiential avoidance. Experiential avoidance is defined as; any attempt to avoid, change, or control unwanted thoughts and feelings when so doing causes harm. Though a multidisciplinary team is recommended for post-surgical care, there are few studies evaluating the psychological treatment of patients undergoing bariatric surgery. In this thesis a protocol based on Acceptance and Commitment Therapy (ACT), was developed and implemented, partly via the Internet, in a clinical setting. In an acceptance-based approach to obesity, psychological well-being is the main outcome. ACT was significantly more effective than ‘treatment as usual’ in terms of body dissatisfaction and quality of life after surgery. Both groups improved in eating disordered attitudes and behaviors. Predictions based on the underlying treatment model were also investigated. Positive treatment outcomes were found to be associated with increased psychological flexibility.  Despite some methodological limitations, the results are promising and future studies should further evaluate ACT in the context of bariatric surgery. This thesis also acknowledges the need for clinical assessment tools appropriate for the bariatric surgery context. The Acceptance and Action Questionnaire for Weight (AAQ-W) is a measure of experiential avoidance, and was evaluated in the present thesis. The AAQ-W was found to be a reliable and valid measure for people undergoing bariatric surgery. Another measure, Disordered Eating in Bariatric Surgery (DEBS) was developed and evaluated. The DEBS was found to posses satisfactory psychometric properties in terms of reliability and validity.  The AAQ-W and the DEBS may facilitate both systematic clinical evaluation and future research within the area of bariatric surgery.

Introduction: Support staff working with individuals with intellectual disability (ID) and challenging behaviour experience high levels of work-related stress. Preliminary theoretical and experimental research has highlighted the potential suitability of acceptance and mindfulness approaches for addressing support staff stress. This study examines the effectiveness of an acceptance and mindfulness-based stress management workshop on the levels of psychological distress and well-being of support staff working with individuals with ID and challenging behaviour. Method: Support staff (n=120) were randomly assigned to a workshop intervention condition (n=66) or to a waiting list control condition (n=54). Measurements were completed at three time points (pre-, post and six week follow-up) for: psychological distress, well-being, perceived work stressors, thought suppression, emotional avoidance/psychological inflexibility. Results: The results showed that for psychological distress there was a significant interaction effect in favour of the workshop. Thought suppression was found to reduce significantly in the intervention group post to follow-up, although no significant change was found in wellbeing or experiential avoidance/psychological inflexibility. For individuals with higher levels of psychological distress at pre-intervention (GHQ>11), larger effect sizes for the interaction were found, suggesting a greater impact of the workshops on the most distressed. Conclusion: Overall, results demonstrated support for the effectiveness of an acceptance and mindfulness-based intervention in reducing distress.

Chronic pain is a one of the most common causes of disability and sick leave. Psychological factors play a central role in the experience of pain and are important in the management of pain. However, for many people with chronic pain CBT is not available. There is a need to develop alternative ways to deliver treatments that reach more individuals with chronic pain. Internet-based treatments have been shown to be effective for several disorders and recent research suggests that internet-based CBT for chronic pain can be effective. The present thesis included four randomized controlled studies with the aim of evaluating whether guided internet-based treatments based on CBT can help individuals with chronic pain regarding psychological variables. Study I investigated the effects of an internet-based CBT intervention with telephone support for chronic back pain. The study showed reductions in some variables assessed.      Study II investigated the effects of an internet-based CBT intervention for chronic back pain without telephone support and with a live structured interview before inclusion. It was found that the treatment can reduce some of the distress associated with chronic pain. Study III investigated the effects of a guided internet-delivered CBT as a secondary intervention. Participants were patients who had previously completed multidisciplinary treatment at a pain management unit. Results showed that the internet-based treatment can be a feasible option for persons with residual problems after completed pain rehabilitation. Effects remained at six-month follow-up.    Study IV focused on the effect of a guided internet-delivered acceptance and commitment therapy (ACT) for persons with chronic pain. Results suggest that an internet-delivered ACT treatment can help persons with chronic pain. Effects remained at six-month follow-up. In conclusion, guided internet-based CBT can decrease distress associated with chronic pain.

Thesis (Ph. D.)--University of Texas at Austin, 2005. / Supervisors: Kristin D. Neff and Stephanie S. Rude. Vita. Includes bibliographical references.

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.